Neurosurgical Training Programs Research Articles

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Jacob Chandy

Jacob Chandy, who passed away in 2007 at the age of 97, was born into a deeply religious Christian family in Kerala, South India. After obtaining his medical education at the Madras Medical College, Madras, he serendipitously came to work with Dr Paul Harrison, a renowned medical missionary, in the Gulf state of Bahrain. Harrison urged Chandy to pursue training in the fledgling specialty of neurosurgery in North America. Chandy received his neurosurgical training at the Montreal Neurological Institute with Wilder Penfield and in Chicago with Theodore Rasmussen. At Harrison's urging, Chandy decided to return to India after completing his training to work at the Christian Medical College in Vellore. Thus, it was in 1949 that Chandy established the first neurosurgery department in south Asia in Vellore. He initiated the first neurosurgical training program in India at the Christian Medical College in 1957, with a distinct North American neurosurgical tradition. He went on to train nearly 20 neurosurgeons, many of whom set up new departments of neurosurgery in their home states. Chandy also had several other remarkable achievements to his credit. Despite the pressures of clinical practice, he insisted on fostering both basic and clinical neurosciences within his department, an arrangement that persists to this day in the Department of Neurological Sciences at the Christian Medical College, Vellore. As the Principal (Dean) of the Christian Medical College, Chandy displayed his skills as a medical educator and administrator. In this role, he was instrumental in starting specialty training programs in several other medical and surgical disciplines. His greatest legacies survive in the form of the department that he founded and his trainees and their students who have helped to establish neurosurgery all over the country.

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Accreditation of neurosurgical training programmes in Europe: Report of JRAAC

Accreditation of Neurosurgical Training Programmes in Europe: Report of JRAAC

Accreditation of Neurosurgical Training Programmes in Europe: Report of JRAAC

Neurosurgery and Global Health: Going Far and Fast, Together

In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus who were admitted to Bugando Medical Centre in Mwanza, Tanzania, as well as to describe their surgical treatment and early clinical outcomes.This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and postoperatively, and their mothers completed a questionnaire providing demographic and clinical characteristics.There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), whereas 7 were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-49 days). Overall, 5 patients (13.2%) died, including 2 who did not receive surgical intervention.We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of whom 2 had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.

The Foundation for International Education in Neurological Surgery

The Foundation for International Education in Neurological Surgery (FIENS) was established in 1969 for the purpose of promoting neurosurgical education and patient care in the developing world. Ghana, the first African site, was adopted in 1989. In 2005 a neurosurgical training program was developed for Ethiopia, Kenya, Tanzania, and Uganda in East Africa and the College of Surgeons of Central, East, and Southern Africa (COSECSA) approved the curriculum.

Initial Audit of a Basic and Emergency Neurosurgical Training Program in Rural Tanzania

As of 2006, only three formally trained neurosurgeons are licensed in Tanzania. Recently, efforts have increased toward training local Tanzanian physicians and assistant medical officers (AMOs) to meet the basic neurosurgical needs of nonurban areas. Between January and July 2006, an initial attempt at such an apprenticeship was undertaken with a locally trained AMO already performing general surgery at Haydom Lutheran Hospital, Tanzania. Fifty-one neurosurgical patients were identified and their patient charts were requested from the medical records office. Records were not available for 4 of the 51 patients for undeterminable reasons. The neurosurgical infrastructure at HLH is basic but adequate for a number of procedures. Cases performed included ventriculoperitoneal shunts, repair of myelomeningoceles, and burr holes and craniotomies for trauma and biopsies. Of 51 patients initially identified, 14 (27%) were confirmed deceased and 20 (39%) confirmed living. The remaining 17 (33%) were lost to follow-up. There were no significant differences in the mortality rates of patients receiving care from the American-trained neurosurgeon and those receiving care from the Tanzanian AMO trained and mentored by the American neurosurgeon. This initial audit provides support for the development of limited neurosurgery programs in underserved communities. Combined utilization of available neurosurgeons and continued training for available local clinicians may help to meet this need.

Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity

Recently, the Institute of Medicine examined resident duty hours and their impact on patient safety. Experts have suggested that reducing resident work hours to 56 hours per week would further decrease medical errors. Although some reports have indicated that cutbacks in resident duty hours reduce errors and make resident life safer, few authors have specifically analyzed the effect of the Accreditation Council for Graduate Medical Education (ACGME) duty-hour limits on neurosurgical resident education and the perceived quality of training. The authors have evaluated multiple objective surrogate markers of resident performance and quality of training to determine the impact of the 80-hour workweek. The United States Medical Licensing Examination (USMLE) Step 1 data on neurosurgical applicants entering ACGME-accredited programs between 1998 and 2007 (before and after the implementation of the work-hour rules) were obtained from the Society of Neurological Surgeons. The American Board of Neurological Surgery (ABNS) written examination scores for this group of residents were also acquired. Resident registration for and presentations at the American Association of Neurological Surgeons (AANS) annual meetings between 2002 and 2007 were examined as a measure of resident academic productivity. As a case example, the authors analyzed the distribution of resident training hours in the University of Virginia (UVA) neurosurgical training program before and after the institution of the 80-hour workweek. Finally, program directors and chief residents in ACGME-accredited programs were surveyed regarding the effects of the 80-hour workweek on patient care, resident training, surgical experience, patient safety, and patient access to quality care. Respondents were also queried about their perceptions of a 56-hour workweek. Despite stable mean USMLE Step 1 scores for matched applicants to neurosurgery programs between 2000 and 2008, ABNS written examination scores for residents taking the exam for self-assessment decreased from 310 in 2002 to 259 in 2006 (16% decrease, p < 0.05). The mean scores for applicants completing the written examination for credit also did not change significantly during this period. Although there was an increase in the number of resident registrations to the AANS meetings, the number of abstracts presented by residents decreased from 345 in 2002 to 318 in 2007 (7% decrease, p < 0.05). An analysis of the UVA experience suggested that the 80-hour workweek leads to a notable increase in on-call duty hours with a profound decrease in the number of hours spent in conference and the operating room. Survey responses were obtained from 110 program directors (78% response rate) and 122 chief residents (76% response rate). Most chief residents and program directors believed the 80-hour workweek compromised resident training (96%) and decreased resident surgical experience (98%). Respondents also believed that the 80-hour workweek threatened patient safety (96% of program directors and 78% of chief residents) and access to quality care (82% of program directors and 87% of chief residents). When asked about the effects of a 56-hour workweek, all program directors and 98% of the chief residents indicated that resident training and surgical education would be further compromised. Most respondents (95% of program directors and 84% of chief residents) also believed that additional work-hour restrictions would jeopardize patient care. Neurological surgery continues to attract top-quality resident applicants. Test scores and levels of participation in national conferences, however, indicate that the 80-hour workweek may adversely affect resident training. Subjectively, neurosurgical program directors and chief residents believe that the 80-hour workweek makes neurosurgical training and the care of patients more difficult. Based on experience with the 80-hour workweek, educators think that a 56-hour workweek would further compromise neurosurgical training and patient care in the US.

Evolution in practice: how has British neurosurgery changed in the last 10 years?

Neurosurgery is a fast-evolving surgical subspecialty driven by technological advances, socio-economic factors and patient expectations. In this study, we have compared the work-load volume in a single institution in the years of 1994 and 2004 and commented on the possible reasons for the changes and the impacts they may have for the future. A retrospective, log-book review of all operations performed in the years 1994 and 2004 in a single, tertiary, neurosurgical centre was performed. Neurosurgical practice has evolved over this period. Current practice has moved away from clipping of aneurysms and towards coil embolisation performed by interventional radiologists. Electrode stimulation of deep brain regions for movement disorders is the current practice, whereas 10 years ago the same disorders were dealt with by lesioning of the relevant regions. In spinal neurosurgery, instrumentation is increasingly favoured currently. In the field of neuro-oncology, current practice favours minimal access to the target area by the use of stereotactic localisation. Changes were most pronounced in the subspecialties of vascular, functional and spinal neurosurgery within this 10-year period. Knowledge of such dynamics is valuable in health resource management as well as planning for neurosurgical training programmes.

Temporal bone dissection for neurosurgery residents: identifying the essential concepts and fundamental techniques for success

Background Many contemporary neurosurgery residents, cordoned by work hour restrictions and drawn to newer technologies such as endovascular therapy, lack the proper direction necessary to learn the essentials of temporal bone dissection. A thorough knowledge of temporal bone anatomy combined with guidance regarding proper surgical technique makes temporal bone dissection an efficacious and fundamental learning activity. There is currently no concise guide for neurosurgical training programs to use in teaching the essentials of this dissection. Methods Over several years, the authors worked with neurosurgery residents to determine the key concepts necessary to gain a fundamental working knowledge of temporal bone dissection. Results We have identified 5 essential surgical principles and developed a step-by-step dissection technique useful for neurosurgery residents. Conclusions Using this template, neurosurgery residents can make the most of their time in the skull base laboratory, becoming familiar with relevant temporal bone anatomy in situ and becoming facile with the surgical techniques necessary for its safe dissection.

THE ROLE OF THE JOURNAL CLUB IN NEUROSURGICAL TRAINING

The journal club (JC) plays a traditional role in resident education. However, little has been written on its current role in neurosurgical training programs. Our goal was to determine resident perception of JCs, factors that make JCs successful, and identifying variables for improving JCs. We electronically surveyed all resident members of the Congress of Neurological Surgeons to determine the format, prevalence, content, and efficacy of neurosurgical JCs. Eighty-five percent of the respondents stated that their residency programs have a JC. The perceived primary goal of JCs is for keeping current with the literature and the dissemination of information. Most JCs meet for 1 hour during the week on a monthly basis and review one to three articles. Residents generally present the articles, which are typically original research articles selected by either the faculty or the residents. Most residents consider JCs of good educational value with positive effects on reading habits. Resident and faculty attendance are important variables to a successful JC. Although the majority of residents have minimal background training in epidemiology, biostatistics, or research, fewer than one-third of the training programs provide any type of supplemental sessions or handouts regarding such methods. JCs have a high perceived value by neurosurgical residents and should be maintained at all neurosurgical residency training programs. Key factors to a successful JC include faculty and resident attendance. Additional studies are needed to assess optimal JC formats and the possible utilization of supplemental educational tools.

Surgical education in the twenty-first century

In this era of increased scrutiny on patient safety, surgical education, and informed consent, Dr. Morgan and his colleagues test an exceedingly important hypothesis regarding the effect that resident participation has on the outcome of major intracranial surgery. It is a very common experience for faculty neurosurgeons at academic medical centers to be asked by patients and/or their family about who will perform the operation. Specifically, the patient wants reassurance that the experienced surgeon—not a trainee—will be performing the operation. The public is increasingly well informed about this particular topic from the media and is perhaps misled by the inaccurate portrayal of surgeons in popular television programs. Furthermore, there have been proposals introduced by the Centers for Medicare and Medicaid Services to specifically identify, through the informed consent process, exactly who will be performing what part of the operation as well as the level of experience of that individual. As counterpoint, neurosurgical training programs are responsible for educating the neurosurgeons of the future who will be taking care of us. In addition, the residency program director in the US now must state for each finishing resident that the resident is competent to independently perform “common” neurosurgical procedures, although there is no definition as to what are common neurosurgical procedures. One can use the guidelines for case numbers posted by the Neurological Surgery Residency Review Committee (www.acgme.org/acWebsite/RRC_ 160/160_guideCaseNumb.asp) as a surrogate for operations that a resident should master by the conclusion of residency. If that is used, then residents performing at least the median number of surgeries could be considered competent in that procedure. Craniotomy for aneurysm is included in this group of procedures. This presupposes that the resident played a significant role in the operation. Morgan and colleagues address the impact that the trainee has on outcome of elective craniotomy for small, uncomplicated aneurysms. They defined an adverse outcome as a new neurological deficit (present 6 months after surgery) caused by the procedure. Data were collected as 3-year increments over a period of 15 years, with 355 cases evaluated (196 with significant trainee participation and 159 with no trainee present). The initial 3-year interval

Training in Cerebrovascular Disease: Do We Need to Change the Way We Train Residents?

With the ongoing development of endovascular techniques and technologies, treatment of cerebrovascular disease is evolving at a fast pace. For neurosurgery to maintain a leadership role in the treatment of these disorders, modifications in neurosurgical training programs are essential. In this article, we discuss the changes perceived to enable residents to acquire the multifaceted understanding and skill set necessary to meet the new clinical reality and prepare to become the leaders of tomorrow in the management of cerebrovascular disease.

Surgery for primary brain tumors at United States academic training centers: results from the Residency Review Committee for Neurological Surgery

Surgery for primary brain tumors has been an important index of the quality of neurosurgical training programs in the US. The scope of such cases and the proportion of surgeries performed transsphenoidally are an interesting means of tracking the effectiveness of residency education. Program Information Forms from the 94 American Council for Graduate Medical Education-approved US neurosurgical residency programs were reviewed for the period between 2000 and 2003. Particular attention was focused on an analysis of the cases requiring craniotomy for primary brain tumor and transsphenoidal surgery. The mean annual number of primary brain tumor cases per program was 195, with a range from 36 to 724 cases. The proportion of primary brain tumors accessed transsphenoidally was 20%. The mean annual number of transsphenoidal operations performed at academic training centers was 39. A wide range in the frequency of transsphenoidal cases from one program to another was also noted. Almost one third of training centers performed fewer than 20 transsphenoidal operations annually and 80% performed fewer than 50. Most neurosurgical training programs provide residents with excellent experience in craniotomy for primary brain tumors. Practice with transsphenoidal surgery, however, is less well represented and tends to be clustered at several active centers. The implications for neurosurgical education are significant.

Changing neurosurgical workload in the United States, 1988-2001: craniotomy other than trauma in adults.

Changes in neurosurgical workload can justify requests for hospital resources and guide planning by neurosurgical training programs. Most previous studies have used non-population-based data sources, such as surveys of professional society members, to explore the neurosurgical workload in the United States. This is a retrospective cohort study of patients in Diagnosis Related Group (DRG) 1 ("Craniotomy other than trauma, age > 17") using the Nationwide Inpatient Sample. Statistical methods were adjusted for complex survey methodology to generate total United States caseload estimates. The total United States DRG 1 caseload increased from 70,800 admissions in 1988 to 105,300 admissions in 2001, a 50% relative increase (P < 0.001). For most diagnostic categories, the relative caseload increase was similar to that for the whole group. Patient age and sex distributions remained stable over time. Medical comorbidities, such as hypertension, chronic pulmonary disease, diabetes, and obesity, became more frequent. Elective admissions increased and in-hospital mortality rates decreased. Length of hospital stay decreased during the first half of the study period and then stabilized. Combined with increasing caseload, this caused total annual inpatient DRG 1 days to increase progressively after 1996. The number of United States hospitals with DRG 1 admissions decreased over time. Per-hospital annual DRG 1 caseloads increased, especially at high-volume centers. For the largest 100 hospitals by DRG 1 caseload, total admissions increased from 8.5% of all United States admissions (1988) to 9.4% (2001), whereas DRG 1 caseload increased disproportionately, from 27% to 38% of the United States aggregate caseload. This is evidence that progressive centralization of DRG 1 admissions took place during the study period. We documented an increase in total caseload and centralization of care for DRG 1 in the United States during the period 1988 to 2001. Defining the reasons for the changes in neurosurgical workload we observed will require further research.

The history of neurosurgery at Temple University.

TEMPLE UNIVERSITY'S NEUROSURGERY program has had a colorful and distinguished history since its creation in 1929. It has always functioned under challenging circumstances with limited resources but with a strong sense of mission. It was one of the 20 neurosurgical training programs in existence when the American Board of Neurosurgery was founded in 1940. Over the past 64 years, the program has trained approximately the same number of neurosurgeons, many of whom have contributed significantly to our specialty. Some of the advances pioneered in part at Temple include clinical hypothermia (Fay), the biplanar stereoscopic angiographic unit (Chamberlain), human stereotactic surgery (Spiegel and Wycis), lumboperitoneal shunts (Scott), posterior lumbar interbody fusion (Lin), microsurgery for acoustic tumors (Buchheit), and new pharmacological approaches to neuroprotectors (Strauss and Narayan). The Temple neurosurgery program has survived many challenges in the past and will no doubt weather the current financial and medicolegal challenges that confront the neurosurgical community in Philadelphia. It remains a strong clinical program that serves an otherwise underserved community and attracts patients beyond its geographic area because of its strong clinical reputation and the excellence of its clinical faculty and residents.

Teaching evidence-based medicine to surgical subspecialty residents.

Curricula for the teaching of evidence-based medicine to residents have been the subject of reports, analyses, and commentary. Specific programs for teaching evidence-based medicine principles to surgical subspecialty residents have not been identified by the authors. The objective of this article is to report our experience in establishing a teaching program in the principles of evidence-based medicine to surgical subspecialty residents. We established a teaching program in the principles of evidence-based medicine for neurosurgical residents in a busy neurosurgical training program. Two hours were set aside every other week, replacing traditional professors' rounds with sessions led jointly by a neurosurgeon and an epidemiologist, but based on case presentations from patients currently being treated. From these presentations, searchable clinical questions were developed, and the literature was searched, critically analyzed, and summarized. Results of several cycles on this process are reported. The group developed a repository of Internet-based resources for evidence-based education and practice. Using these resources, the group analyzed six topics in the first 2 years of the program. These included the "best" way to clinically grade patients after subarachnoid hemmorhage, considerations in the biopsy and treatment of enhancing intracerebral mass lesions in patients with acquired immunodeficiency syndrome, the use of prophylactic anticonvulsants in patients with primary brain tumors, the identification of cervical spine injuries in the emergency department, the grading of the fractures of the odontoid process, and the value of removing retained bullets from the spinal canal. The outcomes ranged from finding insufficient evidence to reach a conclusion, through the identification of well-conducted and well-reported critical syntheses of the topic already available in literature, to the development of the detailed algorithm for cervical spine clearance that was accepted by the institution's emergency department. By dedicating some specific time and using resources readily available in most academic health centers, it is possible to incorporate the teaching of the principles of evidence-based practice into the ongoing education of residents on a busy surgical subspecialty service.

European neurosurgical education--the next generation.

Questionnaires regarding neurosurgical training were sent to all participants of the EANS-training course in Barcelona 1999 and to all national neurosurgical societies of EANS. The completed questionnaires show a significant variation in 1) the demands for education prior to obtaining a neurosurgical training position, 2) in the theoretical training programme and 3) in the surgical experience obtained within the training period. The trainees express a need for improvement of the neurosurgical training programmes. The need for common guidelines for European neurosurgical training as well as regular evaluation of the training programmes are discussed.

Interview with George A. Ojemann.

Abstract George A. Ojemann was born in Iowa City, and received undergraduate and medical degrees from the University of Iowa, and his neurosurgical training at the University of Washington in Seattle. He has been on the faculty of that school ever since, except for a brief period at the National Institutes of Health in Bethesda, MD. He is presently Professor of Neurological Surgery. His clinical interest is in the surgical treatment of epilepsy. In addition to the research interests that are the subject of this interview, he is past chairman of the neurosurgical certifying board, a present member of the neurosurgical training program accrediting body, a member of the NIH Neurological Institute Advisory Council, and the President-Elect of the American Academy of Neurological Surgery. He is also a recipient of an NIH Javitts Award, a Distinguished Alumni citation from the University of Iowa, and an honorary Doctor of Sciences degree from the Medical College of Ohio. His wife is a neurologist with interests in epilepsy, and his two sons are in neurosurgical training programs, while his daughter is in medical school.