Several years ago the Council of State Neurosurgical Societies requested the AANS and CNS to establish a task force to look into the role of specialization within the field of neurological surgery. That task force, under the leadership of Julian Hoff, MD, determined there was interest in evaluating and maintaining quality within specialty fellowships that were promoted within the field of neurological surgery.
Neurosurgery was confronted with a dual challenge. On one hand, specialization would be driven by the market place. On the other hand, those practicing neurosurgeons who did not have specialty training should not be disenfranchised from the practice of neurological surgery.
The official position of the American Board of Neurological Surgery is that residents who are trained in accredited programs have received adequate training to perform all aspects of neurological surgery. Consequently the AANS and the CNS continue to encourage and endorse certification by the ABNS for all neurosurgeons. Currently the ABNS is the only certifying organization that the AANS and CNS endorses.
While the market place is providing the impetus toward sub-specialization, the history of medicine and surgery itself is one of continued specialization. Practitioners in large groups and departments of neurosurgery want specialists. The AANS supports the focused interest of individual neurosurgeons through specialty sections.
Because of this increased need for specialists, the number of fellowships is increasing. Residents, in increasing numbers, believe they need fellowship training. In the 1996 survey of neurosurgery chief residents by David Jimenez, 50 percent believed they had adequate training, 33 percent believed they needed more training and 25 percent planned to have specialty fellowships. Technical advances within neurosurgery have led to the feeling that sub-specialization is needed.
The enhancement of specialization is healthy and our Sections provide the strength for American neurosurgery. Yet we also know that the Sections are one of our biggest challenges. As each Section moves in its own direction, it may leave the parent field of neurosurgery.
The challenge is to maintain the balance of the development of specialties while we maintain a bond with neurosurgery. We all want sub-specialization to bring improved quality for patients and for it to be inclusive for all neurosurgeons. We do not want to face a group of certificate-wielding practitioners as we practice in our own hospitals.
When the CSNS asked for this evaluation of fellowships, there was a concern about the quality of training. The practitioners wanted to ensure that the individuals trained in these fellowships had adequate training. It is our desire to avoid fellowships without scholarship and avoid fellowships that only provide service without adequate training.
The challenge of developing an accredited fellowship is that we must all be certain that it does not interfere with the training of residents. Indeed, the Resident Review Commission (RRC), part of the Accreditation Council for Graduate Medical Education (ACGME), requires that fellowship training not interfere with residency training. It also requires that any fellowship be in an area that represents a new body of knowledge.
Furthermore, if fellowships are to be accredited by the ACGME, they must be approved by other members of the ACGME. That presents a hurdle. As we try to train neurosurgeons to perform endovascular surgery there is concern on the part of radiologists and cardiologists who perform this activity that neurosurgeons are indeed qualified to perform the procedure.
There is a compromise position that will allow neurosurgery to have greater flexibility. That would be for the Society of Neurological Surgery (the “Senior Society”) to take on the role of accrediting fellowships. Dedicated to resident education, the Society would be certain that fellowship training does not interfere with resident educattttion. This process of accreditation has actually been started under the directorship of Richard Winn, MD.
The goal of this mammoth undertaking is to help all of neurosurgery branch into new fields as highly qualified and highly trained surgeons. This accreditation process will be performed without certification. Any certificate that any individual may receive would be issued from the hospital in which the neurosurgeon performed the training.
As the accreditation process matures it will probably develop into an RRC accredited system. Either way it goes, it will help American Neurosurgery develop high quality sub-specialty training programs.
Stewart B. Dunsker, MD, is a practicing neuro-surgeon at The Mayfield Clinic, Professor of Clinical Neurosurgery, Vice Chairman of the Department of Neurosurgery and Director of the Division of Spine Surgery at the University of Cincinnati. Stewart B. Dunsker, MD, is the 2000-2001 AANS President.