AANS Neurosurgeon | Volume 29, Number 1, 2020


Traversing the Paradox of Residency Training

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Paradox: one (such as a person, situation or action) having seemingly contradictory qualities or phases.

Residency training programs are filled with paradoxes that often drive concerns and conflict between trainees and faculty or obscure the true goals of residency. Paradox creates tension between opposing ideas. Finding the balance between the two poles requires continual search and adjustment. The tension driven by these paradoxes is inherent to the system, and to remove the tension would mean altering many of the fundamental characteristics of residency. Changes can often drive new tensions in other areas.

Service vs. Education

This tension is perhaps primary to all residency programs. Residents engage in professional training that is in large part experiential, and experience is not always fun. The ideal balance of residency training that is truly educational versus service-oriented is highly subjective. Residency training programs have created choices, described by some as a false dichotomy.3,4 Identifying a sustainable balance is important and should include remaining mindful of the three main constituents of residency training:

1. Residents

2. Current patients

3. Future patients

In many ways, the reaction that created the 80-hour workweek is part of the tension created by this paradox, and as society changes, the balance of forces changes.

This struggle is not new. Thirty years ago, Charles Bosk addressed neurosurgery:

… with regard to medical care we seem to locate the problems of quality control in the individuals who deliver care rather than in the social system under which the care is given. We rarely ask how competence can be improved by alternative structural conditions.1

It seemed clear to Bosk at the time, and seems prescient today, that sustainable systems are part of the balance.

Supervision vs. Autonomy

Supervision of residents’ work is one of the core roles of faculty and fulfills the commitment to one of the three core constituents of residency training programs – current patients. However:

excessive supervision may lead to unintended harm to patients in the future by limiting the amount of independent decision-making necessary to build confidence and consolidate learning into practice violating our commitment to another core constituent: future patients.2

Here lies another paradox, to train residents now (with current patients) in preparation for patients of the future. We see this tension in the evolution of the Neurosurgery Milestones. We now assess information gathering and critical thinking, which will be skills and principles that serve a career, rather than the specific knowledge points that may grow obsolete over time.

Innovation vs. Tradition

Having spent the past decade at the University of Minnesota, I have learned much of the local lore about this program. Every so often, these discussions turn to what we call the Minnesota Way. It reflects an era in training where one’s training was often evident from how he or she practiced. The tradition reflected in our training is strong. However, we also live in an era where the science of practice grows more robust every day. These changes come from innovation in how we think about old problems. Much of this knowledge is passed on through processes, such as morbidity and mortality conference, where we try not to make the same mistakes repeatedly. However, this paradox represents the growth of a neurosurgeon over a career, from initially asking ‘how do I do this?’ to ‘how do I do this better?’ It is impossible to get to the second question without traversing the first.

Instead of looking at paradoxes as problems to be solved, we should embrace them as ways to blend or balance the often conflicting values inherent in training residents. Residents work to learn how to be a neurosurgeon. We must balance current and future needs as we walk through this process of becoming a neurosurgeon. Understanding our past is key to making the future better.



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1. Bosk, C. (1989). What are the determinants of a competent neurosurgeon? Clinical Neurosurgery, 35, 474–486.

2. Dine, C. J., & Myers, J. S. (2012). Balancing Supervision and Autonomy: An Ongoing Tension | AHRQ Patient Safety Network, (February 2012), 1–6. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/116

3. Kesselheim, J. C., & Cassel, C. K. (2013). Service: An Essential Component of Graduate Medical Education. New England Journal of Medicine, 368(6), 500–501. https://doi.org/10.1056/nejmp1214850

4. Stoff, B. K., Mackelfresh, J. B., & Stoddard, H. A. (2017). Education Versus Service in Residency : A False Dichotomy. Journal of Graduate Medical Education, (June), 395–396. https://doi.org/dx.doi.org/10.4300/JGME-D-16-00836.1


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