Examination

[Next Examination: 4 and 5 October 2017, Budapest, Hungary – for details please scroll down]

INTRODUCTION

The Examination Board of Euro-CNS organises an examination in Diagnostic Neuropathology each year (in the autumn). The examination is held in English. Successful candidates will be elected as ‘European Fellows in Neuropathology’ of the European Confederation of Neuropathological Societies and their names will be listed in the Register of Fellows on this website and in the Euro-CNS Journal ‘Clinical Neuropathology’.

Requirements for entry to the examination for the European Fellowship in Neuropathology

An applicant may expect to be accepted as a candidate for the EFN examination if by the date of the examination s/he will have completed [1] one year of the equivalent of full-time training in Histopathology and [2] one year of the equivalent of full-time training in Clinical Neuroscience and [3] three years of the equivalent of full-time training in Diagnostic Neuropathology.  Clinical Neuroscience may be taken to mean experience in either clinical neurology (adult or paediatric practice) or in neurosurgery (adult or paediatric practice).

During this period of training, an applicant is expected to have:

Examined and reported ~150 brains (and several spinal cords) removed at autopsy (brain cuts)
Examined and reported ~1000 neurosurgical biopsy specimens
Examined and reported ~150 skeletal muscle biopsies
Examined and reported ~30 peripheral nerve biopsies
Examined and reported ~300 cerebrospinal fluid cytological preparations
Acquired a sound working knowledge of techniques used in diagnostic neuropathology, such as immunohistochemistry and electron microscopy.
Acquired general knowledge of the clinical interpretation of modern neuroimaging techniques and molecular biological techniques as relevant for neuropathology, especially surgical neuropathology
Performed and reported ~50 full autopsies, of which half should have been neurological or neurosurgical cases.

These are recommendations and not absolute requirements for entry. Others who wish to sit the EFN examination, but who have not had the supervised training experience specified in the preceding paragraphs, may apply to the Chair of the Board of Examiners for consideration. The application should include full curriculum vitae and should specify periods of supervised training and the range and extent of case material to which the applicant has been exposed.

Potential applicants are strongly advised to read the EFN Curriculum for Diagnostic Neuropathology, which forms the basis on which examiners will assess the knowledge and competence of examination candidates.

Information for candidates  – Conduct and marking of the examination for the European Fellowship in Neuropathology (EFN)

1. Euro-CNS curriculum for trainees intending to sit the EFN examination
The EFN certificate is awarded when examiners are satisfied that a candidate is competent to practice as an independent specialist in diagnostic neuropathology. Prospective candidates and future employers should be informed about the specific competences that a newly elected Fellow is declared to have achieved. Therefore, Euro-CNS has adopted a curriculum, which is a detailed list of the knowledge, skills and attitudes/behaviours that a specialist neuropathologist is expected to have acquired during a period of supervised training, and which will form the basis of assessment in the EFN examination.

The curriculum in Diagnostic Neuropathology is written in a style emphasising the key tasks of a neuropathologist (examining and reporting brain, spinal cord and meninges obtained at autopsy; reporting a neurosurgical biopsy; providing an intra-operative opinion on a neurosurgical biopsy; reporting skeletal muscle and peripheral nerve biopsies; reporting cerebrospinal fluid cytological preparations etc) and places the various competences in the context of specific clinical problems (a mass lesion, a movement disorder, a case of dementia etc). The document also provides guidance on English-language text-books in Neuropathology and related subjects.

2. The EFN examination examines a candidate’s ability to choose additional laboratory tests in a manner that is judicious, economical and informative
The provision of immunohistochemical preparations to candidates in an examination may bypass several important steps in the diagnostic thought process. The examination should test a candidate’s ability to choose which tests are appropriate and necessary in order to establish a diagnosis and to inform on prognosis and likely response to therapy. The selection of further tests should be informed critically by an analysis of the microscopical features in haematoxylin and eosin-stained histological slides, interpreted in the context of the clinical information. The choice of tests should be judicious and justifiable.

Therefore, most examinable histological material will be provided in the form of haematoxylin and eosin-stained (H&E) tissue sections. Candidates will be invited to write a preliminary report in which they [a] express a diagnostic opinion, [b] indicate clearly the level of confidence with which this opinion is expressed, [c] give an indication of which further tests they would propose to undertake within the laboratory (and how these tests will contribute to diagnosis or patient management), and [d] indicate any other tests that may provide useful information (further imaging, clinical genetic testing, molecular testing, microbiological tests etc). This approach is taken in the neurosurgical biopsy component of the EFN examination.

Examiners may choose to provide one or several histochemical and/or immunohistochemical preparations and/or EM photographs in autopsy cases, in skeletal muscle and peripheral nerve biopsy cases, as they judge to be appropriate. However, the principle that the examination should test the candidate’s ability to use a laboratory intelligently, economically and safely is an important one.

Appendix C shows the ‘instructions to candidates’ that will be printed on the examination paper for each of the modules (see also item 8 below and Appendix A).

3. The EFN examination generally avoids questions that produce answers that are too narrow, thus preventing a candidate from accessing the full range of marks
e.g. What is the diagnosis? Name this structure?

Such questions are inappropriate because the examiner can only award either a pass mark (2.5 out of 5 in the mark scheme set out in the next section) or a 0. Such examination questions leave no scope for knowledgeable candidates to provide additional useful information. They provide no opportunity for a candidate who may be unsure of the diagnosis to give a cautious opinion and to indicate which additional tests would resolve the matter. They give no scope to examiners to reward good candidates.

Therefore, candidates receive clear instructions that they are to write a report for a referring clinician, which provides as much relevant information as possible. For the most part, neurosurgical biopsy reporting will be assessed on H&E-stained sections alone and candidates will be assessed on their diagnostic opinion and on the view they take on the need and usefulness of additional histological, immunohistochemical, histochemical, EM and molecular tests.

4. The generic marking criteria
EFN examiners have adopted a ‘close marking’ scheme for each examinable component and for the examination as a whole. Each answer has a theoretical maximum mark of 5.0. The following are an indication of the expected marks.

1.0 a very poor performance or answer, such as benign to malignant reversal.
1.5 definitely incorrect or poorly constructed answer
2.0 unnecessarily indecisive or potentially misleading answer
2.5 an adequate answer
3.0 an adequate answer with some additional relevant information
3.5 a good and comprehensive answer
4.0 an exceptionally good answer

If any section is omitted or has a minimal answer, a nominal mark is awarded but other than this, marks in the range of 0-1 and 4-5 are not used.

Prospective examination candidates should be aware of this marking scheme. It will serve to emphasize [1] that errors such as misdiagnosing a benign (low grade) tumour as malignant or high grade and vice versa are considered serious errors, which receive a very low mark, [2] that errors such as misdiagnosing reactive or inflammatory lesions as neoplastic and vice versa are considered serious errors, which receive a low mark, [3] that an adequate report need not necessarily consist of a firm diagnosis, depending on the complexity and difficulty of the particular case, which is judged a priori by examiners (during standard setting for each examination diet), [4] that a report in which the referring clinician is provided with useful additional information, such as (i) the WHO grade of a tumour, (ii) the need to investigate extra clinical data or to undertake clinical genetic testing because of a likely inherited predisposition, (iii) information on prognosis or likely response to treatment, will receive a high mark.

5. The criteria for a pass in each examinable component is established before the examination scripts are assessed
The specific requirement for an ‘adequate answer’, which is awarded a mark of 2.5, will be pre-determined for every examinable item. This process is known as ‘standard setting’ and is undertaken under similar conditions to the actual examination (similar time-constraint, the same examinable specimens as the candidates, no previous knowledge of examination content, unfamiliar microscope, and same location) by the examiners assigned to each examination session.

6. The standard of the examination as a whole is set before the examination scripts are assessed
This aspect of standard setting seeks to maintain the same standard for the EFN examination from one year to the other, irrespective of which European centre hosts the examination and assembles the examinable material. The organisers (not the examiners) select cases, based on clinical relevance (not important, important, essential) and difficulty (easy, moderate difficulty, very difficult), according to a template in which most cases are moderately difficult and clinically important (see following table).

Target distribution of 20 cases for the Neurosurgical Biopsy component of the EFN

  • Difficult
  • essential
  • important
  • supplementary
  • questionable
  • Difficult
  • 2
  • 1
  • 1
  • questionable
  • moderate
  • 7
  • 4
  • 1
  • questionable
  • easy
  • 2
  • 1
  • 1
  • questionable

The Board of Examiners has established the following criteria on which to categorise various lesions or diseases:

1. Degree of difficulty

a. Relative frequency of such case in routine neuropathological practice
b. Recognition depends on some microscopical features that may be missed on cursory examination
c. H&E appearance is inconclusive and special investigation (special stains, immunohistochemistry, EM) should be undertaken

2. Degree of importance

a. Missing the diagnosis could lead to unnecessary treatment or to a failure to treat
b. The diagnosis carries implications for genetic counselling
c. The diagnosis carries an unexpected prognosis: worse or better than expected

On the day of the examination, the examiners assess whether the particular examination that has been set is relatively easy, difficult or appropriate in terms of these standards. They do this by undertaking their own assessment of relevance and difficulty for each piece of examinable material. This is done at the same time as they are establishing criteria for a pass mark (previous section).

This aspect of standard setting is necessary in order to inform the examiners’ final decision if a candidate were to obtain a mark that is equivalent to a bare pass (50%) or bare fail (49%). Examiners may upgrade such a candidate to a clear pass (51%) if the proportion of difficult questions is excessive or they may downgrade such a candidate to a clear fail (48%) if the proportion of easy questions is excessive.

7. The EFN examinations contain discrete modules that reflect current diagnostic practice

7.1 The EFN examination includes separate sections for paediatric neuropathology, neuromuscular disease and neurodegenerative disease for two reasons: [1] examiners should be able to identify more easily significant weaknesses or strengths across various sub-specialty areas within Diagnostic Neuropathology, thus providing unsuccessful candidates with more detailed feedback, and [2] Euro-CNS wishes to send a strong message that trainees in Neuropathology must acquire a breadth of knowledge and clinical skills, across all areas of neuropathology, even if they intend to practice only within a narrow sub-specialty area (e.g. brain banking for neurodegenerative disease, paediatric neuropathology, skeletal muscle pathology etc.) after acquiring accreditation as a specialist. The Examination Committee takes the view that [1] intra-operative diagnosis by wet smear technique and/or frozen section, [2] neurosurgical biopsy by paraffin sections and [3]skeletal muscle and peripheral nerve biopsy (neuromuscular biopsy) are so important to clinical practice that a candidate will not to be allowed to pass the examination, even if s/he obtains a clear pass mark (51%) overall, without a clear pass mark (51%) in these components.

7.2 The principle of ‘standard setting’, outlined in section 6 (above), will apply at modular level for the three ‘critical modules’. On the day of the examination, the examiners assess whether the examinable material in each of the ‘critical modules’  is relatively easy, difficult or appropriate in the same terms stated in section 6. They do this by undertaking their own assessment of ‘clinical importance’ and ‘difficulty’ for each piece of examinable material. This is done at the same time as they are establishing criteria for a pass mark for each case in the module. Standard setting at modular level will inform the examiners’ decision if a candidate were to obtain a mark that is equivalent to a bare pass (50%) in a critical module. Examiners may upgrade the candidate’s mark for the critical module to a clear pass (51%) if the cases in the module are considered ‘difficult’ or they may downgrade such a candidate to a fail (49%) if the cases are considered ‘easy’.

7.3 A candidate who obtains a mark of less than 40% in  a ‘non-critical’ module (adult autopsy cases, paediatric autopsy cases, computer-based knowledge test, oral examination) will fail  the EFN examination even if s/he obtains a clear pass mark (51%) overall.

8. The components (modules) of the EFN examination

The ‘basic plan’ that is provided in Appendix A lists the various components (modules) of the EFN examination. Appendix B is an example of how this basic plan is translated into a workable time-table for four candidates (a draft time-table). It shows that multiple sets of slides will be required only for the 20 cases intended for the module on neurosurgical biopsy diagnosis. However, it is usually possible to use single cases and single sets of slides (e.g. smear preparations) for the rest of the examination. In this way a maximum of four candidates can be examined on identical, not just similar, cases.

9. An oral examination is used to assess the candidate’s knowledge of the neuropathological autopsy.

It simply is impracticable to have candidates perform an autopsy under examination conditions because of a shortage of cases and medico-legal constraints. However, the requirements for admission to the EFN examination include training in autopsy practice, both general and neuropathological cases. The curriculum includes autopsy-based competences.  The EFN examination will assess the candidate’s knowledge of autopsy practice and his/her ability to provide appropriate guidance on which tissues to remove and how to go about doing so. The oral examination will be used to assess a candidate’s expertise in the neuropathological autopsy.

10. Examination centres

Euro-CNS intends to rotate the examination around several neuroscience centres in Europe. Selection of case material is made under the guidance of the Chair of the Examination Committee and in a manner that ensures comparability between centres, as explained in section 6 of this document.
The host institution provides [1] post mortem cases with history, images of the whole and sliced brain, and a set of histological preparations; [2] several identical sets (one for each candidate and another for the examiners) of neurosurgical biopsies, [3] cases of skeletal muscle and peripheral nerve biopsies. The electronic file for the computer-based knowledge test is produced centrally.

APPLICATION PROCESS AND DEADLINE
Anyone interested in taking the examination is asked to indicate their intention to the Euro-CNS office. The closing date for formal applications is May 2017. Later applications may be judged on an individual basis.

Please send [1] evidence of qualification as a medical doctor and [2] evidence that you have completed (or will complete) the recommended training programme in neuropathology in a European country. The neuropathology training must have been at least 3 years and training/experience should adequately cover the topics as described under the examination requirements.

If you are a candidate in a Euro-CNS member country: the application should be supported, in writing and signed, by the Euro-CNS delegate of your country. For candidates from outside Euro-CNS member countries: the application should be supported and signed by the ISN delegate of your country.  All supporting documents may be sent as PDF documents by e-mail.

Early application is strongly recommended as the number of candidates is likely to be limited to four per examination. Places will be offered on a first-come-first-served basis, provided the applicant meets the requirements.

The Chair will confirm whether the applicant may sit the examination (applicant becomes a candidate). The Euro-CNS office will then send the candidate a registration & payment form, which finally confirms the application. The registration fee is 700 Euro.  Please make sure to read the EFN Curriculum for Diagnostic Neuropathology, which forms the basis on which examiners will assess the knowledge and competence of examination candidates

FUTURE EXAMINATION DATES
The 2017 EFN examination will be held on 4 and 5 October.

LOCATION
Semmelweis University, 2nd Department of Pathology & National Neuropathology Centre for Prion Diseases, Üllői út 93, Budapest, H-1091, Hungary. See the location on google maps.

TRAVEL AND ACCOMMODATION
Hotel suggestion: Hotel Leonardo is a nearby hotel. However, there are many hotels in the more attractive downtown with easy access by public transport to and from the exam venue, The nearest station to the exam venue is Metro line 3, ‘Klinikak’.

FROM THE AIRPORT
From ‘Budapest Liszt Ferenc International Airport’ either take a taxi (approx 35€), or public transport (Airport bus 200E to final stop Kobanya Kispest and from there Metro line 3 to Klinikak, or further to City Centre (approx 3€) if you prefer to book a hotel there.

FINANCIAL SUPPORT
There is no financial support for candidates to attend the Examination.

BOARD OF EXAMINERS OF THE EUROPEAN FELLOWSHIP OF NEUROPATHOLOGY (EFN)
The Examiners are established academic neuropathologists with at least 5 years experience as consultants/specialists in diagnostic neuropathology. Members of the Board of Examiners 2017 • Tibor Hortobágyi (London & Debrecen) – Chairman Euro-CNS Board of Examiners • Herbert Budka (Vienna) • Charles Duyckaerts (Paris) • Isidro Ferrer Abizanda (Barcelona) • Maria Teresa Giordana (Torino) • Paul Ince (Sheffield) •  Werner Paulus (Münster) • Guido Reifenberger (Düsseldorf) • Dirk Troost (Amsterdam) – Chairman Euro-CNS Educational Board • Pieter Wesseling (Nijmegen)

Immediate past chairman:  John Xuereb (Cambridge), chair until 2014

Recommended reading on Neuropathology training Worldwide and in Europe:

Neuropathology Training Worlwide – Evolution and Comparisons by Marc Del Bigio, Johannes Hainfellner, Catriona McLean et al – Brain Pathology ISSN 1015-6305