A Look Back and a Look Forward
My world of neurosurgery stretches nearly 45 years, having started my neurosurgical training in 1977. It is spectacular to think about the progress made in successfully treating so many conditions that were inoperable back in the 1970s. While huge medical advances have occurred in many disciplines through vigorous basic science research, in neurosurgery, much of the progress has come from investments in new technologies, often in partnership with industry partners. Let’s focus on three specific arenas that I have had intimate experience with over many decades:
- Training for independent practice in neurosurgery;
- The practice itself; and
- Administrative burdens.
Training: Change and Progress Realized
Environment of Inquiry
From my earliest days in neurosurgery, it was clear that surgical training, as opposed to medical training, was truly a team sport. When one resident becomes troubled by either illness, divorce or injury, the rest of the team comes in to pick up the slack and help the troubled individual. When a residency program is mature, this process happens seamlessly, often without the faculty even becoming aware of the problem. The ACGME was formed in 1981 and replaced the prior accreditation agency, the Liaison Committee for Graduate Medical Education (LCGME). While the early relationship between the ACGME and neurosurgery was somewhat tense and adversarial, over the years, it has clearly evolved into a very productive relationship. During my years on the Residency Review Committee (RRC) and my years as chair, the focus of the ACGME has been on assuring that the public interest is best served by setting high standards for training programs and sponsoring institutions. The critical question is:
“Can the educational standards set by the American Board of Medical Specialties (ABMS) be transmitted in the sponsoring institution and its participating training programs?”
I have observed that the transformation between a good program and a great program is very simple:
“Has the program produced an environment of inquiry?”
It should not just be tolerable for residents to challenge the status quo, it should be mandated that they challenge by asking questions, doing research and putting together projects to answer important clinical questions.
Duty Hour Changes and Case Minimums
Following the Libby Zion legislation in New York, duty hour standards were mandated that limit residents to 80 hours per week. Initially, that idea was viewed as not survivable, but in fact, we have survived it very well. One can question whether the concept of patient ownership has slipped a bit from our earlier years as a specialty, but certainly our resident graduates are very well trained. The ACGME has worked steadily toward a competency, not time-based, training by establishing the milestones 1.0 and 2.0 and also for procedural specialties setting “case minimums” that should be performed as either a senior or lead surgeon prior to graduation.
The single accreditation system is now upon us and our osteopathic partners will cease residency accreditation in July 2020. Many people envisioned that a Flexner-like effect would occur within the osteopathic community; fortunately, that has not occurred. During my tenure as RRC chair, evaluation of osteopathic neurosurgical programs suggested only two or three of 14 could achieve accreditation. But, in fact, seven of the eight neurosurgical AOA-accredited programs are in either continued pre-accreditation or initial ACGME accreditation. Completion of this transition over the next year will put us in a better place. We should all expect that a physician arriving in an emergency department to treat a family member has successfully completed a very high standard of training.
We have historically had two different educational standards. No more! Last summer, the ACGME Board of Directors unanimously approved a recommendation by Dr. Kristy Rialon to mandate paid parental leave for parents in GME programs. The rationale for this recommendation and approval was the fact that pregnancy complications are higher in women who are serving in GME programs. After the Board approved her recommendation, partner organizations, including the ABMS, unanimously approved it as well. This puts us on a journey towards competency, not time-based, training.
Many of the most common neurosurgical interventions flourished only after I completed my neurosurgical training. The whole concept of advanced spinal instrumentation had yet to emerge, which clearly revolutionized the surgery of the spine. In the 1990s, the endovascular revolution occurred; while this has not always been a smooth ride, it certainly has resulted in many more patients being able to be safely treated than was the case before the 1990s. Radiosurgery came into the mainstream and has expanded the number of patients that can be successfully managed without an incision on their body. More recently, the exploding worlds of artificial intelligence, machine learning, virtual reality, augmented reality and advanced simulation models have come into existence in ways never imagined.
Neurosurgery has rapidly adapted these new disruptive technologies; I believe that access to big data using these tools allows us to become much better at determining which treatments should be offered and what patients should be treated. We will learn more about outcomes with this new technology than prospective random clinical trials have ever demonstrated, in spite of their huge financial cost. To accomplish this goal, it is necessary to create big data, not through electronic records, but through registries. Every practicing neurosurgeon will be a participant in that new reality.
Hospital and university systems have added massive numbers of new non-clinical positions. Many of these are named in such a way that I have really no idea what that individual actually does. While electronic records, such as EPIC, have made certain things a bit easier (access to imaging and results), it has added layers of burden to the practicing physicians in every specialty. Just cleaning up your EPIC inbox after a busy clinic day can take hours to accomplish. From a broader perspective, EPIC has failed in many ways. There is little to no interoperability. On the campus where I sit today, I see three hospitals with three separate EPICs that do not talk (or even like each other). It is clear that we do not have an interoperable electronic medical record, but we do have an expensive and burdensome billing device. Maintenance of certification and compliance with all state legislation and hospital policy occupies entirely too much time for busy practitioners.
I would summarize my perspective at this point with several bullet points:
- Knowledge demands for future neurosurgeons will increase
- Technical demands of future neurosurgeons will continue to change
- Open surgical experience in many areas will be
- Complexity of open cases will increase
- AI, augmented reality, advanced simulation and machine learning will improve training and the conclusions drawn from clinical practice, leading to better decision making.
- Our best days are ahead!
My world of neurosurgery is more than forty years and counting. The changes are many, but I remain optimistic.
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