SPECIAL ARTICLE SPECIAL ARTICLE

Melanie Hayden Gephart, MD, MAS* Pamela Derstine, PhD‡

Resident Away Rotations Allow Adaptive Neurosurgical Training

Nelson M. Oyesiku, MD, PhD§ M. Sean Grady, MD¶ Kim Burchiel, MDk H. Hunt Batjer, MD# A. John Popp, MD Nicholas M. Barbaro, MD** *Stanford University Medical Center, Department of Neurosurgery, Stanford, California; ‡Accreditation Council of Graduate Medical Education, Chicago, Illinois; §Emory University, Department of Neurosurgery, Atlanta, Georgia; ¶University of Pennsylvania, Department of Neurosurgery, Philadelphia, Pennsylvania; kOregon Health & Science University, Department of Neurological Surgery, Portland, Oregon; #University of Texas Southwestern Medical Center, Department of Neurological Surgery, Dallas, Texas; **Indiana University, Department of Neurological Surgery, Indianapolis, Indiana Correspondence: Melanie Hayden Gephart, MD, MAS, Stanford University Medical Center, Department of Neurosurgery, 300 Pasteur Dr, MC5327, Stanford, CA 94305. E-mail: [email protected] Received, August 11, 2014. Accepted, November 24, 2014. Published Online, January 29, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.

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Subspecialization of physicians and regional centers concentrate the volume of certain rare cases into fewer hospitals. Consequently, the primary institution of a neurological surgery training program may not have sufficient case volume to meet the current Residency Review Committee case minimum requirements in some areas. To ensure the competency of graduating residents through a comprehensive neurosurgical education, programs may need for residents to travel to outside institutions for exposure to cases that are either less common or more regionally focused. We sought to evaluate off-site rotations to better understand the changing demographics and needs of resident education. This would also allow prospective monitoring of modifications to the neurosurgery training landscape. We completed a survey of neurosurgery program directors and query of data from the Accreditation Council of Graduate Medical Education to characterize the current use of away rotations in neurosurgical education of residents. We found that 20% of programs have mandatory away rotations, most commonly for exposure to pediatric, functional, peripheral nerve, or trauma cases. Most of these rotations are done during postgraduate year 3 to 6, lasting 1 to 15 months. Twenty-six programs have 2 to 3 participating sites and 41 have 4 to 6 sites distinct from the host program. Programs frequently offset potential financial harm to residents rotating at a distant site by support of housing and transportation costs. As medical systems experience fluctuating treatment paradigms and demographics, over time, more residency programs may adapt to meet the Accreditation Council of Graduate Medical Education case minimum requirements through the implementation of away rotations. KEY WORDS: Education, Neurosurgery, Residency, Rotation, Training Neurosurgery 76:421–426, 2015

DOI: 10.1227/NEU.0000000000000661

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reating centers of excellence to provide high quality care for a particular surgical focus area requires the consolidation of subspecialized healthcare services into a limited number of hospitals with trained staff and sufficient case volume. The Residency Review Committee (RRC) for Neurological Surgery has set minimum expected case volumes for numerous procedural areas that act as a surrogate for the assurance of a proper breadth of clinical training. ABBREVIATIONS: ACGME, Accreditation Council of Graduate Medical Education; RRC, Residency Review Committee Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.neurosurgery-online.com).

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These case minimums define the diversity and depth of exposure to be provided by a program and help to ensure that a neurosurgery resident graduates with sufficient variety of experience and expertise to allow independent clinical practice. Certain patient populations, such as pediatrics and trauma, and procedures including carotid endarterectomy, temporal lobectomy for epilepsy, and endovascular neurosurgery, are often regionally concentrated. Medical centers separate from university-based training programs may receive the majority of referrals for certain types of care, often on the basis of historical referral patterns or local clinician reputation. Consequently, some training programs may not be able to provide residents with the full spectrum of mandatory cases, requiring resident rotations at distant institutions to ensure a comprehensive neurosurgical training experience. Although rotations outside of the primary

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institution are not unique to neurosurgery, as a specialty, we have not determined the extent to which residents participate in away rotations and the characteristics of these experiences. Compiling these data will allow us to determine over time how our changing healthcare infrastructure affects the geographic challenges of neurosurgical training.

METHODS Survey questions were created by the members of the RRC for Neurological Surgery of the Accreditation Council of Graduate Medical Education (ACGME). The questions were distributed electronically through an online survey to program directors throughout the country. Of the 105 programs queried, 95 responded, and all were included in our analysis. Data were also extracted from the ACGME accreditation system that monitors the number and location of participating sites per program, the distance of the rotation away from the primary site, and the accreditation status of programs. A participating site was considered to be a training location with a formal agreement or affiliation with the host academic institution (primary site) to train neurosurgery residents. An away rotation was defined as one in which the resident must stay away from home .3 days to complete the requirement. Multiple participation sites within the same city were not considered an away rotation. Mandatory rotations were defined as those undertaken by all residents in a program; elective rotations were defined as those available to all residents in a program. Unique electives taken by individual residents were excluded because the core objective of our study was to examine institutional changes to accommodate overarching changing workforce needs. The questions of the survey are included in the Supplemental Digital Content (http://links.lww.com/NEU/A716).

RESULTS Eighty-nine percent of the 105 programs had at least 1 additional participating site (Figure 1A); there was an average of 3.15 participating sites per program (SD = 1.36; range, 1-6 sites). Four programs had 6 different participating sites for resident rotations; however, most participating sites hosted only 1 program (SD = 0.14; range, 1-5; Figure 1B). The majority of participating sites were within 10 miles of the primary site (Figure 2A), but for 4 sites, programs were located .1000 miles away. Regardless of the required distance to travel, most of the rotations were required (Figure 2B). The duration of the rotation and subspecialty experience gained are presented in Figure 2C. One in 5 programs had a mandatory rotation in which the resident stayed away from home to complete the requirement (n = 24); 10% of programs had an elective away rotation that required separate residence (n = 9). For mandatory rotations, the requirement was fulfilled mostly during the midlevel years, whereas elective rotations were generally completed during postgraduate year 5 or 6 (Table 1). Most mandatory rotations of sufficient distance to require separate residence were 3 to 6 months (n = 24 of 95 reporting programs; range, 1-15 months). The rationales described by the survey respondents (n = 95) for having the mandatory rotation included the need for additional cases in a subspecialty (63%, n = 9), a unique service provided by

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FIGURE 1. Neurosurgery program usage of participating sites. A, residents at most of the 105 programs rotated through 2 to 5 affiliated sites (average = 3.15; SD = 1.36; n = 105). B, most participating sites hosted only 1 program, but 15% hosted $2 (average = 1.33; SD = 0.14; n = 189).

the away rotation that was not available at the home institution (71%, n = 10), and an international experience or a particular practice type (n = 1). Case deficiencies mentioned to be motivating factors for the away rotation were mainly peripheral nerve, functional, epilepsy, and pediatrics but also included trauma, radiosurgery, and oncology. The majority of elective rotations were to fulfill a unique international experience (67%, n = 6) rather than to provide needed cases or service (33% and 44%; n = 3 and 4, respectively). Of the responding programs with elective away rotations (n = 8), 5 were international locales, including Ireland, New Zealand, and Uganda. Program directors commented that the international rotation represents “the critical point in our training,” providing a unique professional and personal experience of living abroad and working within a different practice environment. Elective external rotations were also chosen for research or special fellowship-level training in a particular subspecialty. All programs had written agreements with the host institution for mandatory rotations (n = 16) compared with 70% (n = 7) with elective rotations. The primary institution generally

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AWAY ROTATIONS IN NEUROSURGERY TRAINING

FIGURE 2. Distance of participating site from host institution. A, 87% of participating sites were ,50 miles from the 105 host institutions (average = 59.1 miles; SD = 223 miles; n = 226). B, the majority of these rotations were required, regardless of the distance from the primary site. C, the duration of the rotation was up to 1 year, most commonly covering a variety of neurosurgical subspecialties. PGY, postgraduate year.

covered malpractice insurance and salary. Additional supplements to help defray the costs of an away rotation are detailed in Table 2. Components of our analysis from the program director survey were dependent on the number of respondents; Table 2 had 11 responders, which may limit the ability to generalize these data. Most of the benefits were in the form of a housing supplement, provided by 10 of the 11 responding programs. This occurred either with or without additional stipend or relocation costs.

DISCUSSION The neurosurgery RRC has determined case category minimums for graduating residents as one metric of evaluation for overall quality in trainee education and competency of graduating residents. As a result of shifting referral patterns, medical treatment paradigms, reimbursement structure, and practice attributes, many core neurosurgical cases have become centralized in large centers equipped for the unique demands required by a particular patient population or disease. The RRC approves additional sites for primary programs on the basis of educational

TABLE 1. Postgraduate Year Level During Which an Away Rotation Required Separate Residencea Postgraduate Year Level 1 2 3 4 5 6 7

Mandatory, %

Elective, %

19 6 38 44 38 13 6

0 0 11 22 56 67 22

TABLE 2. Program Accommodations for Mandatory Away Rotationsa Benefit

%

Housing Stipend Relocation Car Food

90 27 36 18 9

a a

Of the responding programs with mandatory away rotations (n = 16), the majority of residents fulfilled the requirement during their third through fifth years of training. Elective rotations were more commonly undertaken during the fifth and sixth years (n = 9).

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Program accommodations for mandatory away rotations. Responding programs (n = 11) had varying methods of defraying the costs associated with a rotation distant from the primary institution. The percentage refers to the number of responding programs providing this benefit for residents while at a distant off-site location.

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GEPHART ET AL

rationale, institutional case volume, and case minimums for rotating residents (logging cases as either an elective or primary rotation). The impact of away rotations is tracked through the RRC designation of the level of case involvement (assistant, senior, or lead resident surgeon) and annual reporting of the impact of “other learners” on the annual Resident Survey submitted to ACGME. For cases performed during an elective to be entered into and tracked by the ACGME case log system, the elective must meet certain criteria such as being at an ACGME-approved training site. These metrics will help in the monitoring of resident education and the necessity of away rotations after the implementation of Committee on Advanced Subspecialty Training–accredited subspecialty enfolded fellowships. The requirement of programs to ensure resident exposure to a minimum number of index cases, combined with work hour restrictions and financial considerations, necessitates innovation in structuring rotations to enable residents to meet their academic requirements and aspirations. The difficulty of meeting the expectations of case breadth and volume as determined by the RRC is not unique to neurosurgery. As burn, transplantation, endoscopy, and trauma cases have become more concentrated in specific centers, general surgery program directors have created specific rotations at these locations to ensure resident exposure to these subspecialties.1-3 For example, 77% of patients with the highest severity of burns in Michigan are treated in 4 high-volume hospitals (treating .100 patients per year), but 23% of general surgical programs did not have a formal educational affiliation with a regional burn center.4 In neurosurgery, there are frequently deficiencies in case volumes for carotid endarterectomy, intracranial vascular surgery, pituitary surgery, craniotomy for trauma, and epilepsy surgery. This was reflected in our findings of the subspecialty rotations motivating the external rotations. Just as the shift to nonoperative conservative management of blunt abdominal trauma creates difficulty for general surgery residents to become competent in surgical treatment of abdominal trauma, so too in neurosurgery has the increased use of endovascular treatment of intracranial aneurysms made it difficult to ensure competency in open surgical management. Likewise, regional consolidation of expertise such as with pituitary tumors (Jane, Journal of Neurosurgery, 200512; McLaughlin, Neurosurgery, 201213) limits the exposure of some residents to the necessary breadth and volume of cases. Regardless, both the General and Neurological Surgery RRCs have set case category minimums demonstrating clear expectations for resident experience as a reflection of what each specialty determines is fundamental to trainee education. Courses offered through industry and national organizations may supplement resident knowledge base and comfort with rare procedures5; however, rotations at high-volume centers help to ensure a wellrounded training experience. Benefits of an away rotation include diversification of the resident surgical experience, but away rotations carry a significant potential cost. Programs recognize the unique potential burden an away rotation has on a resident and make special accommodations

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for expense reimbursement. Neurosurgery programs with away rotations frequently provide housing and transportation costs, consistent with other surgical training programs with subspecialty away rotations.3 Logistical considerations such as rotation agreements, rotation chief, continued resident involvement in didactic education, and malpractice coverage must be negotiated in advance. Additional considerations include the service needs of the primary institution left with fewer residents and the effect of visiting residents on the host institution training capacity of their primary residents. Distant rotations can create financial and emotional burdens, particularly for residents with families, which must be preemptively mitigated. A survey of the spouses of thoracic surgery applicants found that the 3 highest factors for the selection of a program were the quality of fellowship, the geographic location, and the proximity to family.6 Away rotations have the potential to disrupt some of the more important features of a desirable training program. In a survey of general surgery program directors regarding mandatory transplantation surgery rotations at sites distant from the primary program, 78% considered travel to be a poor aspect of the experience.3 Separate training sites complicate exposure to academic didactics and limit the ability of the host institution to monitor incremental progress in achieving independent capacity as a neurosurgeon. In addition, mandatory rotations that require trainees to drive for extended distances to outlying sites necessitate particular attention to and amelioration of resident fatigue. Thus, the personal and financial burdens of an away rotation must be carefully balanced against the increased depth of professional experience to be gained. Although beyond the scope of our study, an important next step would be to query the residents regarding their experiences on the educational value of off-site rotations and to look more in depth at the additional costs shouldered by both the resident and training program to provide this exposure. International rotations form a distinct subcategory of away rotations. Formalizing the relationship with an academic center and hospital abroad creates a unique personal, cultural, and surgical experience. Residents have the opportunity to interact with patients of diverse backgrounds and pathology using a different approach to resource management.7-9 Close to 60% of orthopedic specialties have opportunities in global health, most with some funding available for the traveling residents.10 Of the participating orthopedic programs surveyed, 69% of residency directors believed this experience shaped future volunteer efforts, and many considered it to be a significant consideration in attracting residents to a training program.10 International rotations increase cross-cultural sensitivity, a sense of service, and understanding of the global burden of disease.7,11 Neurosurgery programs with international rotations found this experience to be a critical aspect of the resident’s overall training for both professional and personal development.

CONCLUSION Most neurosurgery programs conduct resident training at multiple sites. Away rotations in residency help to diversify the

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AWAY ROTATIONS IN NEUROSURGERY TRAINING

surgical experience through greater exposure to rare cases and different patient populations. Programs support these rotations through a variety of financial mechanisms, carefully accounting for the personal impact on residents. A periodic evaluation of these rotations from the perspective of neurosurgery program directors and residents would be important to understanding the changing demographics and needs of resident education. Expansion of this study format to incorporate other surgical specialties on a national scale would also be worthwhile. Further consolidation of care in specialized centers may increase the need for rotations distant from the primary institution. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. All are members of the ACGME Neurosurgery RRC.

REFERENCES 1. Bulinski P, Bachulis B, Naylor DF Jr, Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma. 2003;54(1):161-163. 2. Vo DM, Gauvin JM, Chen SL. Endoscopy education in general surgery residencies: meeting the new RRC requirements. J Surg Res. 2010;163(2):210-213. 3. Bittner JG IV, Fryer JP, Cofer JB, et al. Program directors’ views on general surgery resident travel for transplant rotations. Am J Surg. 2011;202(5):618-622. 4. Pacella SJ, Harkins D, Butz D, Kuzon WM Jr, Taheri PA. Referral patterns and severity distribution of burn care: implications for burn centers and surgical training. Ann Plast Surg. 2005;54(4):412-419. 5. Sheehan JP. Resident perceptions of radiosurgical training and the effect of a focused resident training seminar. J Neurosurg. 2010;113(1):59-63. 6. Bohl M, Reddy RM. Spouses of thoracic surgery applicants: changing demographics and motivations in a new generation. J Surg Educ. 2013;70(5):640-646. 7. Jarman BT, Cogbill TH, Kitowski NJ. Development of an international elective in a general surgery residency. J Surg Educ. 2009;66(4):222-224. 8. Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc. 2010;85(8):734-741. 9. Tarpley M, Hansen E, Tarpley JL. Early experience in establishing and evaluating an ACGME-approved international general surgery rotation. J Surg Educ. 2013;70 (6):709-714. 10. Clement RC, Ha YP, Clagett B, Holt GE, Dormans JP. What is the current status of global health activities and opportunities in US orthopaedic residency programs? Clin Orthop Relat Res. 2013;471(11):3689-3698. 11. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009;84(3):320-325. 12. Jane JA Jr, Sulton LD, Laws ER Jr. Surgery for primary brain tumors at United States academic training centers: results from the Residency Review Committee for Neurological Surgery. J Neurosurg. 2005;103(5):789-793. 13. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012;71(5):916-924.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.neurosurgery-online.com).

COMMENTS

T

he authors report on data compiled from a survey to neurosurgery residency program directors, as well as from the Accreditation Council

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of Graduate Medical Education accreditation system regarding participating sites per program, to delineate the current state of away rotations in North American neurosurgery residency training. Although reports of away rotation requirements exist in general surgery, similar reports are lacking in the neurosurgery literature. This report is therefore an important benchmark for neurosurgery residency programs against which future changes can be measured. Their work is an important contribution, yet it also highlights the limits of the information we currently have about such rotations. In particular, the distinction between the home program’s own remote sites and rotations at other programs needs to be more specific. Neurosurgery has a long history of neurosurgeons scholars visiting other programs to expand the depth and diversity of their experience, a function the away rotation can often serve. Considering the need to meet new required minimum case numbers for graduating residents, information about away rotations becomes even more relevant. Currently, cases done on away rotations that are sponsored by other residency programs cannot be counted toward a resident’s cases for American Board of Neurological Surgery certification. We question whether these should be counted if done at another Accreditation Council of Graduate Medical Education/Residency Review Committee– approved residency program. Because many residents go to away rotations specifically to get more experience with cases of a type that they cannot get at their home program, this would allow programs with enough cases of a given type to contribute to the education of residents from programs that lack the same case type without penalizing the home institution for granting them this opportunity. This flexibility should further promote resident education. Although future work will delineate the value and unique challenges of these described training rotations, the authors are to be commended for their efforts to describe the current state of away rotations and sites per training program in neurosurgery. Mark E. Oppenlander Peter Nakaji Phoenix, Arizona

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his is a very timely report that is relevant to every neurosurgical training program in the United States. Regional hospital subspecialization and referral patterns can create difficulties for some neurosurgical training programs trying to meet Accreditation Council of Graduate Medical Education minimal case volume requirements in certain areas. These minimal case requirements are the backbone for maintaining the scope of training necessary for the transition to independent clinical practice. This report is a first step in paving the way for programs with deficiencies in one area of neurosurgical subspecialization to partner with a program with a more-than-adequate complementary case volume for those types of cases. With information from this report and further work in the future, one could envision a number of neurosurgical residency training programs working together to exchange trainees between these programs to allow maximal exposure to the breadth and depth of neurosurgical training. Randy L. Jensen Salt Lake City, Utah

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he Residency Review Committee has given us a glimpse into a possible future of training. With a variety of causes, the authors have found that 20% of programs have mandatory away rotations to cover deficiencies in their own caseload. This is a bit surprising. Half of those required the

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resident to move to a new residence during this time. Appropriately, the programs typically provide for these expenses. These rotations occur most often in the middle years of a resident’s term. The authors provide a thorough discussion of the benefits and drawbacks of away rotations. This practice is not new; I spent a year in Sweden 20 years ago during my own training, albeit for bench research. Nevertheless, this practice seems to be gaining traction. I do wonder if it is possible to account for the phenomenon of “enfolded fellowships” during research time as it would pertain to understanding the evolution of these rotations. As ongoing consolidation in the healthcare marketplace continues, some programs may find it increasingly difficult to provide the proper breadth of caseload, which I foresee will likely see lead to an increase in the need for away rotations. Craig H. Rabb Oklahoma City, Oklahoma

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he authors are to be commended for taking on this study. It is traditional, educationally efficient, and often easiest to stay in or around one parent institution for residency training. Fellows are often encouraged to travel elsewhere to benefit from additional perspectives. Nevertheless, there are advantages to traveling, even during residency. One clear benefit is the potential to enrich the pathology seen and the patient population treated. A second is exposure to different

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operative strategies and approaches and to variations in technique and technologies. A third is seeing different treatment options afforded by the differences in resources provided by different institutions. Next there is the matter of innovation and how it may be encouraged, introduced, and implemented. Then participation in training and routines: What are different strategies for teaching, training and learning? What are variations in operational routines in a neurosurgical practice, and what is to be learned from them? Finally, there is the research side with exposure to different translational medical and surgical approaches. Rotations away also increase intellectual flexibility and imagination. They enlarge one’s professional network. The impact of seeing variations in therapeutic approaches and technologies is far greater than reading about them or watching or hearing presentations. This is how advances in science and surgery can be stimulated and careers inspired. So long as the scope and sequence of neurosurgical training can be maintained, personal hardships can be minimized, and adequate supervision can be provided, the experience of rotations away can enhance neurosurgical training and inure to the benefit of the resident and, over the long run, inure to the benefits of patients and colleagues. T. Forcht Dagi Newton Centre, Massachusetts

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Resident away rotations allow adaptive neurosurgical training.

Subspecialization of physicians and regional centers concentrate the volume of certain rare cases into fewer hospitals. Consequently, the primary inst...
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