Developing the Mind of the Neurosurgery Resident
The period of residency training represents a critical time in the development of a competent clinician. The typical medical school curriculum, while well designed to provide the foundation upon which medical knowledge, technical skills and professionalism are developed, does not typically allow for independent decision-making. Similarly, residents must acquire independent skills over time with graded responsibility and oversight by faculty members who are ultimately responsible for their patients’ outcomes.
ACGME Changes the Game
Over the past several years, there have been significant changes in the ACGME program requirements for neurosurgery resident training. These include restrictions on the number of hours residents can be on duty in clinical situations, standardization of training time to seven years, development of core competencies and institution of Milestone evaluations and reporting. While each was developed with good intentions, they also create new challenges for the faculty members responsible for graduating residents who are competent and prepared for the life-long learning required to maintain excellence over an entire career. In addition, they have added significant administrative burden to faculty members and, most especially, to the residency program director who must manage these issues.
Faculty Mentoring is Key
Medical students choose a particular specialty for a number of reasons. One of the most important is the example set by faculty members during the early years of training. It is not possible to overestimate the importance of faculty members as role models and mentors during these formative years. There is ample evidence that practice habits, for better or worse, develop during residency. Similarly, mentoring programs seem to result in better measurable outcomes. Given the challenges of practicing neurosurgery in an increasingly regulated environment, it is critical that faculty members remain mindful of their responsibility to provide the best examples and be available for guidance.
Psychology of Neurosurgery
There is increased awareness of the psychological impact of practicing medicine. In neurosurgery, where patient outcomes can range from near-miraculous cures to heartbreaking tragedy, there is great risk of developing deep-seated harm. Burnout is an important area of concern in training and beyond. Although neurosurgeons seem to be somewhat less subject to burnout than their peers, there is ample evidence of the impact of stress on neurosurgeons. Lack of control of the environment, sleep deprivation and poor patient outcomes are especially true for neurosurgery residents.
Counter-balancing factors of autonomy, mastery of skills and a sense of belonging to a valued community can all be developed during residency and should be emphasized by program leaders. We are tasked with giving residents progressive levels of responsibility while providing sufficient oversight to protect patients. The mastery of knowledge and technical skills requires years of study and practice and is bolstered by developing a sense of community, including memberships in professional organizations.
Transition to Practice Challenging
The transition from residency to independent practice represents another challenge in the development of an individual. Regulatory oversight of faculty members makes it difficult to allow residents to completely “own” their patients. Similarly, up to this time in their lives, residents have had a structured environment in which they moved from one level of training to another. These go back to high school with a series of standardized tests, application forms and a well-organized residency matching program. Chief residents face the daunting task of finding their first “real job” without a formal process to guide them. In addition, they often have partners and possibly children to consider. The ability of faculty members to provide advice and mentorship during this time is possibly more important than anything they have provided previously.
In summary, there are many aspects to developing the minds of residents. The transition from a relatively passive participant in patient care to one where the individual is completely responsible for decisions and outcomes is perhaps the most important part of training. By setting examples as role models and developing mentoring relationships, faculty members are essential participants in this process. Residents most often learn from what we do rather than what we say. Being mindful of this is essential in creating the next generation of neurosurgeons.
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