Developing a Core Foundation Essential for Successful Practice of Neurosurgery
Core competencies and simulation are popular buzz words in the lexicon of contemporary graduate medical education. Additionally, the development of more comprehensive and uniform curricular structure and metrics for measuring competency have evolved in graduate medical/surgical education in the recent past. These changes might suggest that trainees across programs should be exposed to similar learning environments and thus, be more likely to graduate with a uniform, solid foundation of basic neurosurgical skills. However, at the same time that there have been significant attempts to improve graduate surgical education there have also been a variety of forces both from within and outside of neurosurgery that may negatively impact the quality and depth of the educational experience. These include the adoption of duty hour restrictions during training as well as a substantial increase in regulation of resident supervision (which by itself has both positive and negative impacts on training).
Seeking Specialized Training
As a potential response to some of these developments, there has been a near simultaneous increase in the number of trainees seeking specialized fellowship training after completion of residency training. This shift in training culture (toward subspecialized training), accompanied by the reorganization of many group practices, has impacted the types of procedures that both new and experienced neurosurgeons might consider themselves well qualified to perform within the scope of their “typical” individual practices (1,2). There has been an increase in subspecialization within neurosurgery and thus, a resultant decrease in the number of practitioners who “see and do” the full scope of the field of neurosurgery.
Some contemporary neurosurgeons may have the “good” fortune to practice within a group or system where there are separate, individual experts in all areas of neurosurgery – spine, cerebrovascular, neuro-oncology, functional, pain, neuro-trauma, pediatrics, etc. Even within such a system, it is not inconceivable that a surgeon with a narrowly focused practice scope might be called up to provide call coverage for diseases that fall outside the scope of his or her typical practice or that he or she might even be called upon to provide surgical care that is not in line with what he or she would have to provide within his or her elective practice. How then should a neurosurgeon react to the call to provide care that is not within the scope of his or her typical practice?
Consider the Following
Consideration of a couple of clinical scenarios may help to make the problem easier to envision. For the sake of argument, imagine that a moderate-sized clinical practice, with each practitioner specialized into one of the above mentioned categories of subspecialization in neurosurgery, has the responsibility to provide call coverage at a full service adult and pediatric hospital. Additionally, consider that there may be times when most of the group’s providers are not immediately available to care for patients with new and time-sensitive neurosurgical problems (think of the weeks during the AANS Annual Scientific Meeting and CNS annual meeting).
In such a scenario, it is not difficult to imagine the quandaries that might arise if (a) a patient presents with a ruptured anterior circulation aneurysm and the cerebrovascular specialist is away, or (b) a different patient presents with acute cauda equina syndrome from a very large upper lumbar disc herniation with resultant severe spinal stenosis and all of the spine providers are absent for CME. Which, if either, of these two scenarios is more problematic? The reality is that each situation poses important difficulties for the individual neurosurgeon involved and for neurosurgery as a profession.
Can subspecialized neurosurgeons only take call for the types of cases that are part of their everyday, elective practice? For scenario (a), there are obvious potential concerns for the neurosurgeon that may need to take this patient to surgery – potential for blood loss, potential for stroke, potential for catastrophic intra-operative changes in the patient’s clinical status (brain swelling, avulsion of the aneurysm from the parent vessel, etc.); but for scenario (b), there are also potential challenges – unintentional dural injury, traction injury to the neural elements, wrong level surgery, the possibility of spinal instability either intrinsically before surgery or as a result of the surgery performed – to name just a few. So which scenario is really more challenging?
The Need for a Strong Foundation
There is likely no easy answer to the question posed above, but that does not resolve the real dilemma that providers are not infrequently asked to work outside of the potentially narrow scope of their preferred practice. This reality reinforces the need for a strong foundation in general neurosurgical principles during residency training. Despite the growth and evolution of neurosurgery over time, there remains a critical need to provide all trainees with a robust and diversified educational basis in all aspects of neurosurgery – trauma, spine, cerebrovascular, tumor, pediatrics, functional, etc. This does not mean that every trainee will become a true expert in each subspecialty area of neurosurgery – but it does mean that each trainee will be held accountable for obtaining a reasonable degree of knowledge and technical ability so that when faced with acute common neurosurgical problems, there is no question that appropriate care will be provided.
Most neurosurgeons can likely identify at least one area of neurosurgical practice where they feel less comfortable than others. When working in arenas of less personal familiarity, recalling experiences from training (neuro-anatomy and surgical orientation) and earlier practice combined with the realization that even the most complex neurosurgical procedures are “constructed” out of individual surgical components that are common to multiple types of procedures (opening, delicate handling of neural tissue, closure techniques, etc.) help to reduce the apprehension felt when facing less commonly conducted procedures.
Meeting the challenge to provide a strong and broad core of neurosurgical education should be the express goal for curricular development – providing a level of educational development that lets all trainees understand, diagnose and treat the wide range of common neurosurgical disorders. Trainees not meeting this minimal standard cannot and should not be graduated without completion of adequate remediation for areas where they fall short. Certification through the written and Oral Board Examinations has traditionally been the ultimate test of the trainee’s preparedness for independent practice – the responsibility of these examiners remains as robust today as it has been at all times in the past.
Neurosurgeons must be prepared to care for the patients that will present themselves in a wide variety of arenas – hospital based consults, clinic visits and emergency room visits. Dedication to life-long learning, reflection on personal experience and the ability to rely on a solid foundation of skills covering the breadth of neurosurgery taught in quality residency training programs are the best assets the practicing neurosurgeon has to bring to bear on the variety of neurosurgical pathologies he or she is likely to come across in elective and non-elective practice.
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