Recognizing the Need for Improved Post-Residency Training Programs

Specialization of labor and skills has been part of human culture throughout history. Acquisition of new ideas and concepts has led to an ever expanding knowledge base which, in turn, leads to the compartmentalization of much of that knowledge. An example of that process occurred in general surgery in the early 20^th century, when neurological surgery established itself as a unique and separate entity. The very process that created neurosurgery continues to affect our surgical specialty today. As research and clinical investigations continue to evolve, so too has the need to subspecialize.

This evolutionary concept has been corroborated by a recent survey of 141 neurosurgeons who have finished residency training during the last five years. Survey results (84.3 percent response rate) indicated that, during the past five years, between 24 and 28 percent of respondents had pursued post residency training in the form of a formal fellowship.

Currently, there are 126 U.S. and 12 Canadian programs offering fellowships in 10 different areas (Table 1). Spinal surgery is the most common fellowship offered with 27 established programs in the U.S. Others include cerebrovascular, pediatrics, trauma/critical care, and most recently, endovascular neurosurgery.

Variance in Neurosurgical Fellowship Programs

Although the first formal fellowships were established in the late 1960s and early 1970s, there has not been any formal mechanism established by organized neurosurgery to standardize length of training, quality of training or the ultimate goals of these fellowships.

According to the survey, neurosurgical fellowships vary in length from two months to 24 months, with the majority being approximately 12 months in length, thereby demonstrating the wide variance between programs.

This lack of standardization also is evidenced by the significant variance in the total number of cases performed per year by the fellows in the different subspecialties. Respondents indicated that the total number of cases done per year by specialty ranged between 150 for oncology, to as much as 10,371 for pediatrics and 9,585 for spine. More importantly, the median number of yearly cases performed by each fellow also varies significantly, with as little as 18 cases for peripheral nerve fellows to as high as 550 for spine, and from 313 cases for endovascular fellows to 300 cases for pediatric fellows.

Impact of Fellowships

In order to ascertain the impact of doing a fellowship on the current practice of the surveyed neurosurgeons, they were asked what percentage of their practice comprised their area of post residency training. Interestingly, spine and pediatrics are the two areas that made up the majority of the neurosurgeons’ practices.

This appears to indicate that, currently, there is room for continued growth in these fields. In contrast, epilepsy and peripheral nerve accounted for the least percentage of their practices (Table 2). Another finding was that, of the fellows surveyed, 74.8 percent were not in favor of subspecialty board certification, but 73 percent did favor the concept of establishing a subspecialty certificate of added qualifications (CAQ).

A resolution was passed at a recent meeting of the Council of State Neurosurgical Societies, which called for the creation of an AANS/CNS Task Force to address the issue of fellowships in the United States. The recommendations of the Task Force were presented in a recent Bulletin article (Spring 1998, pages 10-11). Among the Task Force recommendations, was a request for the development of standards for fellowships by the individual Sections. This process is currently taking place.

Whether one agrees with fellowship training in neurosurgery or not, the reality is that post-residency training programs exist and significantly impact our specialty. We have much more to gain by recognizing them,, standardizing their curricula and providing appropriate quality assurance for this very important aspect of neurosurgical training. Fortunately, this process has begun.

David F. Jimenez, MD, FACS, is Associate Professor of Neurosurgery at the University of Missouri School of Medicine. An eight-year AANS member, Dr. Jimenez is Chairman of the AANS Young Neurosurgeons Committee and a member of the AANS/CNS Task Force on Fellowships.

David F. Jimenez, MD, FACS, is Associate Professor of Neurosurgery at the University of Missouri School of Medicine. An eight-year AANS member, Dr. Jimenez is Chairman of the AANS Young Neurosurgeons Committee and a member of the AANS/CNS Task Force on Fellowships. ]]>