AANS Neurosurgeon | Volume 28, Number 4, 2019


Graduated Responsibility: The Role of Feedback and the Influence of Concurrent Surgery on Neurosurgical Resident Training

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“To those currently awaiting their services, neurosurgeons owe efficiency in the use of limited resources, including their time. They must also train the next generation of neurosurgeons how to provide excellent care for future patients.”

-Position statement on the “Intraoperative Responsibility of the Primary Neurosurgeon” released jointly by the American Association of Neurological Surgeons (AANS), American Board of Neurological Surgeons (ABNS), Congress of Neurological Surgeons (CNS) and the Society of Neurological Surgeons (SNS) in 2016.

Many issues regarding patient safety and care arise from the performance of concurrent surgery. When neurosurgeons are responsible for multiple procedures, it clearly creates concerns as to whether sufficient supervision can be given to each operation. Often, a portion of the procedure may be delegated to a neurosurgical resident or other trainee. The absolute educational benefit to the surgeon-in-training of such an opportunity is unclear. There are two overriding principles regarding the value of resident education to be considered in this situation: graduated responsibility and the role of feedback.

Graduated Responsibility
The principle of graduated responsibility, defined as the progressive accumulation of skill by neurosurgical residents that allows for the granting of greater involvement and independence by senior surgeons, forms much of the groundwork for surgical residency training. However, this tenet is heavily dependent on sufficient case volume and resident operative experience. The latter can be supplemented by the performance of simultaneous procedures that allow residents greater exposure to an increased number of cases and a wider breadth of pathology. Accompanying such exposure is a greater opportunity for escalating autonomy and, as a result, an overall benefit to surgical education.

However, permitting greater levels of operative responsibility to neurosurgical trainees can only occur when an assessment is made that current performance is worthy of such advancement. Although that assessment can be made based on a post hoc review of trainees operative results, it is likely to be better applied following direct observation. The question can be raised as to whether graduated responsibility can be appropriately granted when only the outcome is evaluated rather than the process utilized to achieve that outcome.

Finally, as patient safety is the primary concern surrounding the performance of overlapping surgery, it is imperative that a system is available for when a neurosurgical resident, working independently without the supervising surgeon in the operating room, requires immediate assistance. It has to be readily apparent to the trainee to whom the “non-critical” portion of the procedure has been delegated that immediate assistance is available and there should be no hesitancy in requesting it. This may be difficult for some residents, and even some attending surgeons, who might view such requests as a sign of weakness or even a hindrance that may limit the resident’s level of independence in the future. These attitudes cannot be allowed to permeate a surgical culture in which concurrent surgery occurs. When concurrent surgery is the norm, assistance must be freely asked for and readily given – without repercussion – by the attending or back-up surgeon.

Role of Feedback
The advancement and progression of trainees in all fields, including neurosurgical residency, is heavily dependent on detailed and timely feedback of their performance. This allows for the development of proper and efficient work habits and the elimination of ones that are detrimental. Feedback to neurosurgical residents can be provided in many forms both in and out of the operating room.

Feedback can be either intrinsic or extrinsic. Concurrent surgery and the ability to work independently provide ample opportunities for intrinsic feedback to residents in the form of self-assessment. Perhaps of equal, or even greater, importance in surgical training is the extrinsic feedback from an external source, namely a senior, experienced surgeon. Although simulation and didactic teaching are rapidly replacing the apprenticeship model of neurosurgical training, there is tremendous value in one-on-one instruction in the operating room.

The most effective and helpful feedback is based on observable behaviors. (2)  Timely, real-time critiques of residents surgical decisions and technique are critical to improving their knowledge base as well as acquiring and developing proper surgical skills. This is difficult, and may even be nearly impossible, for neurosurgical faculty to do adequately from another operating room. Without proper feedback, a resident’s good performance cannot be reinforced and mistakes may persist uncorrected (1).

Much of the controversy surrounding concurrent surgery involves patient safety, but another significant concern is that of its impact on resident education. Arguments can be made both in favor (e.g. increased independence for the resident) and against (e.g. lack of supervision and opportunities for timely feedback) its value to neurosurgical training. To ensure the safety of all patients, a well-defined system must be enacted to guarantee that there is educational value to residents rather than their being used to simply fill the work gap.

Lastly, care should be taken with the terminology used to define the practice of concurrent surgery. The definition of ‘critical’ portions of surgical procedures suggests that there are ‘non-critical’ aspects as well. It is with the latter that residents are typically entrusted. This may ingrain an improper lesson that the surgical details (e.g. positioning, exposure, closure) are not vital to a procedure. Instead, neurosurgical trainees should quickly learn that no matter how well the aneurysm is secured or the tumor resected, if the wound falls apart, that is a very unsatisfactory outcome. 

1. Ahmed, N., Devitt, K. S., Keshet, I., Spicer, J., Imrie, K., Feldman, L., … & Kulkarni, A. V. (2014). A systematice review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Annals of surgery, 259(6), 1041-1053.

2. Dennis, B. M., Long, E. L., Zamperini, K. M., & Nakayama, D. K. (2013). The effect of the 16-hour intern workday restriction on surgical residents’ in-hospital activities. Journal of surgical education, 70(6), 800-805.

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Dave Anderson | September 21, 2018 at 5:29 pm

I think that it is awesome how greater levels of surgery and responsibility can be given to neurosurgical trainees when an assessment is made that they can do it. I wouldn’t want a trainee having sole responsibility of me if they were not worthy of it. I know that would scare me, but it would also scare my wife. I am glad that neurosurgeons are trained very cautiously!