Perspectives Commentary on: Impact of Fellowship Training on Research Productivity in Academic Neurological Surgery by Agarwal et al. World Neurosurg 80:738-744, 2013

Daniel L. Barrow, M.D. Professor and Chairman Department of Neurosurgery Emory University School of Medicine

Neurosurgical Training Daniel L. Barrow


he natural course for a medical or surgical specialty is to become more subspecialized. Neurosurgery itself evolved from the discipline of general surgery through the pioneering efforts of surgeons who focused their practices on disorders of the nervous system. As neurosurgery has become more specialized, it has also become more complex. With that increasing complexity, more rigorous and lengthy training has been required. Once achieved by apprenticeships, neurosurgical training in the United States is now a mandatory 7 years of residency after medical school. Despite the lengthy training, a substantial percentage of neurosurgical trainees voluntarily choose to add 1 or more years to their training by engaging in fellowships. The past 2 decades has witnessed an increasing number of neurosurgical trainees pursuing subspecialty fellowships. Yet, American neurosurgery has been cautious about embracing and recognizing the notion of subspecialization. The American Board of Neurological Surgery is 1 of 5 of the 24 member boards of the American Board of Medical Specialties that does not certify any subspecialties. The others are ophthalmology, colon and rectal surgery, allergy and immunology, and nuclear medicine. As a result, other options for neurosurgical subspecialty training and subspecialty recognition have evolved. This includes fellowships within individual institutions, enfolded training, apprenticeships, postgraduate courses, and fellowships approved by the Committee for Accreditation of Subspecialty Training (CAST) of the Society of Neurological Surgeons.

Key words Academic productivity - Academic promotion - Academic rank - H-index - Neurological surgery fellowships - Neurological surgery fellowship training - Neurological surgery - Scholarly impact - Scholarly productivity -

Abbreviations and Acronyms CAST: Committee for Accreditation of Subspecialty Training


CAST has now accredited many fellowship programs in endovascular surgical neuroradiology, stereotactic and functional neurosurgery, peripheral nerve, spine, pediatric neurosurgery, neurosurgical oncology, neurosurgical critical care, and open cerebrovascular surgery. Currently, CAST does not certify individuals but only programs providing subspecialty training. Furthermore, CAST currently recognizes only postgraduate fellowships and not subspecialty training enfolded into residency. In his 2012 Society of Neurological Surgeons Presidential Address, Dr. Arthur Day proposed consideration of a new neurosurgical curriculum of 7 years, the first 4 of which would be devoted to learning the “core” of neurosurgery. The core is defined and codified by the Milestones and Matrix curriculum projects. The Matrix curriculum is a learning curriculum developed under the guidance of the Society of Neurological Surgeons with input from many stakeholders. The Milestones project is a hierarchical learning-based curriculum organized by the Accreditation Council for Graduate Medical Education (ACGME) competencies, level of training and clinical domains (including critical care, neurology, trauma, endovascular, spine, cranial, functional, and pediatrics). The final 3 years of the residency could be individually directed subspecialty training, including certification. This would include subspecialty-related research and administrative skills. This restructuring would allow individual trainees to follow their core training with subspecialty training and research all within the confines of the standard 7-year program and potentially reduce the number of individuals pursuing postgraduate fellowship training.

Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA To whom correspondence should be addressed: Daniel L. Barrow, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2014).



Some neurosurgical subspecialties such as pediatric neurosurgery and endovascular neurosurgery have made it nearly impossible to be accepted into their fold without postgraduate fellowship training. Like other neurosurgical subspecialties, the skills required for these disciplines can likely be acquired during the 7 years of neurosurgical training but have been dominated by leadership that has insisted on postgraduate training. The findings in the study by Agarwal et al. are not surprising. There are a number of reasons why an individual neurosurgical resident may choose to pursue fellowship training. Some of those motivations may have no relationship to the potential for academic productivity. For example, one may elect to complete a fellowship because there is inadequate volume, clinical material and/or expertise in their residency. Some pursue fellowship training to improve their position in the marketplace. Others simply desire an opportunity to expand their clinical experience by exposure to another philosophy or approach to the subspecialty.


Indeed, many neurosurgical trainees pursue fellowship training for the additional research opportunities or to prepare them for a more specialized academic practice. In their study, the subspecialty of functional and stereotactic neurosurgery had the highest mean H-index score. This too is not surprising. The field of neuromodulation is dynamic, with rapid advances, and is academically oriented. The use of deep brain stimulation, gene therapy, and stem cell therapy in the subspecialty likely results in the preselection of individuals who are more likely to pursue an academic career.

Citation: World Neurosurg. (2014). Journal homepage: Available online: 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.


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