AANS Neurosurgeon | Volume 26, Number 1, 2017

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Neurosurgical Subspecialization

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The decades-old issue and debate in regards to neurosurgical subspecialization is paradoxical: the specialty arose as an offspring of the field of general surgery. As such, William S. Halsted’s disciple, Harvey Cushing, with a general surgery background, pursued the surgical treatment of diseases of the nervous system. As is well known, Halsted was one of the first national proponents of surgical subspecialization and encouraged his faculty to pursue the same. Cushing, famously, in 1905, dedicated himself to the “special field of neurological surgery.” The field has its origins in the early 20th Century in this country, but by the latter part of that century, it was clear that the specialty’s scope had expanded considerably; as such, advances in the field had significantly expanded both the breadth and depth of neurosurgical knowledge.

What is the State of Neurosurgical Practice as 2017 Approaches? 
A number of factors influence the trends of neurosurgical practice; these include, but are not limited to changing population demographics, the Affordable Care Act, socioeconomic pressures and available manpower.

The data supports decreased morbidity and mortality as a center’s patient and surgical volume increase. This also holds true for an individual surgeon’s experience. Given this, why would any practicing neurosurgeon choose to not subspecialize? The reasons are many and varied. In rural and less-populated areas, where the number of neurosurgical practitioners may be low, it is advantageous to have a general neurosurgeon available for both elective and emergent neurosurgical care. Most would agree that these patients could be managed expeditiously and effectively by an individual who has completed training in a Residency Review Committee (RRC) accredited neurosurgical training program. Patients requiring neurosurgical care outside the scope of the neurosurgeon’s practice would then be referred to a tertiary care center.

As such, centers of excellence should be recognized and established; these are often but not necessarily academic neurosurgical departments. These centers should benefit from seeing high volume and a complexity of cases; the expectation is that at these centers, neurosurgical care should be delivered with minimal morbidity and mortality to the patients. In U.S. academic neurosurgical departments, what is the current practice and expectation? Are faculty members encouraged to pursue sub-specialization and increase their technical and neurosurgical acumen? Conversely, are neurosurgical faculty financially incentivized to perform any and all surgical cases they feel capable of handling with little regard for the excellence that subspecialization should engender?

Neurological surgery is a discipline that has long prided itself on excellence, both in and out of the operating room. Cushing set the tone for those who followed by establishing a precedent of scientific inquiry, intellectual curiosity and technical acumen, all for the purposes of delivering the best care to the neurosurgical patient. Given the explosion of knowledge in the field, it would appear that subspecialization is the most prudent course of action, in order to further the development of the field and to continue delivering excellence in neurosurgical care to the public. It is evident that the high competence of the subspecialist would further attract patient referrals to the academic centers, thus leading to increased volume and better outcomes.

It Starts With Training
Neurosurgical training should be the foundation upon which a surgeon’s career is built; during these seven years, due to the efforts of the American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), Society of Neurological Surgeons (SNS), RRC and American Board of Neurological Surgeons (ABNS), the trainee should meet the requirements of the Matrix curriculum, defined by achievement of milestones in the core competencies. This curriculum allows for imparting both medical and procedural knowledge in subspecialty and general neurosurgical areas. Post-graduate subspecialty training can be undertaken by those seeking additional experience in a given area. Although, historically, post-graduate fellowships were undertaken by those wishing to pursue an academic appointment, that is no longer the case.

In the U.S. today, there is a need for both general and subspecialist neurosurgeons. While both groups should be capable of delivering emergent and elective care of the neurosurgical patient, the subspecialist’s mission should include advancement of the subspecialty and the field overall. Only by aligning his or her practice, clinical interests and research focus, can the neurosurgeon hope to advance “the special field of neurosurgery.”

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