In this issue of the AANS Bulletin, our featured subject explores the ramifications of subspecialty certification in neurosurgery. While the subject of this review may appear innocuous to the practicing neurosurgeon, aspects of this topic are explosive and evoke great passion in a substantial proportion of the AANS membership. The mere process of certification brings with it differentiation and, hence, an implication about quality of care delivered by two groups of neurosurgical practitioners – those with subspecialty certification and those without.
A Brief History
As our knowledge base grows and as we refine patient care delivery, the trend toward subspecialization seems inevitable. For example, as medicine evolved it became apparent that mastery in surgery required focus on progressively smaller segments of the surgical universe.
Indeed, the specialty of neurosurgery was born out of that evolution driven by a realization that research and patient care for problems of the nervous system were quite different from those in other areas of surgery. From this historical perspective, it would appear that those who wish to subdivide the specialty of neurosurgery by subspecialty certification have legitimate historical support and patient care focus that lend credibility to their argument. Indeed, when one moves from the facts of history to a theoretical plane the argument becomes even more persuasive. Would it not be better, for example, to have all pediatric neurosurgical care rendered by individuals whose sole interest and experience focused on caring for children with neurosurgical disorders? Furthermore, would this concentration on a specialty area not lead to greater advances in the field if most of the experience accrues to a relatively small group of physicians specializing in that area?
Realities of Neurosurgical Practice
Despite the apparent rectitude of this theoretical stance, when one contemplates the realities of neurosurgical practice the propriety of such thinking becomes less certain. While no one doubts the need for referral to specialty centers for certain rare disorders or for some complex operative procedures that are beyond the experience or ability of an individual practitioner, what happens to those patients with less complicated but equally emergent problems who are often distant from the tertiary care centers that offer subspecialty care?
Despite having approximately 4,500 neurosurgical practitioners in the United States, a significant portion of our population is remote from subspecialty care and even the most sophisticated medical centers may have only one or two individuals subspecializing in a particular area of neurosurgery. What happens, then, when the pediatric patient with shunt failure arrives in the emergency room of the tertiary care center on Saturday night and the staff pediatric neurosurgeon is not on call? Generally, care is rendered by a neurosurgical colleague of the pediatric neurosurgeon who is on call that night. Hopefully that individual will have had the proper experience during neurosurgical residency to deliver superb care to that child; I believe that is what occurs most of the time. Yet that same practitioner may be viewed with suspicion by the very family of the child to whom care has been rendered since care was rendered by a “non certified” surgeon.
From my personal perspective, I believe that the move toward subspecialty certification must take into account the realities of neurosurgical practice. Residency training should educate residents to deliver care to the spectrum of patients with surgically treatable problems of the nervous system and when to refer patients requiring care beyond their abilities.
I believe that the ABNS and RRC do an excellent job in assuring that training programs meet these goals and that certification in neurosurgery denotes competence in the entire field. Furthermore, the AANS, as an association that exists for the betterment of its membership, recognizes that continuing education in the form of meetings, publications and CME courses is essential to maintain competency after residency training.
Value of Subspecialization
We owe gratitude to those individuals that have led neurosurgery by specialization. They have advanced our specialty by broadening our scope of practice. Recall the advances in spinal surgery — a field extended and preserved for all neurosurgeons by a few who chose to subspecialize.
We must not rush to judgment about the best approach to answer these questions about subspecialty certification, but we must develop a strategy. As H.L. Mencken wrote, “For every complex problem there is a solution that is simple, neat and wrong”.
Fully airing this complex topic may help the neurosurgical community come closer to consensus. Continuing the debate without a conclusion merely prolongs the life of a fractious dispute at a time when unity in neurosurgery is necessary. Neurosurgery must continue to evolve. Will the process of subcertification facilitate this evolution, enhance our field, and assure excellence? The answers to these questions are critical to the future of our specialty.