AANS Neurosurgeon | Volume 29, Number 2, 2020

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The Evolution of Neurosurgery Education Over Four Decades: My Perspective

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To say the least, neurosurgery education has certainly changed over the past four decades. It has evolved from an on-the-job training scheme, that was often aptly characterized by the phrase “see one, do one, teach one,” to a comprehensive and complex education and quality of education monitoring process. The on-the-job training process was not standardized and, hence, could be safely  characterized as ‘hit or miss.’ This ‘hit or miss’ process gradually gave way to the standardization of training via the program accreditation and re-accreditation processes. The documentation of the quality of education truly gained traction with the initiation and implementation of program information forms that, among other things, broke down the assessment process into 6 domains, termed core competencies. Many other changes ensued, including an ongoing real-time assessment process, as exemplified by the Milestone Project. 

Electronic and digital media have indeed revolutionized the education and documentation process. Four decades ago, information regarding program and resident performance was gathered and stored on paper ‘hard copies.’ The application for residency programs (accreditation) and subsequent re-evaluation (re-accreditation) were presented in the aforementioned hard copy format. An application or re-accreditation would commonly include hundreds of pages of documentation, and altogether be well over an inch thick.  Study guides were sparse. Textbooks were helpful, but often dated.  ‘In the day,’ my recommendation for young neurosurgery trainees started with the book Diagnosis of Stupor and Coma by Plum and Posner and was supplemented with clinical treatment guides.

Four decades ago, we used typewriters to create patient care guides. Changes were difficult to make, and so, were often changed by hand.  These were then copied and distributed to young trainees. One such document is illustrated here (Figure 1 A and B). This represents my checklist, if you will, regarding the management of head injury patients. Although rudimentary, it served a purpose, considering the circumstances.

Today, with the internet, an infinite amount of valuable information is available to the neurosurgery trainee. Hard copy journals and books are becoming dinosaurs and with good reason. The rate of information accumulation is increasing exponentially. Books and printed journals simply cannot compete.

Duty hour modifications, a focus on the mitigation of sleep deprivation, and an increased utilization of advanced practice providers have all altered the landscape regarding neurosurgery resident well-being. Yet, many things have not changed. The resolve of neurosurgeons and neurosurgery residents to succeed in a high stakes environment is no different today from four decades ago. Lifelong learning is perhaps discussed more today than in the past. The emphasis on lifelong learning has not changed as long as I can remember.

Today we take a much ‘kinder and gentler’ approach to neurosurgery education. Empathy, effective, and collegial communication is accentuated more so than in the past. The impact on resident education by restricted duty hours has been offset by an increase in advanced practice provider assistance.  Overall, the provision of an optimal outpatient and inpatient, as well as surgical resident experience has been challenging, to say the least. Nonetheless, I am encouraged by my observations in this regard. It seems to me that organized neurosurgery has very effectively negotiated the resident education abyss by a relentless resistance to radically slash duty hours, and hence, quality of education with an accompanying obligatory decrease in responsibility and ‘patient ownership’ by the residents. In the end, logic prevailed. The  struggle culminated  in the provision of a much improved, if not near optimal, resident clinical experience – while, at the same time creating the aforementioned  ‘kinder and gentler’ enriched environment for learning, patient care and personal growth.

Figures 1 A-B. A two-sided ‘Head Sheet’ functioned as checklist and guide for managing head injury patients. Circa early 1980s.

In the mid-90s, two programs (University of South Florida and University of New Mexico) were campaigning to have their respective neurosurgery programs accredited. David Cahill, the Chair at University of South Florida and myself, as the Chair at the University of New Mexico communicated frequently, comparing notes while attempting to successfully negotiate the neurosurgery educational abyss.  The process of accreditation and re-accreditation have changed as technology and our foundation of knowledge regarding the process of neurosurgery education has changed.

Bottom line, things have changed immensely. 

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