AANS Neurosurgeon | Volume 26, Number 2, 2017

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Projecting the Present Into the Future: Evolution of Neurosurgical Education

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 “The principal means of projecting the present into the future is by training those who will follow.”

                                                                        -William J. German, MD
                                                             AANS Presidential Address, 1953 (1)

The 1953 AANS Presidential Address in Hollywood, Fla., by Dr. German, outlined that the evolution of neurosurgery was rooted in recognition of its past and the debt that its practitioners owed to its future. The future, as he defined it, was dependent on the proper education. American neurosurgical education including residency training has been shaped by four factors:

The Establishment of Organized Neurosurgical Societies
Since neurological surgery was recognized in 1919 as a distinct surgical specialty (3), multiple organizations were spurred to promote the discipline and provide professional education. The Society of Neurological Surgeons (SNS) was established in Boston, in 1920, with an educational role defined in its nascence through its original Purposes of the Society. These included ‘education of the medical profession’ and the ‘idea that neurological surgery requires a special training in addition to that of the general surgeon (1).’ A 1996 SNS update of the statement of purpose would again emphasize the goal of ‘continuing development of the field of neurological surgery including graduate and post-graduate education (4).’

A decade later, the Harvey Cushing Society was formed out of concern over the restrictive membership of the SNS (1). Ultimately, the Cushing Society was renamed the American Association of Neurological Surgeons (AANS) in 1967 and would continue to play a key educational role in organized neurosurgery (3). The Congress of Neurological Surgeons (CNS), created in 1951, was formed under different ideals than the Cushing Society, but with a similarly strong commitment to education. The Harvey Cushing Society disseminated its scientific developments during the annual spring meeting and in its publication, the Journal of Neurosurgery (JNS) (3). A more didactic format for its educational brand was adopted by the CNS. Although the CNS would follow the example of the Cushing Society by inviting leaders in the field to discuss their work at its annual fall meeting, it would also encourage a more inclusive society, encouraging the participation of its younger members and resident physicians. 

Ultimately, most of the many other neurosurgical organizations, including subspecialty groups, have fervently embraced education and training. Ongoing professional education is a critical component of neurosurgical practice that complements and supplements resident training.

The Formulation of Formal Residency Training System
In the early 1900s, most neurosurgeons were trained by completing a general surgery program with an emphasis on the nervous system. When Harvey Cushing completed his surgical residency under chief of surgery William Halsted at Johns Hopkins Hospital, it was common for Halsted to suggest special research interests to the house officers. He typically divided the areas of surgery among his assistant residents with the expectation that they would be innovative practitioners of their respective small surgical subspecialty (5). As Halsted’s neurosurgical delegate, Cushing traveled abroad, spending a year with Victor Horsley, Theodor Kocher and Charles Herrington. This method of using observerships to learn the subspecialty was the model for neurosurgical training at the time. In fact, it was Ernest Sachs, nearly a decade later, who is believed to be the first American specifically trained to be a neurosurgeon (6).

With its recognition by the American College of Surgeons (ACS) in 1919 and the creation of the SNS one year later to promote education, neurosurgical training quickly evolved in 15 centers in the U.S.in 1920 (1).  Later that decade, the American Medical Association (AMA) created a program to approve postgraduate medical education in the U.S. (7). The first entry in the AMA directory for a neurosurgical training program was made in September 1933: “Medical College of Virginia…Richmond, offering one position under the supervision of Claude C. Coleman, a contemporary of Harvey Cushing and one of the founders of the SNS. (7)” Although notable for its being the initial offering for formal neurosurgical training under the auspices of the AMA, this announcement for the Richmond position also emphasized the significance of both Harvey Cushing and the SNS in the subspecialty’s educational origin. By 1934, six programs offered nine positions in the directory, even though the AMA would not recognize neurosurgery as an established surgical specialty until three years later (3,7).

In 1940, ‘fellowships’ were added as an additional training designation, and the number of residency programs would swell to 194 listings by 1965 (7). To better accommodate applicants for neurosurgical training, the first national matching program for residency positions was established in 1983. That year, a total of 276 applicants submitted rank lists for 132 positions. All of the positions were filled, with the average applicant ranking seven programs with 57 percent of applicants being unsuccessful in obtaining a position (7). Comparable 2017 National Resident Matching Program (NRMP) data reveals 107 neurosurgical residency training programs with 218 total positions available. There were 311 total applicants, and all programs were filled. On average, 12.5 programs were ranked per applicant, and 30 percent of applicants went ‘unmatched (8).’

The Regulation of Neurosurgical Training
Quickly after the publication of the AMA training position, it became clear that regulation of such programs would be necessary. In June 1938, the organization of a certifying board in neurological surgery was approved, and the American Board of Neurological Surgery (ABNS) was activated two years later. Among the primary objectives of the ABNS were to accredit training programs and develop a procedure for examining and certifying neurosurgeons (1). Additionally, by 1945, the ABNS assumed a role in approving residency training programs.

When the number of residency training programs peaked to 194 in 1965, over a quarter of these were not affiliated with a medical school and largely consisted of a personal preceptorship with a director. The need for adequate control of postgraduate neurosurgical education led to the formation of a Residency Review Committee (RRC) tasked as the approving body for residency training programs in the U.S. (the ABNS maintained its responsibility for the certification of residents) (9). Closer regulation resulted in only 94 programs with 130 residency positions by 1983. At the time, however, residents were accepted to programs by individual program directors, sometimes years in advance for outstanding candidates. This led to the SNS establishing the National Neurological Surgery Matching Program (NSMP) as a binding process intended to be fair for both applicants and programs.

With the ABNS, RRC and NSMP, neurosurgical training was influenced and shaped by neurosurgeons, largely removing it from the strong general surgery presence that existed previously. This trend continued when the Accreditation Council of Graduate Medical Education (ACGME) incorporated the first postgraduate (PGY1) year into all U.S. neurosurgery residency programs in July 2009 (10). This has permitted academic neurosurgery full oversight of the entire residency training period. 

Progression From Apprenticeship Model to Active/Intentional Learning
The ‘Halstedian’ model of surgical training was based largely on apprenticeships, relying on large surgical volumes, a wide variety of cases and pathology and demanded extended time within the hospital (11). This time-intensive method created an education that was largely circumstantial and thus idiosyncratic. This was the model for much of the 20th century when it became evident that it was no longer a sustainable system.

The origins of more structured postgraduate medical training are found in the introduction of defined educational goals and curriculums. In 1999, the ACGME released their six basic resident competencies, establishing a framework for the principles around which residents should be taught. Established goals and more structured training systems became even more necessary with the institution of resident duty hour restrictions (DHR) in 2003 (12). Attempting to eliminate the technical errors potentially associated with resident fatigue, these limitations effectively made the apprenticeship model of education impractical.  Residents could no longer spend unlimited time in the hospital, as the restricted work hours reduced time for patient exposure and operative experience.

The ACGME work hour restrictions have been poorly received, especially in the highly technical and labor-intensive field of neurosurgery. As the DHR was intended to “ensure proper [resident] education” while improving patient safety, some have noted the decrease in resident academic productivity and unchanged patient morbidity and mortality statistics as a failure of these goals (12). Definite benefits of the DHR to resident education have been noted, including enhanced team communication, improved supervision and teaching responsibilities by academic faculty and an emphasis on a culture of patient safety (12).

Indisputable is that DHR impacted the evolution of neurosurgical resident education by forcing an examination of the educational value of nearly every aspect of resident training. It was clear that as a low-cost component of health care delivery, residents were often utilized strictly as a member of the work force, performing menial but necessary patient care tasks.  Much of this was not contributing to education (4).

In response to the DHR, neurosurgical residency has been forced from an experience-based model to an outcome/proficiency-based one (11). In 2013, the Neurological Surgery Milestones were established, involving 24 domains in eight sub-specialties and the general competencies previously set forth by the ACGME (11). These milestones were based on competency rather than time and the number of cases ‘logged.’ To achieve the desired levels of competency, residency training is now heavily dependent on training adjuncts, e.g., simulators, cadaveric dissections, microsurgical laboratories and ‘purposeful skills practice outside the operating room (11).’

Currently, organized neurosurgery should be recognized for enthusiastically answering the charge to evolve and design a new neurosurgical residency training program for the future. Mechanisms have evolved with a more scientifically based, educationally dense and demanding, efficiently delivered system (13). One highly successful such project is the SNS regional ‘boot camp’ courses for incoming residents along with the web-based education modules of the ‘CNS University of Neurosurgery.’ Didactic lectures alone, however, will never replace the operative experience and guidance by a seasoned surgeon, and the current system must continue to incorporate both aspects to optimize surgical training (10).”
 
“Great education empowers, focuses, and enriches, but never replaces, personal mentorship (10).”
 
The best method by which to “project the present into the future,” as suggested by Dr. German in 1953, is to acknowledge and embrace our past, while continually working to improve upon it (1).

References
1. German, W. J. (1953). Neurological surgery: its past, present and future. Journal of neurosurgery, 10(5), 526-537.

2. “People, places and publications in AANS History.” (2007). History of the American Association of Neurological Surgeons. Donning Company Publishers

3. Hauber, C. H. & Phillips, C. A. (1995). The evolution of organized neurological surgery in the United States. Neurosurgery,  36(4), 814-826.

4. Popp, A. J. (2008). Navigating the Strait of Magellan: mapping a new paradigm for neurosurgical residency training. Journal of neurosurgery, 109, 576-582.

5. Smith, D. C. (1997). The Evolution of modern surgery: a brief overview. Greenblatt SH (E). A History of Neurosurgery. The American Association of Neurological Surgeons. Park Ridge, 11-26.

6. Keller TM. California’s Cushing connection: Harvey Cushing trained California’s first neurosurgeons. J Neurosurg 97: 728-35, 2002

7. Pevehouse BC. Residency training in neurological surgery, 1934-1984: evolution over 50 years of trial and tribulation. J Neurosurg 61: 999-10004, 1984

8. Results and Data: 2017 Main Residency Match, April 2017. (http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf. Accessed: May 13, 2017

9. Clark, W. K. ( 1979). Residency Review Committee for Neurological Surgery. Neurosurgery, 5(1 Pt 2), 86-7.

10. Selden, N. R. (2017). Mentorship: service, education, progress. The 2015 CNS presidential address. Journal of neurosurgery, 126, 158-164.

11. Chowdry, S. A., & Spetzler, R.F. (2014). Genealogy of training in vascular neurosurgery. Neurosurgery, 74, S198-S203.

12. Bina, R. W., Lemole Jr, G. M., & Dumont, T.M. (2016). On resident duty hour restrictions and neurosurgical training: review of the literature. Journal of  neurosurgery, 124(3), 842-848.

13. AANS Neurosurgeon. The post-2003 neurosurgical resident: assessment of quality in the era of work-hour limitations, December 2014. http://v1archives.aansneurosurgeon.org/departments/the-post-2003-neurosurgical-resident-assessment-of-quality-in-the-era-of-work-hour-limitations/.  Accessed: May 10, 2017

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