Canadian Neurosurgery Residency Research Articles

A Canadian National Survey of the Neurosurgical Management of Intracranial Abscesses.

Intracerebral abscess is a life-threatening condition for which there are no current, widely accepted neurosurgical management guidelines. The purpose of this study was to investigate Canadian practice patterns for the medical and surgical management of primary, recurrent, and multiple intracerebral abscesses. A self-administered, cross-sectional, electronic survey was distributed to active staff and resident members of the Canadian Neurosurgical Society and Canadian Neurosurgery Research Collaborative. Responses between subgroups were analyzed using the Chi-square test. In total, 101 respondents (57.7%) completed the survey. The majority (60.0%) were staff neurosurgeons working in an academic, adult care setting (80%). We identified a consensus that abscesses >2.5 cm in diameter should be considered for surgical intervention. The majority of respondents were in favor of excising an intracerebral abscess over performing aspiration if located superficially in non-eloquent cortex (60.4%), located in the posterior fossa (65.4%), or causing mass effect leading to herniation (75.3%). The majority of respondents were in favor of reoperation for recurrent abscesses if measuring greater than 2.5 cm, associated with progressive neurological deterioration, the index operation was an aspiration and did not include resection of the abscess capsule, and if the recurrence occurred despite prior surgery combined with maximal antibiotic therapy. There was no consensus on the use of topical intraoperative antibiotics. This survey demonstrated heterogeneity in the medical and surgical management of primary, recurrent, and multiple brain abscesses among Canadian neurosurgery attending staff and residents.

Implementation of competence by design in Canadian neurosurgery residency programs*

Objective The Royal College of Physicians and Surgeons of Canada (RCPSC) recently redesigned the Canadian neurosurgery residency training curriculum by implementing a competency-based model of training known as Competence by Design (CBD) centered around the assessment of Entrustable Professional Activities (EPAs). This sequential explanatory mixed-methods study evaluated potential benefits and pitfalls of CBD in Canadian neurosurgery residency education. Methods Two four-month interval surveys were distributed to all Canadian neurosurgery residents participating in CBD. The surveys assessed important educational components: CBD knowledge of key stakeholders, potential system barriers, and educational/psychological impacts on residents. Paired t-tests were done to assess changes over time. Based on longitudinal survey responses, semi-structured interviews were conducted to investigate in-depth residents’ experience with CBD in neurosurgery. The qualitative analysis followed an explanatory approach, and a thematic analysis was performed. Results Surveys had 82% average response rate (n = 25). Over time, most residents self-reported that they retrospectively understood concepts around CBD intentions (p = 0.02). Perceived benefits included faculty evaluations with more feedback that was clearer and more objective (53% and 51%). Pitfalls included the amount of time needed to navigate through EPAs (90%) and residents forgetting to initiate EPA forms (71%). There was no significant change over time. During interviews, five key themes were found. Potential solutions identified by residents to enhance their experience included learning analytics data availability, mobile app refinement, and dedicated time to integrate EPAs in the workflow. Conclusion This study was the first to assess resident-perceived benefits and pitfalls of the neurosurgery CBD training program in an educational framework context. In general, residents believed that theoretical principles behind CBD were valuable, but that technological ability and having enough time to request EPA assessments were significant barriers to success. Long-term studies are required to determine the definitive outcomes of CBD on residents’ performance and ultimately, on patient care.

Interest and participation in global neurosurgery: a survey of Canadian neurosurgery residents.

The lack of access to primary neurosurgical care presents a significant burden for patients in low- and middle-income countries (LMICs). Efforts to decrease the inequities in access to surgical care have become an increasing focus of initiatives and advocacy within the international neurosurgery community. Although residents may represent highly active members of international teams, the extent of their availability for and interest in global neurosurgery opportunities remains unclear. The objectives of this study were to assess the degree of participation, the level of interest, and the perceived barriers for residents of Canadian neurosurgery programs in engaging in neurosurgery initiatives in LMICs. A cross-sectional survey was administered to 144 residents from all accredited Canadian neurosurgery residency programs. The survey was used to determine the level of participation and interest in global neurosurgery initiatives. The survey response rate from residents at Canadian neurosurgery programs was 45/144 (31%), although not all respondents answered every question; thus, the denominator for each question is not always 45. Most neurosurgery residents (n = 30, 68%) were unaware of any global neurosurgery opportunities available during residency. Despite 64% of residents having an interest in participation (strongly agree/agree; n = 28), with most residents planning on participating as attending staff (strongly agree/agree; n = 28, 64%), only 3 residents (7%) had taken part in LMIC neurosurgery initiatives. The most cited perceived limitations for participation were lack of time (n = 37, 84%) and finances (n = 26, 59%). Among surveyed residents from Canadian neurosurgery programs, there was a low participation rate in global neurosurgery initiatives and limited knowledge of available opportunities, despite relatively high interest. Many respondents identified time and financial constraints as barriers to participation. Many residents felt that interest could increase were there a structured program dedicated to global neurosurgery available in their residency program.

P.106 A pilot-project for neurosurgery competency-based design implementation

Background: In preparation for July 2019 rollout of competency-based design (CBD) in Canadian neurosurgery residency training, the University of Calgary launched a pilot-program of five representative EPAs using the One45 program. Our study objectives were to examine the uptake of CBD with residents and faculty and to quantify CBD implementation barriers. Methods: Phase one of the One45-based CBD pilot-program launched on November 1st, 2018 and ended on January 8th, 2019, after which a questionnaire was sent to each participating resident. The questionnaire examined number of EPAs initiated, measures of favourability, importance, ease of use, and barriers encountered. Results: Results obtained from the survey show 93.8% response rate (15/16 residents). 66.7% of residents feel that CBD is moderately important or higher to their education. Over the 10 study weeks, there were only 8 completed EPAs (expected was 50), five of which were completed by a single resident. Major expressed barriers of implementation of CBD were time involved (50.0%) and technical unfamiliarity with the platform itself (50.0%). Conclusions: This study demonstrates the critical importance of piloting a CBD program prior to official implementation as immediate buy-in was significantly slower than anticipated. Technical and time barriers exist which need to be rectified in advance of July 2019.

Mobile Applications in Neurosurgery: A Systematic Review, Quality Audit, and Survey of Canadian Neurosurgery Residents

In the past decade, smartphone applications (Apps) have experienced remarkable development across all fields of medicine, including neurosurgery. However, owing to a lack of regulatory oversight and peer review, a clear need exists for a comprehensive review and audit of the existing available Apps. In the present study, we systematically reviewed the existing mobile Apps in neurosurgery, evaluated their clinical use by neurosurgery residents in Canada, and performed a quality audit of the most popular Apps. Indexed Apps were identified from either the Google Play Store or the iOS App Store using a comprehensive list of keywords related to neurosurgery. A subsequent cross-sectional survey of 76 Canadian neurosurgery residents was conducted, including a section on smartphone App use. We next evaluated the most popular Apps among the residents using the Healthcare Smartphone App Evaluation Tool and performed a quality audit of their content using established medical references. The survey identified 118 mobile Apps related to neurosurgery. The 3 most used Apps used by the current cohort of Canadian neurosurgery residents were Neurosurgery Survival Guide, Neuromind, and the Journal of Neurosurgery App. Each of these 3 Apps received an excellent score on the Healthcare Smartphone App Evaluation Tool. A quality audit of 30 pages of the Neurosurgery Survival Guide and 40 clinical scores of the Neuromind App, performed by 10 neurosurgery residents, failed to reveal inaccurate or false statements. The present study has highlighted the current landscape of neurosurgery mobile Apps and their use among neurosurgery residents.

Smartphone Usage Patterns by Canadian Neurosurgery Residents: A National Cross-Sectional Survey.

Smartphones and their apps are used ubiquitously in medical practice. However, in some cases their use can be at odds with current patient data safety regulations such as Canada's Personal Health Information Protection Act of 2004. To assess current practices and inform mobile application development, we sought to better understand mobile device usage patterns among Canadian neurosurgery residents. Through the Canadian Neurosurgery Research Collaborative, an online survey characterizing smartphone ownership and usage patterns was developed and sent to all Canadian neurosurgery resident in April of 2016. Questionnaires were collected and completed surveys analyzed. Of 146 eligible residents, 76 returned completed surveys (52% response rate). Of these 99% of respondents owned a smartphone, with 79% running on Apple's iOS. Four general mobile uses were identified: 1) communication between members of the medical team, 2) decision support, 3) medical reference, and 4) documentation through medical photography. Communication and photography were areas where the most obvious breaches in the Canadian Personal Health Information Protection Act were noted, with 89% of respondents taking pictures of patients' radiologic studies and 75% exchanging them with Short Message System. Hospital policies had no impact on user behaviors. Smartphones are used daily by most neurosurgery residents. Identified usage patterns are associated with perceived gains in efficacy and challenges in privacy and data reliability. We believe creating and improving workflows that address these usage patterns has a greater potential to improve privacy than changing policies and enforcing regulations.

Demographics, Interests, and Quality of Life of Canadian Neurosurgery Residents.

Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.

P.105 Smartphone and mobile app use among Canadian Neurosurgery residents and fellows

Background: Communicating with senior neurosurgical colleagues during residency necessitates a reliable and versatile smartphone. Smartphones and their apps are commonplace. They enhance communication with colleagues, provide the ability to access patient information and results, and allow access to medical reference applications. Patient data safety and compliance with the Personal Health Information Protection Act (PHIPA, 2004) in Canada remain a public concern that can significantly impact the way in which mobile smartphones are utilized by resident physicians Methods: Through the Canadian Neurosurgery Research Collaborative (CNRC), an online survey characterizing smartphone ownership and utilization of apps among Canadian neurosurgery residents and fellows was completed in April 2016. Results: Our study had a 47% response rate (80 surveys completed out of 171 eligible residents and fellows). Smartphone ownership was almost universal with a high rate of app utilization for learning and facilitating the care of patients. Utilization of smartphones to communicate and transfer urgent imaging with senior colleagues was common. Conclusions: Smartphone and app utilization is an essential part of neurosurgery resident workflow. In this study we characterize the smartphone and app usage within a specialized cohort of residents and suggest potential solutions to facilitate greater PHIPA adherence

P.019 Report from the Canadian Neurosurgery Research Collaborative – One year of resident-led multicentre research initiatives

Background: The Canadian Neurosurgery Research Collaborative (CNRC) was founded in November 2015 as a resident-led national network for multicentre research. We present an annual report of our activities. Methods: CNRC meetings and publications were reviewed and summarized. The status of ongoing and future studies was collected from project leaders. Results: In its first year, the CNRC produced two papers accepted for publication in the Canadian Journal of Neurological Sciences: A CNRC launch letter and a study of operative volume at Canadian neurosurgery residency programs. Three manuscripts are in preparation: 1) a study of the demographics of Canadian neurosurgery residents, 2) an assessment of mobile devices usage patterns and 3) a validation study of the most utilized neurosurgery mobile apps. In addition, protocols for two multi-centre studies are currently undergoing national Research Ethics Board review: A retrospective study of the incidence and predictors of cerebellar mutism and a prospective registry of external ventricular drain procedures and complications. The network is now a registered not-for-profit organization endorsed by the Canadian Neurosurgical Society. Conclusions: The CNRC is a feasibile, relevant and productive resident-led national research network. As the CNRC matures, we look forward to expanding the scope and impact of its projects.

P.107 Standardizing resident operative-case logging: the first step of a prospective national study of resident operative volume

Background: No standardized method of resident operative-case logging exists. Our study sought to develop a standardized form used by residents to log operative-cases. Methods: Members of the Canadian Neurosurgery Research Collaborative (CNRC), a national resident-led research organization have created a standardized document based on the current Royal College objectives for operative procedures (section 5). Modifications to structure and content will be guided via consensus from Canadian neurosurgery program-directors. Results: Program directors in each CNRC collaborative institution will be asked to modify the standardized form. The CNRC currently involves thirteen of the fourteen Canadian neurosurgery residency programs. Additional consensus, if necessary, can be reached at the Royal College meeting for program directors of neurosurgery March 20th 2017. Conclusions: A standardized operative-case log represents the first step in a prospective study towards compiling operative volume of all Canadian neurosurgical residents over one academic year. Such data will be essential to guide informed decisions with regard to Royal College requirements as Canadian neurosurgical programs transition to a competency based framework.

Operative Landscape at Canadian Neurosurgery Residency Programs

Anonymized administrative operative data were gathered from each neurosurgery residency program from January 1, 2014, to December 31, 2014. Procedures were broadly classified into cranial, spine, peripheral nerve, and miscellaneous procedures. A number of prespecified subspecialty procedures were recorded. We defined the resident case index as the ratio of the total number of operations to the total number of neurosurgery residents in that program. Resident number included both Canadian medical and international medical graduates, and included residents on the neurosurgery service, off-service, or on leave for research or other personal reasons. Overall, there was an average of 1845 operative cases per neurosurgery residency program. The mean numbers of cranial, spine, peripheral nerve, and miscellaneous procedures were 725, 466, 48, and 193, respectively. The nationwide mean resident case indices for cranial, spine, peripheral nerve, and total procedures were 90, 58, 5, and 196, respectively. There was some variation in the resident case indices for specific subspecialty procedures, with some training programs not performing carotid endarterectomy or endoscopic transsphenoidal procedures. This study presents the breadth of neurosurgical training within Canadian neurosurgery residency programs. These results may help inform the implementation of neurosurgery training as the Royal College of Physicians and Surgeons residency training transitions to a competence-by-design curriculum.

Supplementary Educational Models in Canadian Neurosurgery Residency Programs.

The proposed implementation of work hour restrictions has presented a significant challenge of maintaining the quality of resident education and ensuring adequate hands-on experience that is essential for novice surgeons. To maintain the level of resident surgical competency, revision of the apprentice model of surgical education to include supplementary educational methods, such as laboratory and virtual reality (VR) simulations, have become frequent topics of discussion. We aimed to better understand the role of supplementary educational methods in Canadian neurosurgery residency training. An online survey was sent to program directors of all 14 Canadian neurosurgical residency programs and active resident members of the Canadian Neurosurgical Society (N=85). We asked 16 questions focusing on topics of surgeon perception, current implementation and barriers to supplementary educational models. Of the 99 surveys sent, 8 out of 14 (57%) program directors and 37 out of 85 (44%) residents completed the survey. Of the 14 neurosurgery residency programs across Canada, 7 reported utilizing laboratory-based teaching within their educational plan, while only 3 programs reported using VR simulation as a supplementary teaching method. The biggest barriers to implementing supplementary educational methods were resident availability, lack of resources, and cost. Work-hour restrictions threaten to compromise the traditional apprentice model of surgical training. The potential value of supplementary educational methods for surgical education is evident, as reported by both program directors and residents across Canada. However, availability and utilization of laboratory and VR simulations are limited by numerous factors such as time constrains and lack of resources.

National Perspectives on the Training of Neurosurgery Residents in Stereotactic Radiosurgery.

Despite the critical role played by neurosurgeons in performing radiosurgery, neurosurgery residents in Canada have limited exposure to radiosurgery during their training. A survey of neurosurgery residents and faculty along with radiation oncology faculty was conducted to analyze perspectives regarding incorporating formal radiosurgery training into the neurosurgery residency curriculum Methods: An online survey platform was employed. Descriptive statistics were used to summarize center and respondent characteristics. Categorical variables were compared using odds ratios and corresponding 95% confidence intervals. The chi-squared test was utilized to assess statistical significance. A value of p<0.05 was considered significant Results: The response rate was 31% (119/381); 87% (102/119) of respondents were from the neurosurgical specialty and 13% (17/119) from radiation oncology. Some 46% of residents (18/40) were "very uncomfortable" with radiosurgery techniques, and 57% of faculty (42/73) believed that dedicated radiosurgery training would be beneficial though impractical. No respondents felt that "no training" would be beneficial. A total of 46% of residents (19/41) felt that this training would be beneficial and that time should be taken away from other rotations, if needed, while 58% of faculty (42/73) and 75% (28/41) of residents believed that either 1 or 1-3 months of time dedicated to training in radiosurgery would suffice Conclusions: Canadian neurosurgeons are actively involved in radiosurgery. Despite residents anticipating a greater role for radiosurgery in their future, they are uncomfortable with the practice. With the indications for radiosurgery expanding, this training gap can have serious adverse consequences for patients. Considerations regarding the incorporation and optimal duration of dedicated radiosurgery training into the Canadian neurosurgery residency curriculum are necessary.

P.015 Demographics of Canadian neurosurgery residents – a national cross-sectional study from the Canadian Neurosurgery Research Collaborative

Background: The Canadian Neurosurgery Research Collaborative (CNRC) is a new consortium of neurosurgery residency programs set-up to facilitate the planning and implementation of multi-center studies. As a trainee-led organization, it will focus on resident-initiated, resident-driven projects. The goal of this study is to assess the demographics of Canadian neurosurgery residents, with particular focus on their academic and subspecialty interests. Methods: After approval by the CNRC, an online survey will be sent to all Canadian neurosurgery residents and fellows with reminders at 2, 4 and 6 weeks. Anonymous, basic demographic data will be collected. Specific interest towards the various subspecialties, research and academic vs community practice will be measured. The data will be crossed with the ongoing Canadian Neurosurgery Operative Landscape study to assess the impact of case volume on academic and subspecialty interests. Results: This is the first study providing a snapshot of Canadian neurosurgery residents at all levels of training. The study is ongoing and the official results will be presented at the meeting. As one of the first CNRC studies, it will also demonstrate the effectiveness of the collaborative. Conclusions: Understanding the demographics and interests of Canadian neurosurgery residents will allow the CNRC to better fulfill its mission.

An analysis of attrition from Canadian neurosurgery residency programs.

To determine the magnitude of and reasons for attrition from neurosurgical residency programs in Canada. Directors of the 13 Canadian neurosurgery residency programs were asked to complete questionnaires on their programs, magnitude of attrition, reasons for attrition, and selection criteria. Open-ended questions were assessed with content analysis and quantified with dual-scaling techniques. Similar questionnaires were sent to 30 residents who had completed training; six residents who had voluntarily withdrawn were interviewed. Twelve of the 13 directors (92%) responded. Forty-two residents voluntarily withdrew from residency training between 1980 and 1992; withdrawal rates grew during that period. The number of dismissals--approximately 1.8 per year--remained constant. Reasons for voluntary withdrawal focused on excessive workloads and unexpected residency demands, whereas reasons for dismissal related primarily to deficits in professional attitudes and behaviors such as interpersonal skills and ethics. In selecting residents, programs with low attrition rates gave more importance to a candidate's work ethic than did programs with high attrition rates. The low-attrition programs also gave more importance to the relationship developed with residents during training. These results suggest that voluntary attrition from neurosurgical residency is significant and is related to issues of lifestyle control. Dismissal is rarely related to cognitive or psychomotor deficits, but usually occurs for concerns about professionalism such as ethics and interpersonal skills and behaviors. Further studies are necessary to confirm these findings across specialties and countries.