Neurosurgical Residency Training Research Articles

Neurosurgery Residency Programs on Twitter (X): Current Use and Future Potential

Study DesignCross-sectional study ObjectivesTwitter (X) is increasingly utilized by medical residency programs to boost engagement and potentially enhance ranking. This study aims to evaluate the role of Twitter (X) in neurosurgery residency programs, assessing their online activity, followership, and content to identify current practices and potential improvements. MethodsWe identified 97/123 neurosurgery residency programs in the United States with Twitter accounts. Active accounts, posting in 2022 and 2023, were matched with the American Association of Neurological Surgeons (AANS) Neurosurgical Residency Training Program Directory. Tweets from January 2022 through June 2023 were categorized as original or retweets and further subcategorized based on content. Descriptive and correlation analyses were conducted. ResultsTwitter (X) accounts were found for 78.8% of accredited neurosurgery programs (n=97/123), with 68.3% active as of July 2023 (n=84/123). All active accounts amassed 167,068 followers. Among 5,612 tweets identified, 2,764 were original content and 2,848 were retweets. Tweets primarily focused on resident or program information (64.3%), research publications (32.0%), and conference participation (9.4%). Only 12.3% (n=341) of original tweets contained public medical information. A significant correlation (r = 0.493, p <0.001) was observed between Twitter (X) following and program ranking. ConclusionsThe majority of US neurosurgery residency programs actively use Twitter (X), primarily to showcase academic achievements and aid in recruitment. The correlation between Twitter following and program ranking suggests that online engagement reflects program visibility and impact, underscoring the importance of social media in program outreach and strategic management for maximizing program benefits.

Enhancing the Evaluation System of Training Hospitals for Neurosurgical Residency Training and Education in South Korea : Striving for Balanced Participation and Differentiation.

The Korean Neurosurgical Society, with its 62 years of history, has witnessed substantial growth in the field of neurosurgery, producing over 3,400 neurosurgeons, establishing 12 divisions and 9 regional branches, and advancing in clinical management, diagnostic methods and academic research. Despite these developments, the regulations governing neurosurgical training and evaluation methods for training hospitals have remained largely unchanged, necessitating comprehensive revisions in response to evolving medical environments. To provide balanced participation opportunities for neurosurgery residents, the Korean Neurosurgical Society formed the Training Status Investigation Standard Change Task Force (TF Team) under the Training Education Committee. This paper presents the TF Team's findings and proposals for revising training status investigation standards and evaluation criteria. Through the processes including a lot of team meetings, workshops, education programs, official communications with 12 division societies, benchmarking from other societies and analysis of encrypted data from the past 5 years for neurosurgical training hospitals, the TF Team created a revised training status investigation proposal, supplemented main surgery criteria. And we applied this revised proposal to the training status investigation data collected from training hospitals in 2022 for simulation. We reduced the score for main surgeries to 10 points, introduced core competency surgery standards, allocating 5 points each for brain core competency surgery and spine and peripheral core competency surgery, for a total of 10 points. We also adjusted the major surgery score to 13 points, expanding the total surgery index score to 33 points. We introduced additional definitions for main surgeries in the areas of spine, pediatrics, and functional surgery. The equipment score was reduced from 17 points to 9 points. We specified minimum requirements for resident allocation eligibility, and if a hospital meets all of these criteria, they become eligible to apply for resident allocation. We introduced a new bonus point system for hospitals performing mechanical thrombectomy or stenting and peripheral nerve. The proposed revisions aim to improve the training and education of neurosurgical residents and overall neurosurgical care in Korea by creating a balanced and differentiated evaluation system for training hospitals. Further monitoring, communication, and adjustments are crucial for successful implementation.

Enhancing the Microneurosurgical Training: Development of the Folded Placenta Model for Simulation of the Deep Operative Field Challenges of Cranial Procedures

Neurosurgery relies heavily on advanced manual skills, necessitating effective training models for skill development. While various models have been utilized, the human placenta has emerged as a promising candidate for microneurosurgical training due to its anatomical similarities with cerebral vasculature. However, existing placenta models have primarily focused on simulating superficial procedures, often neglecting the complexities encountered in deep operative fields during cranial surgeries. This study obtained ethical approval and implemented a modified placenta model to address the limitations of existing training models. The key modification involved folding the placenta and placing it within a rigid container, closely mimicking the structural challenges of cranial procedures. The placenta preparation followed a standardized protocol, including the use of specialized equipment for documentation. The primary feature of the modified model is the folded placenta within the rigid container, which replicates cranial anatomy. This innovative approach enables trainees to engage in a comprehensive range of microsurgical exercises, encompassing vessel dissection, aneurysm clipping, tumor resection, and more. The model successfully mirrors the complexities of real cranial procedures, providing a realistic training experience. The presented modified placenta model serves as an effective tool for simulating the conditions encountered in deep cranial surgeries. By accurately replicating the challenges of deep operative fields, the model significantly enhances the training of neurosurgical residents. It successfully prepares trainees to navigate the intricacies and difficulties inherent in real cranial surgeries, thus contributing to improved surgical skills and readiness for neurosurgical practice.

"Home Field Advantage": The Presence of a "Home" Neurosurgical Residency Training Program is Associated With Improved Match Outcomes.

Competition for neurosurgical residency training positions remains fierce. The support provided by applicants' home neurosurgery residency training programs (NRTP) is suspected to play a key role in the National Resident Matching Program (NRMP) process. We sought to evaluate the impact of the presence of an Accreditation Council for Graduate Medical Education-accredited NRTP at medical students' home institutions has on NRMP match outcomes. Our cross-sectional observational study examined all US allopathic senior student Electronic Residency Application Service applications to a single NRTP from 2016 to 2022. We analyzed a total of 1650 Electronic Residency Application Service applications to a single NRTP, of which 1432 (86.8%) were from schools with an Accreditation Council for Graduate Medical Education-accredited NRTP (NRTP+) and 218 (13.2%) were from schools without a residency (NRTP-). NRTP+ applicants matched a higher rate on both pooled analysis (80.8% vs 71.6%, P = .002) and paired analysis (P = .02) over the seven-cycle study period. This difference was present before (82.4% vs 73.9%, P = .01) and after (77.2% vs 65.6%, P = .046) the COVID-19 pandemic. Cohorts were overall similar; however, NRTP+ applicants had more publication experiences (19.6 ± 19.0 vs 13.1 ± 10.2, P < .001) and were more likely to complete a research gap year (RGY) (25.8% vs 17.0%, P = .004). Completing a RGY was associated with an increased likelihood of matching for NRTP+ applicants but not for NRTP- applicants: NRTP+: 84.9% vs 78.1% (P = .0056); NRTP-: 70.3% vs 70.9% (P = .94). The presence of a NRTP at a medical student's home institution is associated with improved NRMP match outcomes. This held true both before and after the COVID-19 pandemic. Applicants from schools with a NRTP had more publication experiences and were more likely to complete a RGY. Completion of a RGY is associated with an increased likelihood of matching only for students with an affiliated NRTP.

Perception and Representation of LGBTQ+ Individuals in U.S. Neurosurgical Training

ObjectiveThe aim of this study is to gauge the current social climate in neurosurgical residency training and attitudes regarding sexual orientation and gender identity. MethodsWe conducted a cross-sectional study through a 35-question questionnaire distributed to roughly 1,700 residents at all U.S. neurosurgical residency programs. ResultsA total of 107 responses were obtained. 17 residents (16%) identified as being an LGBTQ+ individual. 76% of LGBTQ+ residents were concerned about how their sexual orientation would be perceived while applying to programs and 47% endorsed purposefully concealing sexual orientation at work for fear of rejection or reprisal. 56% of those surveyed have witnessed homophobic/transphobic remarks by patients. While at work, 29% of LGBTQ+ individuals stated they are uncomfortable being open with their sexual orientation, and three LGBTQ+ individuals endorsed being the target of direct homophobic/transphobic comments. ConclusionsThis is the first study to our knowledge that has been conducted assessing the presence, perception, and treatment of LGBTQ+ trainees in neurosurgical residency. Our study outlines the challenges LGBTQ+ individuals face when applying to neurosurgical programs, which involves the perception of their sexual orientation, their witnessed instances of homophobic and transphobic comments by coworkers and patients, and their hesitation with discussing their social lives compared to their non-LGBTQ+ peers at work for fear of judgement or reprisal. Ongoing research is needed to address these issues to obtain workplace respect and fairness in this population, and thus create an accepting atmosphere and achieve social justice in neurosurgery training.

Pediatric neurosurgery training during residency in Switzerland and the need for dedicated subspecialization training

IntroductionPediatric Neurosurgery as a subspeciality started to emerge during the late 1950s, with only a few dedicated pediatric neurosurgeons in the Western world. Over the last few decades, the awareness that children require subspecialized care by dedicated pediatric neurosurgeons and an interdisciplinary team has been growing worldwide, leading to an increase in pediatric neurosurgeons. Several studies have shown that subspecialized care for pediatric patients improves outcomes and is cost-effective. This survey aims to assess the current setting of pediatric neurosurgery and training of neurosurgical residents in pediatric neurosurgery in Switzerland.MethodsWe conducted an online survey by sending e-mail invitations in 2021 to all neurosurgical residents in Switzerland. The survey included questions regarding the participants' demographics, current workplace structures, the care of specific pediatric neurosurgical pathologies, and participants’ opinions of the Swiss training program for pediatric neurosurgery and possible improvement. We defined at the beginning of the survey that a pediatric neurosurgeon is a board-certified neurosurgeon with at least one year of dedicated pediatric neurosurgical fellowship training abroad.ResultsWe received a total of 25 responses from residents, of which 20 (80%) were male. Twenty-two participants (88%) worked in one of seven major hospitals in Switzerland at the time of the survey, and four (16%) were interested in pursuing a fellowship in pediatric neurosurgery. Seven (35%) and five residents (25%) feel comfortable taking care on the ward of a craniosynostosis and hydrocephalus patient younger than 6 months, respectively. Twelve residents (60%) feel comfortable taking care of a pediatric brain tumor patient. The majority (n = 22, 88%) of all residents agree that a fellowship-trained pediatric neurosurgeon should treat children, while two (8%) residents state that any neurosurgeon with an interest in pediatric neurosurgery should be able to treat children. All residents (n = 25, 100%) agree that pediatric neurosurgery training and care in Switzerland needs to be improved.ConclusionPediatric neurosurgery training in Switzerland is rather heterogeneous and not very well structured, with varying frequencies of children-specific neurosurgical pathologies. Most residents agreed that a subspecialized pediatric neurosurgeon should oversee the care of children in neurosurgery, while all agree that pediatric neurosurgical training and care should be improved in Switzerland.

Training Cerebrovascular and Neuroendovascular Surgery Residents: A Systematic Literature Review and Recommendations.

Background: The rapid evolution of neuroendovascular intervention has resulted in the inclusion of endovascular techniques as a core competency in neurosurgical residency training. Methods: We conducted a literature review of studies involving the training of neurosurgical residents in cerebrovascular and endovascular neurosurgery. We reviewed the evolution of cerebrovascular neurosurgery and the effects of these changes on residency, and we propose interventions to supplement contemporary training. Results: A total of 48 studies were included for full review. Studies evaluated trainee education and competency (29.2%, 14/48), neuroendovascular training models (20.8%, 10/48), and open cerebrovascular training models (52.1%, 25/48), with some overlap. We used a qualitative analysis of reviewed reports to generate a series of suggested training supplements to optimize cerebrovascular education. Conclusion: Cerebrovascular neurosurgery is at a crossroads where trainees must develop disparate skill sets with inverse trends in volume. Continued longitudinal exposure to both endovascular and open cerebrovascular surgical fields should be mandated in general resident education, and blended learning tactics using adjunct simulation systems and models should be incorporated with didactics to both optimize learning and alleviate restraints placed by decreased volume and autonomy.

Innovative growth and development of a neurological surgery residency cadaveric spine-simulation training program: a single-institution experience.

Cadaveric and dry 3D model-based simulation training is a valuable educational tool for neurosurgical residents. Such simulation training is an opportunity for residents to hone technical skills and decision-making and enhance their neuroanatomy knowledge. The authors describe the growth and development of the Oregon Health & Science University Department of Neurological Surgery resident-focused, hands-on, spine-simulation surgery courses and provide details of course evaluations, layout, and setup. A four-part spine surgical simulation series, including two human cadaveric and two dry 3D model-based courses, was created to provide resident spine procedure training. Residents participated in the spine simulation series (2017-2021) and completed annual course curriculum and anonymous post-course evaluations. Evaluations included both Likert scale items and free-text responses. Responses to Likert scale items were analyzed in Python. Free-text responses were quantified using the Valence Aware Dictionary for Sentiment Reasoner. Descriptive statistics were calculated and plotted using Python's seaborn and matplotlib library modules. The analysis included 129 spine (occipitocervical, thoracolumbar, and spine model fusion I and II) simulation course evaluations. Likert responses demonstrated high average responses for evaluation questions (4.67 ± 0.90 and above). The average compound sentiment value was 0.58 ± 0.28. This is the first time Likert responses and sentiment analysis have been used to demonstrate how neurosurgical residents positively value a hands-on spine simulation training. Simulation is an essential component of neurosurgical resident education training. The authors encourage other neurosurgical education programs to develop and leverage spine simulation as a teaching tool.

A patient-specific, interactive, multiuser, online mixed-reality neurosurgical training and planning system.

Mixed-reality simulation is an emerging tool for creating anatomical models for preoperative planning. Its use in neurosurgical training (NT) has been limited because of the difficulty in real-time interactive teaching. This study describes the development of a patient-specific, interactive mixed-reality NT system. The authors took cases of intracranial tumor resection or neurovascular compression (NVC) as examples to verify the technical feasibility and efficacy of the mixed-reality NT system for residents' training and preoperative planning. This study prospectively enrolled 40 patients who suffered from trigeminal neuralgia, hemifacial spasms, or intracranial tumors. The authors used a series of software programs to process the multimodal imaging data, followed by uploading the holographic models online. They used a HoloLens or a standard iOS device to download and display the holographic models for training. Ten neurosurgical residents with different levels of surgical experience were trained with this mixed-reality NT system. Change in surgical strategy was recorded, and a questionnaire survey was conducted to evaluate the efficacy of the mixed-reality NT system. The system allows the trainer and trainee to view the mixed-reality model with either a HoloLens or an iPad/iPhone simultaneously online at different locations. Interactive manipulation and instant updates were able to be achieved during training. A clinical efficacy validation test was conducted. The surgeons changed their exploration strategy in 48.3% of the NVC cases. For residents with limited experience in surgery, the exploration strategy for 75.0% of all patients with NVC was changed after the residents were trained with the mixed-reality NT system. Of the 60 responses for intracranial tumors, the trainee changed the surgical posture in 19 (31.7%) cases. The change of the location (p = 0.0338) and size (p = 0.0056) of craniotomy are significantly related to the experience of the neurosurgeons. The mixed-reality NT system is available for local or real-time remote neurosurgical resident training. It may effectively help neurosurgeons in patient-specific training and planning of surgery for cases of NVC and intracranial tumor. The authors expect the system to have a broader application in neurosurgery in the near future.

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Spine Surgical Subspecialty and Its Effect on Patient Outcomes: A Systematic Review and Meta-Analysis.

Systematic review and meta-analysis. To perform a systematic review and meta-analysis to identify if intraoperative or postoperative differences in outcomes exist between orthopedic and neurological spine surgeons. Spine surgeons may become board certified through orthopedic surgery or neurosurgical residency training, and recent literature has compared surgical outcomes between surgeons based on residency training background with conflicting results. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a search of PubMed and Scopus databases was conducted and included articles comparing outcomes between orthopedic spine surgeons and neurosurgeons. The Newcastle-Ottawa scale was used to determine the quality of studies. Forest plots were generated using mean differences (MD) for continuous variables and odds ratios (OR) for binomial variables, and 95% CI was reported. Of 615 search term results, 16 studies were identified for inclusion. Evaluation of the studies found no differences in readmission rates [OR, ref: orthopedics: 0.99 (95% CI: 0.901, 1.09); I2 = 80%], overall complication rates [OR, ref: orthopedics: 1.03 (95% CI: 0.97, 1.10); I2 = 70%], reoperation rates [OR, ref: orthopedics: 0.91 (95% CI: 0.82, 1.00); I2 = 86%], or overall length of hospital stay between orthopedic spine surgeons and neurosurgeons [MD: -0.19 days (95% CI: -0.38, 0.00); I2 = 98%]. However, neurosurgeons ordered a significantly lower rate of postoperative blood transfusions [OR, ref: orthopedics: 0.49 (95% CI: 0.41, 0.57); I2 = 75%] while orthopedic spine surgeons had shorter operative times [MD: 14.28 minutes, (95% CI: 8.07, 20.49), I2 = 97%]. Although there is significant data heterogeneity, our meta-analysis found that neurosurgeons and orthopedic spine surgeons have similar readmission, complication, and reoperation rates regardless of the type of spine surgery performed.

Resilience and recovery in neurosurgical residency: Unpacking lessons from video game mechanics

IntroductionNeurosurgical residency is a challenging journey demanding cognitive acuity and resilience, mirrored strikingly in the dynamics of video gaming. Gaming concepts of Down-But-Not-Out (DBNO), Heal-over-Time (HoT), and Damage-over-Time (DoT) can serve as compelling analogues to elements of neurosurgical training. Material and methodsAn innovative, cross-disciplinary methodology was implemented, blending elements of autoethnography, personal reflective narrative, and comprehensive literary review. The cornerstone of this approach was an experiential reflective analysis, where two neurosurgical residents critically examined the parallels between their residency experiences and video game mechanics, thereby applying a lens of heuristic introspection to their professional journey. Complementing this, a comprehensive narrative synthesis of existing literature on resilience, wellness, and stress in neurosurgical residency training was conducted. ResultsThe DBNO concept parallels the resilience demonstrated by neurosurgical residents, emphasizing the importance of a supportive network. The HoT concept, analogous to wellness practices, underscores the incremental restoration of energy necessary for maintaining stamina in neurosurgery training. The DoT concept symbolizes the need to manage the often insidious and deleterious effects of chronic stress on residents' wellbeing. Discussion and conclusionThese gaming concepts provide an integrative framework for understanding the challenges faced and strategies employed in neurosurgical residency. The interplay between resilience, wellness practices, and effective stress management, represented by DBNO, HoT, and DoT respectively, is critical for maintaining health and fostering professional excellence. By embedding these metaphors within the training paradigm, the neurosurgical residency journey can be navigated more effectively, promoting not only professional success but also personal growth and wellbeing.

A look at the global impact of COVID-19 pandemic on neurosurgical services and residency training

BackgroundThe COVID-19 pandemic has left an indelible effect on healthcare delivery and education system, including residency training. Particularly, neurosurgical departments worldwide had to adapt their operating model to the constantly changing pandemic landscape. This review aimed to quantify the reduction in neurosurgical operative volume and describe the impact of these trends on neurosurgical residency training. MethodsWe performed a comprehensive search of PubMed and EMBASE between December 2019 and October 2022 to identify studies comparing pre-pandemic and pandemic neurosurgical caseloads as well as articles detailing the impact of COVID-19 on neurosurgery residency training. Statistical analysis of quantitative data was presented as pooled odds ratio (OR) and 95% confidence intervals (CI). ResultsA total of 49 studies met the inclusion criteria, of which 12 (24.5%) were survey-based. The case volume of elective surgeries and non-elective procedures decreased by 70.4% (OR=0.296, 95%CI 0.210–0.418) and 68.2% (OR=0.318, 95%CI 0.193–0.525), respectively. A significant decrease was also observed in functional (OR=0.542, 95%CI 0.394–0.746), spine (OR=0.545, 95%CI 0.409–0.725), and skull base surgery (OR=0.545, 95%CI 0.409–0.725), whereas the caseloads for tumor (OR=1.029, 95%CI 0.838–1.263), trauma (OR=1.021, 95%CI 0.846–1.232), vascular (OR=1.001, 95%CI 0.870–1.152), and pediatric neurosurgery (OR=0.589, 95%CI 0.344–1.010) remained relatively the same between pre-pandemic and pandemic periods. The reduction in caseloads had caused concerns among residents and program directors in regard to the diminished clinical exposure, financial constraints, and mental well-being. Some positives highlighted were rapid adaptation to virtual educational platforms and increasing time for self-learning and research activities. ConclusionWhile COVID-19 has brought about significant disruptions in neurosurgical practice and training, this unprecedented challenge has opened the door for technological advances and collaboration that broaden the accessibility of resources and reduce the worldwide gap in neurosurgical education.

The Effect of Multiple Scopus Profiles on the Perceived Academic Productivity of Neurosurgeons in the United States

Bibliometrics assessing academic productivity plays a significant role in neurosurgeons' career advancement. This study aimed to evaluate the influence of multiple author profiles on Scopus on neurosurgeon author-level metrics (h-index, document number, citation number). A list of 1671 academic neurosurgeons was compiled through public searches of hospital and faculty websites for 115 neurosurgical residency training programs. The h-index, document number, and citation number for each neurosurgeon were collected using the Scopus algorithm. For surgeons with multiple profiles, total document number and citation number were calculated by summing results of each profile. Cumulative h-indices were calculated manually. Comparisons were made between surgeons with a single Scopus profile and surgeons with multiple profiles. A total of 124 neurosurgeons with multiple profiles were identified. Gender distribution (P= 0.47), years in practice (P= 0.06), subspecialty (P= 0.32), and academic rank (P= 0.16) between neurosurgeons with a single profile versus multiple profiles were similar. Primary profile h-index median was 16 (interquartile range [IQR]: 8-34), combined profiles median was 20 (IQR: 11-36), and percent loss median was 17.3% (IQR: 3%-33%) (P < 0.001). For document number, primary profile median was 46 (IQR: 16-127), combined profiles median was 55 (IQR: 22-148), and percent loss median was 16.2% (IQR: 7%-36%) (P < 0.001). For citation number, primary profile median was 1030 (IQR: 333-4082), combined profiles median was 1319 (IQR: 546-4439), and percent loss median was 14.1% (IQR: 4%-32%) (P < 0.001). U.S. academic neurosurgeons with multiple existing profiles on Scopus experience a 17.3% loss in h-index, a 16.2% loss in document number, and a 14.1% loss in citations, heavily undercounting their perceived academic productivity.

United States Neurosurgery Department Program Directors: A Cross-Sectional Evaluation of Current and Future Trends and Attributes

While United States (U.S.) neurosurgery residency programs have been subject to many studies, none have focused solely on the program directors (PDs). We aim to analyze the demographic, educational, and academic attributes of this cohort to understand current and future trends of PDs. One hundred sixteen neurosurgeons listed as PDs at U.S. accredited neurosurgical residency training programs as of August 2022 were assessed. Descriptive data including age upon acceptance of role, gender, and h-index were collected from publicly available sources. Most PDs matriculated to their positions before the age of 45 years, were male, and had been hired internally. Approximately 25% of PDs had earned an additional degree. Departments with higher aggregate h-indexes were more likely to hire PDs with higher average publications per year (P < 0.001) and have a higher h-index (P < 0.001). PD subspecialty influenced h-index (P < 0.05) and total average publications per year (P < 0.05) with neuro-oncology subspecialists having higher averages in both. More recently hired PDs had a higher average number of publications per year (P < 0.05) and were more likely to hold an additional degree (odds ratio 1.14, P < 0.05). Female PDs were hired at a younger age (P < 0.05). Neurosurgery PDs typically rise to their position after 10 years of practice and more recent PD hires are more likely to have additional degrees and more publications. As academic neurosurgery becomes more competitive, increased academic productivity and acquisition of additional degrees will become increasingly necessary.

Introduction. Education methodology and metrics in the training of neurosurgical residents.

Introduction. Education methodology and metrics in the training of neurosurgical residents.

Construct validity of the Surgical Autonomy Program for the training of neurosurgical residents.

There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky's social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time. The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses. Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11-2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17-0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29-1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67-0.77, p < 0.001). This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors' smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

Neurosurgery Lectures Benefit from a Flipped Class Approach

In a flipped classroom, students learn lecture material before class and then participate in active learning during in-person sessions. This study examines preferences for flipped classroom activities during a neurosurgery presentation on traumatic brain injury. Two hundred twenty-five third- and fourth-year medical students on their core neurology rotation watched an online podcast about traumatic brain injury before meeting for in-person, active learning activities with a neurological surgeon. Before and after the class, students were given rank-based surveys with an optional section for comments. The initial survey assessed preference for specific active learning activities, and the final survey assessed satisfaction with the experience. The students also answered an online 20-question postlecture test as part of the standard neurology class assessment. Every student scored over 90% on the postlecture test. Of the 81 students who answered the first survey, most students (83.95%) strongly preferred or preferred case scenarios with group discussion. The average Likert score for case scenario preference (4.37/5) was significantly higher than the score for all other activities (P<0.05). Of the 207 students who answered the second survey, 80.19% of students reported that they would probably or definitely like to see more flipped classroom activities. Medical students highly preferred case scenarios because according to their comments, this method was relevant to real-life situations and led to higher information retention. This information suggests that the flipped classroom model for neurosurgical-based lectures is preferred, is beneficial, and should incorporate case scenarios. This methodology may also apply to neurosurgical residency training.

Impact of COVID-19 on the Neurosurgical Resident Training Program: An Early Experience.

The present study evaluates the impact of COVID-19 pandemic restrictions during the first lockdown period in spring 2020 on the neurosurgical resident training program, and provides constructive approaches to deal with such situations. A concurrent embedded mixed methods design was used. Qualitative data were collected through in-depth interviews from all neurosurgical residents at three university hospitals in Germany. Concurrently, quantitative data of the number of performed surgeries, outpatient visits, and the usage of telemedicine in the period from October 2019 to July 2020 were collected and analyzed accordingly. During the period of COVID-19 pandemic restrictions in spring 2020, there was a marked reduction in the number of surgeries performed by neurosurgical residents, from an average of 41.26 (median 41) surgeries per month to 25.66 (median 24) per month, representing a decrease of 37.80%. The decrease in the operations was concerning mainly spinal and functional surgery. Outpatient visits were reduced significantly, with a concurrent fivefold increase in the usage of telemedicine. General and pediatric neurosurgery outpatient clinics were the most affected. However, although surgical exposure was reduced during the lockdown phase, neurosurgical residents focused on conducting research and improving theoretical knowledge. Nevertheless, the global uncertainties caused by COVID-19 generated notable psychological stress among some residents. The COVID-19 pandemic restrictions significantly affected the neurosurgical training program. Innovative solutions need to be developed to increase teaching and research capacities of neurosurgical residents as well as to improve surgical skills by installing surgical skill laboratories or similar constructs.

Telementoring Feasibility Using a Novel Low-cost Lazy Glass Microsurgical Simulator: A “Proof of Concept” Experimental Study

In order to mitigate the challenges in microsurgical skill acquisition and training, especially in the COVID-19 era, we devised a novel microsurgical telementoring protocol for imparting microsurgical skill training in a socially distanced setting. We objectively analyzed its feasibility among neurosurgical trainees. In a controlled experimental design, 8 residents at different stages of their tenure participated in a lazy glass microsurgical simulator-based telementoring exercise. Microsuturing with 4-0 silk, 10-0 nylon on silastic sheets, and eggshell peeling tasks were performed by the residents prior to and after a telementoring session by a panel of 4 neurosurgical experts. Impact of telementoring was assessed in terms of surgical accuracy, efficiency, and dexterity by providing objective (Performance score [PS]), subjective (Neurosurgery Education and Training School [NETS] score), and cumulative scores (CS). Subgroup analysis was performed to assess the impact at different stages of residency. PS, NETS score, and CS were significantly improved by telementoring sessions for 10-0 nylon micro-suturing (P < 0.001), and egg-hell peeling tasks (P < 0.01). PS and CS improved significantly (P= 0.01) after telementoring sessions for 4-0 silk microsuturing. Both pre- and post-training CS were similar across the 2 subgroups PGY 1-4 and PGY 5-6 (P > 0.05). Telementoring is a viable alternative for neurosurgical resident training in the COVID-19 era, where reduction in elective surgeries and social distancing norms preclude conventional teaching. Lazy glass microsurgical simulator-based structured telementoring protocol is a cost-effective tool to augment surgical proficiency and finesse, irrespective of stage of residency.