Building the Neurosurgical Mind: Critical Appraisal in Neurosurgical Training
The primary goals of neurosurgical training are focused on specialty knowledge acquisition, development of technical skills involving eye-hand coordination, learning how to collect important patient data and enhancement of critical thinking ability. Both residents and attending neurosurgeons place the highest value on execution of patient care modalities as the cornerstone of development of fine neurosurgical practitioners. Aside from the technical abilities that programs set out to instill in their trainees through the apprenticeship portion of the training, there is the academic development that varies from program to program. The basic knowledge that underlies clinical decision making is necessary, not only for understanding patient and practice variability, but is also essential for passing the American Board of Neurological Surgery examinations – a point at which training programs are evaluated for their effectiveness. In addition, many trainees set out to find places within academic training programs for post-residency fellowships and, ultimately, as academic attendings. To contribute to the medical literature of the future, it is necessary to learn study methodology in the present and develop the ability to critically appraise the medical literature so as to measure its usefulness.
All of the academic goals are potentially facilitated by instruction in clinical research methodology and critical appraisal directed at the published – and presented – medical literature. Aside from reading to stay abreast of the evolution and practice of the specialty, an education in the best methods helps to develop a new kind of critical thinking for the resident (and for any attending who undertakes the process). In this scenario, carefully looking at the structure of research with conclusions that try to promote changes in practice helps the learner add skills in evaluation of the data and to be able to decide, factually, whether the ideas promulgated are worthy of inclusion in one’s clinical practice – or, more importantly, not.
Critical appraisal techniques that focus on dissecting research structures may further be utilized to evaluate one’s own data for developing personal critical pathways as a physician and surgeon. As residents struggle to learn these new approaches, they may not see the inherent or appropriate value in practice. However, the longer they use the critical techniques, the more facilitative the procedures become and the more adept residents become at their utilization. They initiate questions regarding the population studied and its similarities – or lack thereof – to their own target patient population, thus defining practical utility.
Examples of information that residents can be led to look for in their critical appraisal exercises and subsequent learning experiences include:
- Study inclusion of specific patient population details (to allow for appropriate application to their patient or patients);
- Interventions that can be duplicated in their own practice with the same diagnostic and treatment opportunities;
- Careful attention to details regarding potential alternative hypotheses to explain the results; and
- Currency of the science upon which the study rests.
While most understand that those who are heading into academic neurosurgery need to have these abilities and pass them on to mentees, there may be an even greater need for those heading into a non-academic milieu to have these abilities. Why would that be true? One of the most attractive parts of academic practice is the challenge that residents bring to us with their intelligence and intense (hopefully confident) inquiries. They bring us questions that we may not have the answers to as our specialty progresses, and we must find the answers – usually via resident academic productivity and critical appraisal of the specialty’s literature with our support and tutelage. However, our colleagues who chose private practice do not have this same opportunity on a regular basis through trainees. Without continual attendance at national or international meetings and continued reading of current literature, they may fall behind in their abilities to properly evaluate the latest research. However, if they have been taught in residency to properly evaluate the literature or information presented at meetings or through seminars, then they will sustain lifelong learning and remain up-to-date practicing neurosurgeons.
This basic concept of careful understanding of the successes and failures of clinical research in our specialty and development of the ability to utilize these data in the treatment of our patients became known at the end of the twentieth century as evidence-based medicine. A complete comprehension of the important role this plays in applied clinical science is central to the practice of modern neurosurgery and essential for the best-trained – academic or nonacademic – neurosurgeon. In no way are we allowed to adhere to the belief that ignorance is bliss.
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