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Training the Neurosurgeon for the Twenty-first Century Robert G. Ojemann, M.D. Department of Surgery, Harvard Medical School, and Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts
In January 1992 the next neurosurgical resident match will be held. Under the current requirements of the American Board of Neurological Surgery (ABNS) the earliest any of the applicants accepted in that match would complete their neurosurgery residency is in June 1998. None of these applicants will be eligible to take the Oral Examination of the American Board of Neurological Surgery until after the year 2000. Many factors will influence the training of the neurosurgeon for the twenty-first century. At the 1990 Society meeting Robert Petersdorf, M.D., president of the American Association of Medical Colleges (AAMC), outlined eight issues in graduate medical education he said required sustained effort from all parts of the academic community [6]. I will summarize his comments and relate them to neurosurgery. The issues were the following: 1. Innovation in education. He discussed the problems of the fourth-year medical school curriculum and the suggestions that have been made to radically alter the structure of this training. This Society [of Neurological Surgeons] will need to follow developments in this area closely, since many residency programs place considerable weight on the performance of the student during a rotation on neurosurgery. 2. New clinical settings for clinical education. The problem of less exposure to inpatients and the changing patient population in some institutions with fewer routine cases was reviewed. For neurosurgery one of the problems is the increasing same-day admissions for most spine and some cranial operative procedures. How many programs have developed a way to involve the resident who will participate in the operation in the preoperative evaluation of such patients ? Another problem for some neurosurgical programs is the difficulty in providing the senior
The presidential address given to the Society of Neurological Surgeons at its 82nd annual meeting, Charleston, South Carolina, May 8-11, 1991. Address reprint requests to: Robert G. Ojemann, M.D., Massachusetts General Hospital, Boston, Massachusetts 02114. Received August 27, 1991; accepted August 30, 1991. © 1992 by Elsevier Science Publishing Co., Inc.
resident with enough experience in managing inpatient surgical cases. 3. Assuring competency (selection and evaluation). The evaluation of residents during the training program was discussed. What was not mentioned was the problem of resident selection. This Society believes that these two issues, selection and evaluation, are interrelated, and this subject has been the focus of a hard-working committee. I would use the title "selection and evaluation of residents" rather than "assuring competency." 4. Residency accreditation. Dr. Petersdorfdiscussed the views of the AAMC and referred to problems related to the functioning of the Residency Review Committee (RRC). The relationship of the RRC and the neurosurgical training programs was the topic of an extended discussion at this meeting. 5. Working conditions. This has been the subject of numerous public and professional discussions. This is another area in which major restrictions could have a significant impact on neurosurgical training programs. 6. Financing graduate medical education. With changing patterns in reimbursement and reduced support from the federal government, this topic will be of increasing concern, particularly for our specialty, in which the training program is longer than most. The Washington Committee for Neurological Surgery is monitoring this issue. 7. Autonomy of the specialty boards. The tendency to issue more and more certificates of special or added competence, which he termed "certificamania," was deplored. Fortunately, our specialty has resisted this tendency. 8. Manpower distribution. The overproduction of specialists and subspecialists at the expense ofgeneralists was discussed. We need to continually review our personnel needs. Are we training enough neurosurgeons to meet the replacement needs for disability and retirement, to meet the needs of an increasing elderly population, to provide enough neurosurgeons for academic programs, to take advantage of expanding opportunities in areas such as epilepsy, and to regain our leadership role in areas such as the treatment of spinal disorders? 0090-3019/92/$5.00
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A major issue that Dr. Petersdorf did not specifically mention is the structure of the training program; this is the subject that I will review in some detail. Periodically we should reevaluate our training programs to see if we will be adequately meeting the needs of future neurosurgeons. Do changes need to be made to adapt to the development of subspecialization, the treatment of traditional neurosurgical problems by other specialists, and the need for more sophisticated research to advance our field? Or is the present system still the best? We should ask several questions. Are the required 36 months of general neurosurgery appropriate? Are 3 months of neurology just right, too much, or too little? Should time on neuroradiology still be recommended? What are programs doing with the elective period of 21 months in the 5-year and 33 months in the 6-year programs? Is the time allotted for research being used wisely? With problems of funding longer training programs, should there be an opportunity for subspecialization within the residency program, or should more fellowships be developed for the neurosurgeon who has completed a residency program, or should both be encouraged?
History of the Requirements
of the ABNS
To have more understanding of why we have the present training requirements, I reviewed the ABNS minutes in relation to the times when major changes in these requirements were made. I am indebted to David Kline, former secretary of the ABNS, who had summarized many o f these changes; to Julian Hoff, the current secretary; and to his staff in the A B N S office, Mary Louise Davis and Elsie Ford, who retrieved the appropriate information. In 1940 individuals were granted certification without examination if they held the following credentials: 1. Practice in the United States or Canada 2. Professional rank of neurosurgeon 3. Practice limited to neurosurgery for 10 years prior to 1/1/40 4. Satisfactory moral and ethical standing 5. Membership in AMA or equivalent Canadian society or a society recognized by the AMA Council on Medical Education and Hospitals Training for these individuals had for the most part been by preceptorship. The operative experience was usually opening and closing the operative incisions and observation during the intracranial or intraspinal part of the procedure.
The initial training requirements for examination were as follows: 1. Graduation from a medical school in the United States or Canada recognized by the AMA Council on Medical Education and Hospitals or a foreign medical school acceptable to the A B N S 2. Surgical internship o f not less than I year in an approved hospital 3. Three years of neurosurgical training emphasizing the basic sciences related to neurosurgery 4. Two years of practice In 1950 the ABNS stated that the training in clinical neurosurgery must be progressive-at least two years of this training must be in one institution. This period of special training shall be of such a character that the relation of the basic sciences of anatomy, physiology, pathology, bacteriology and biochemistry is emphasized--the Board will not credit periods of study limited to the basic sciences of longer than six months. In 1954-1955 there were apparently long discussions at the board meeting about changing the length o f the training program to 4 years after the year o f general surgery. Some members thought that another year of general surgery should be added because o f the lack of knowledge of general surgical principles displayed by the candidates. Others thought the extra time should be spent in neurology, but several seemed to feel that it was more important to allow more flexibility in the program. In April 1955 the program was lengthened to 4 years with the stipulation that at least 30 months must be devoted to clinical neurosurgery. In addition it was stated for the first time that the candidate must be prepared to pass examinations in general surgery, organic neurology, neuropathology, neuroanatomy, neurophysiology, neuroophthalmology, and neuroradiology. Over the next decade the training requirements remained unchanged. T h e r e were more discussions about adding another year of general surgery. In 1965 the bylaws were amended as follows to meet a presumed need at that time: The residency period must be chiefly clinical and not didactic, and there should be continuous concurrent instruction in the basic neurological sciences and medical neurology, particularly as they relate to neurosurgery. There must be training in the surgical performance of contrast studies and the indication for these studies, as well as pre and postoperative care of such patients subjected to the various procedures. The training must also include the evaluation of such contrast studies.
Training the Neurosurgeon--21st Century
In 1968 another change was made in the bylaws, reflecting the changing background of the board. No longer was there the perceived need for additional general surgical training. It was stated that "at least 30 months of this period (4 years neurosurgical residency) must be devoted to clinical neurological surgery and the remaining 18 months should be devoted to some aspect of the neurological sciences." In the early 1970s the subcommittee on graduate medical education of the Education Committee of the American Association of Neurological Surgeons (AANS) became concerned about the fact that the requirements for neurosurgical training had not significantly changed in many years and were not in keeping with the thoughts of many program directors. Suggestions were developed and Dr. Robert King, chairman of the Education Committee, made a presentation to the ABNS, where, I understand, there was considerable skepticism. Nevertheless, the ABNS asked the Society of Neurological Surgeons to appoint a task force on graduate medical education to review this issue. The task force was charged with developing recommendations for upgrading the quality of training in neurological surgery. In May 1975 the task force reported to this Society. The chairman was Dr. Robert King. The members were Drs. Chou, Desaussure, Goldring, Langfitt, and Meagher. They proposed a minimum of 12 months of fundamental clinical skills related to surgery and a minimum of 60 months in the neurosciences to include the following: 1. 2. 3. 4.
Basic neuroscience--optional time Research--optional time Neuroradiology and neuropathology--optional time Neurology--3 months minimum (6 months recommended) 5. Clinical neurosurgery--36 months minimum (12 months as senior resident)
These recommendations were eventually accepted and have been the requirements for training since 1979. It has been 16 years since the report of the task force was made. To prepare the neurosurgeon for the twentyfirst century it is time to review these guidelines and to decide if any changes should be recommended in relation to the questions I have raised. Essential to this review was the question of data on how the neurosurgical programs were using the elective time--21 months for the 5-year program and 33 months for the 6-year program. Some information was available in the 1988 summary of individual resident programs published in Neurosurgery, but more details were needed [3]. Therefore, a survey was undertaken to supplement the published information.
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Table 1. Neurosurgical Training Beyond the Mandatory
36 Months Number of 5-year programs
Number of 6-year programs
Required Option to extend Elective None
30
28
7 14
10 4
Total
51
42
10
2
Results of Survey In the fall of 1990 a survey was sent to all the neurosurgical program directors in the United States asking about the use of the elective time. Replies were received from 86 programs. In March 1991 an updated summary of neurosurgical residency programs was published in Neurosurgery [4]. Information from this summary was used to supplement the survey results. The information from 93 neurosurgical programs forms the basis for the following summary. There were 51 5-year programs and 42 6-year programs. Five programs had the option to extend the program from 5 to 6 years, usually by adding 1 year of research. These are included with the 5-year programs. Three programs usually extended the residency to 7 years. This was either additional research or subspecialty training. I have included them with the evaluation of the 6-year residencies.
Neurosurgery The number of programs having required and elective time on neurosurgery beyond the mandatory 36 months is listed in Table 1 for the 5-year and 6-year programs. In 58 of the 93 programs additional neurosurgical rotations were required. In 12 of these 58 programs more neurosurgery could be elected beyond the additional required rotation. In 17 of the other 35 programs neurosurgical rotation could be elected beyond the required 36 months. In 16 programs the resident who did not wish to do research or only wanted 1 year instead of 2 years of research could elect other rotations. Several of the 29 programs with elective time allowed the resident to take specialized training in a neurosurgical area. The options included epilepsy, pediatrics, oncology, spine, stereotactic, trauma, and vascular. The amount of additional time spent on neurosurgery is recorded in Table 2. In the 5-year programs, eight had additional time in pediatric neurosurgery that ranged from 3 to 6 months, one program required a spine and vascular rotation, and one program sent the resident to
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T a b l e 2. Time Spent Beyond the Mandatory 36 Months in Neurosurgical Training
Additional time
Number of 5-year programs
Number of 6-year programs
3 months 6 months 12 months 3-24 months
9 11 4 13
0 8 15 15
Total
37
38
another institution for 6 months of neurotrauma. In the 6-year programs subspecialty-required training included 6 months of pediatric neurosurgery and 6 months of posterior fossa surgery in one, 6 months of pediatric neurosurgery and 6 months of spine surgery in one, 6 months of pediatric neurosurgery and 6 months of stereotactic surgery in one, 6 months of epilepsy in one, and 6 months of spine surgery and 6 months of stereotactic surgery in one. Several of the programs mentioned the opportunity for elective subspecialty training. Six of the 5-year programs provided time for the resident to go to another program for 3 months to 1 year in a number of different rotations. Four 6-year programs offered the option of going to another program for specialized training.
T a b l e 4.
Time in Neuropathology Training
Training time
Number of programs
Required 1-2 months 3 months 4 months 6 months Combined Elective None
81 9 56 4 6 6 2 10
or a research rotation. Several of the program directors mentioned weekly neuropathology conferences.
Neuroradiology In 41 of the 93 programs a full-time rotation of 1-3 months on neuroradiology was required (Table 5). In 19 other programs time on neuroradiology was combined with some other rotation. Several program directors emphasized that neuroradiology was an integral part of the teaching during the entire residency program.
Other Clinical Rotations
In 52 of the 93 programs there was additional time on neurology beyond the required 3 months (Table 3). In six programs the resident could elect to take from 1 month to 3 months of additional neurology or electrodiagnostic studies.
In three 5-year programs 1 month of neuroophthalmology was required, and in four this rotation could be elected at the resident's discretion. One program required 3 months of basic science. Two 6-year programs required neuroophthalmology as a planned rotation, and in one this was elective. Four had rotations on the intensive care unit for 3 - 6 months and in two others it was an elective. Two had a designated basic science rotation.
Neuropathology
Research
In 81 of the 93 programs neuropathology was required as part of the residency program (Table 4). In six programs this rotation was combined with neuroradiology
All of the programs provided time for research. In a number of programs basic science training and microsurgical laboratory experience were part of this rotation. In a few programs other areas, such as neuroradiology and neuropathology, were taken during this time. Research
Neurology
T a b l e 3.
Time in Neurology Training
Training time Required 3 months 4 months 6 months Additional elective 1-3 months
Number of programs 41 7 45
6
T a b l e 5.
Time in Neuroradiology Training
Training time Required 1-3 months Required in combination with another rotation Elective None
Number of programs 41 19 2 31
Training the Neurosurgeon--21st Century
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Table 6. Time in Research, 5-Year Program Time in researcha,b 6 9 12 15 21
months months m onth s m onths months
Total
No clinical duties
Clinical duties
6 3 13 1 1
5 4 17 1 0
24
27
Option to extend time: 2 programs. Not required: 14 programs.
time with no clinical duties was provided in 53 of 93 programs (Tables 6 and 7). In 41 of the 53 the time allotted was 12 months or longer. In 40 programs the research time was combined with clinical duties, usually night and weekend call or vacation coverage. In 31 of these 40 programs the time was 12 months or longer. In summary, 72 of 93 programs are providing research periods of at least 12 months. In 16 of these programs the time spent for research is 18-24 months and eight other programs have an option to lengthen the time to 18-24 months. However, in at least 16 programs the resident could elect a clinical rotation instead of research.
Discussion What conclusions and recommendations can we draw from this review in regard to the structure of the neurosurgical training program?
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could provide a maximum of only 4 months. Program directors seem to agree with the need for sound neurology training. More than half require some additional time and 45 of 93 programs require 6 months of neurology. Is it important to continue devoting 6 months to neurology? The basic skills of the neurologic examination are no less important now than they were in the days before computed tomography and magnetic resonance scans. The importance of an adequate history and examination in making difficult decisions in neurosurgical problems cannot be overemphasized. However, owing to the increased numbers of neurologists available, no longer are most neurosurgeons required to see a large number of neurology patients in their practice. In addition the problems of differential diagnosis have been considerably lessened. The ABNS is considering modification of the neurology portion of the oral examination. The answer to this question is not easy, because the quality and content of neurology rotations is quite variable. Perhaps a review of the neurology portion of the written examination with a comparison of those who had 3 and those who had 6 months of neurology would be useful. I would also recommend that guidelines for training require the neurology rotation within the two first years, preferably the first year of the residency. In a few programs it comes later, and residents do not have the benefit of using this knowledge as they learn to care for neurologic problems.
Neuropathology Neurology In the recommendations of the 1975 task force a minimum of 3 months of neurology was required and 6 months recommended. It is my understanding that 6 months of neurology was the original recommendation of the task force, but the required time was reduced to 3 months because several program directors said they
Program directors believe a neuropathology rotation is important, with 81 of 93 programs requiring this rotation. Three months was the usual time. I do not have details of what the resident actually does during this rotation, but a number of programs include basic science training as part of this rotation.
Neuroradiology Table 7. Time in Research, 6-Year Program Time in research"b 6 12 18 21 24
mo nths months months months mo nths
Total
No clinical duties
Clinical duties
3 17 2 1 6
0 7 3 1 2
29
13
~Option to extend time: 10 programs. b Not required: 2 programs.
Several programs mentioned that neuroradiology was best taught in the day-to-day activities of the service, and 33 programs had no designated training in neuroradiology. There is a great variation among programs in the involvement of the neurosurgical resident with the neuroradiology department. For the most part neurosurgical residents no longer participate in the performance of diagnostic tests. Because of this, consideration should be given to recommending that for most programs neuroradiology is no longer appropriate as a separate rotation.
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Research W h e r e does research stand in the planning of the neurosurgical program? All programs had available a research rotation, and in 72 it was at least 12 months. It has been said that any time period of less than a year of research is probably not productive, and with the complexity of research 1 8 - 2 4 months is preferable. Some have stressed that m a x i m u m benefit is achieved if there are no clinical duties during the research time. Some program directors stated that not every resident needs a research rotation. I believe this rotation is important for several reasons. G e o r g e Ojemann, writing in 1985 on the role of research training in a neurosurgical residency, said The essential features of research are making systematic observations and organizing these into hypothesis and written documents. Often, but not always, this is done in planned experiments. With this definition research training has a place in every neurosurgical residency program regardless of the trainees' ultimate career goals. For opportunities to make new observations--of unique cases, the effects of therapy, pathophysiology of neurosurgical diseases, or the function of the nervous syst e m - w i l l occur in every neurological career [5]. H e went on to say that research training for the majority of residents who will follow a practice career should have two major goals. The first is to develop skills necessary to evaluate the effectiveness of therapy, and the second is to acquire techniques for systematic observation. These skills will improve the trainee's clinical abilities and provide the basis for critical evaluation of reports in the literature. Similar thoughts were expressed by Ralph Dacey, writing in 1991 on the research training component of a neurosurgical residency [1]. Another reason for this rotation is that while only about 15 % of neurosurgical residents end up in predominantly academic positions, many trainees are unsure of their interest at this stage of their career [5]. Recently I was chairman of a Harvard committee to evaluate a m e m ber of another clinical department for promotion to the rank of professor. As part of the extensive evaluation that Harvard does, former trainees were interviewed. One, now the chairman of a clinical department in another institution, said, " H e is an exceedingly committed t e a c h e r - - I had originally planned to go into private practice but he turned me on to academics." In 1982 T o m Langfitt [2] also considered the topic of research training in the neurosurgical program. As he pointed out, there is not one structure for this training that is necessarily better than others. In some programs the research is done under the guidance of the neurosurgical faculty m e m b e r s who are trained in basic or clinical
Ojemann
research disciplines, and in others the training is in the laboratory of a basic scientist within the department, in another department in the university, or in another institution. The important point that he stressed, however, is the quality of the research program. Doing only one or m o r e retrospective clinical studies is usually p o o r use o f the time. I believe we must have some guidelines for research training to ensure this quality just as we do for clinical training. Those programs providing less than 1 year of research should carefully assess the value of that time.
Clinical Neurosurgery H o w was the period of 36 months selected by the task force as the required m i n i m u m time for neurosurgical training in the residency? T h e r e does not appear to be any scientific basis for this figure. As one might expect, the details of what are referred to as "spirited discussions" in the A B N S meetings are not recorded in the minutes. H o w was the original period o f 3 years of training decided in 1940? Mary Louise Davis, o f the A B N S Office, was able to provide the following information: The reason 3 years was originally set for the residency requirement in 1940 was that it was the minimum time stipulated by the Advisory Board of Medical Specialties, a standard accepted by the various medical specialties already organized in the 1930s. This was actually rather hard for neurosurgery to adhere to because most of its programs offered only 2 years. In fact, at the time that 3 years became an accrediting requirement, although many programs professed to have 3-year programs, very few actually offered that. The result was that most of the neurosurgeons initially certified by the ABNS had done their training in more than one place in order to come up with 3 years. During the 50-year history of the A B N S the m i n i m u m requirement for clinical neurosurgical training within the residency was never less than 30 months. Talking to many of my colleagues turned up a sense that on balance it takes about 36 months to train a neurosurgeon in all of the basic disciplines of neurosurgery. In the survey 35 of the 93 programs provided only the required 36 months of neurosurgical training. T h e n why do the other 58 programs require more? In some programs it is the need to provide adequate clinical coverage. In some the program director believes 42 or 48 months is needed for adequate training. H o w e v e r , in several programs time is required for training in a subspecialty, and others provide considerable flexibility in allowing the resident to choose a specialized area of clinical training in elective time. We already have more than 20 programs that are
Training the Neurosurgeon--21st Century
providing the opportunity for some subspecialty clinical training within the residency program. I would recommend that the minimum neurosurgical training period be left at 36 months. It is important to acquire the broad base of knowledge and experience that is built up over this period of time. Our specialty has resisted the trend to give special certificates for every possible subspecialty area. Our primary certificate implies that the neurosurgeon is trained in a broad base of surgical knowledge covering infection, pain, pediatrics, spine, trauma, tumor, and vascular problems. This will continue to be the basis for certification. Dr. Petersdorf said in referring to a proposal for a subspecialty certificate in orthopedic trauma, "One may question, if the orthopaedic surgeon does not know how to take care of trauma, what does the initial certificate mean?" [6]. While I believe we should maintain the basic definition of our primary certificate, we cannot stand idly by and expect the status quo will persist. Other specialties are giving or preparing to give certificates of special competence in clinical areas that have traditionally been in the neurosurgical field. We must recognize that some areas in neurosurgery have become highly specialized and require unique training that only a small percentage of the neurosurgeons will want to pursue. Examples are epilepsy surgery, focused stereotactic radiation therapy, some aspects of skull base surgery, and interventional neuroradiology. There are also residents who want more focused training in one of the primary components of neurosurgery. Many residents have a clear idea of a subspecialty early in the residency. H o w can we provide this training? We should not continue to lengthen the training program without careful consideration. Most of our residents are in their 30s before they finish and there is the increasing problem of the cost of training. I believe that for many residents part or all o f a subspecialty training program can be provided as part of the planned residency. Through careful planning this time might be provided by considering the following recommendations: 1. Giving more credit for related work done in the past, particularly to those who already have a PhD or have had specialized training in another related discipline. I believe we need to be a little more flexible. 2. Eliminating the full-time rotation on neuroradiology and emphasizing the integration of this training in the day-to-day care of the patient. 3. Better utilizing the time already being used for neurosurgery beyond the 36 months. There are already 75 programs with either required or elective neurosurgical rotations in the time beyond the basic requirement that could be used for this training. What other issues does this recommendation for sub-
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specialty training as part o f the residency program raise ? We need to develop minimum training requirements for the subspecialty areas. The institution can give a certificate that says the individual has taken the specialized training program just as certificates are given by hospitals now for fellowships taken after the training program. But the specialized training will not have much meaning and may not be adequate unless guidelines are set for that training. Another consideration will be the timing of the training. Just before or just after the chief resident year would seem the appropriate time. It will also be important that the programs that provide specialized training not detract from their own basic residency programs. This would have to be carefully monitored. What if the resident develops an interest in an area not available in his or her program? At the present time there are only a small number of residencies offering their trainees the option o f taking specialized training in another residency during the training period. Mechanisms will need to be developed by this Society to facilitate these opportunities. Dr. Gian Franco Rossi [7], writing from Italy in Surgical Neurology on subspecialization in neurosurgery at Dr. Eben Alexander's invitation, also made the point that subspecialization has to stem from a solid basis o f knowledge of neuroscience. However, he thought that a period of practical experience in the most common fields should be undertaken and that subspecialization should follow certification. This might be ideal but from a practical standpoint would be difficult to follow in this country. It seems to me that the trend will be to subspecialization within the residency that is combined in some cases wtih one extra fellowship year. An example of what might be worked out comes from a proposed program that evolved out o f the discussions between the AANS Task Force on Neuroradiology and a group of interventional neuroradiologists appointed by their society to consider training in the latter subspecialty. Two avenues o f training, one for those coming from radiological and the other for those from a neurosurgical background, were developed. T h e r e were four important considerations: 1. Individuals must receive minimum training to obtain board certification in their primary specialty. 2. The overall program for both specialities would be 7 years after medical school. 3. Adequate training in radiological interventional neuroradiology must be achieved by individuals in both specialities. 4. The neuroradiologist would receive up to 1 year o f training on a neurosurgical service. The joint program for the radiologist would be as follows:
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1. 2. 3. 4. 5.
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PGY I Radiology: 36 months Neuroradiology: 12 months Neurosurgery: 12 months Endovascular: 12 months (minimum 80 cases)
The joint program for the neurosurgeon would be as follows: 1. 2. 3. 4. 5.
PGY I Clinical neurosurgery training: 36 months Neurology: 3 months Neuropathology or other electives: 3 months Basic radiology and neuroradiology skills and related research: 18-21 months 6. Endovascular: 12 months (minimum 80 cases)
In a 5-year program only one extra year of fellowship would be required. In a 6-year neurosurgical program it would be possible to acquire nearly all of the specialized training during the neurosurgical residency. This plan is under consideration by both specialities. A program for specialist training in pediatric neurological surgery for 24 months has been proposed. The suggested curriculum would include 12 months in clinical pediatric neurological surgery, 3 months in pediatric neurology, and the remaining 9 months in related disciplines and research. Guidelines for minimum number of patients and procedures for a training program are to be determined. With careful planning most of this training could be made part of the full residency program. For epilepsy the minimum requirements might include 6 months in a program that does a significant number of therapeutic operations for epilepsy yearly and provides sufficient experience in medical management and the clinical, electroencephalographic, and imaging evaluations of patients with difficult seizure disorders. The minimum number of patients required for a training program would need to be determined. This program could be easily planned as part of a residency program.
Recommendations In summary, I have recommended that the following proposals be considered: 1. Guidelines be established for subspecialty training within the residency program.
2. Mechanisms be developed to help the resident seeking such training. 3. The time now devoted to neurosurgery beyond the 36 months be carefully evaluated by each program director. 4. Neuroradiology as a separate rotation be carefully evaluated and eliminated when it is not an important part of the training program. 5. The length of training in neurology be reviewed and this training be given within the first two years of the residency, preferably the first year. 6. More credit be allowed for past work in related fields. 7. Guidelines or review mechanisms be established to ensure the quality of the research experience. I would propose that the ABNS consider these issues and if they deem it appropriate, appoint a task force, as was done 20 years ago, to review the structure of the training program in light of the information gained in this survey, the proposals I have made, and the needs of our specialty for the twenty-first century. Undoubtedly additional recommendations would be developed. The charge would be the same as recorded in the first paragraph of the preamble of the report: The Task Force was charged with developing recommendations for upgrading the quality of training in neurological surgery so that training programs might better prepare men (and women) for the practice of neurological surgery. We recognize fully that the recommendations which we propose for adoption at this time will require further modification in the future. I believe it is again time to consider modifications of these recommendations.
References 1. Dacey RG Jr: The research training component of a neurosurgical residency. Neurosurgery 1991;28(part 2):$3-$4. 2. Langfitt, TW: Research and training in the neurosurgical sciences: with comments on some key issues that confront neurosurgery. J Neurosurg 1982;57:733-8. 3. Neurosurgical residency training programs in the United States and Canada. Neurosurgery 1988;22:177-283. 4. Neurosurgical residency training programs in the United States and Canada. Neurosurgery 1991;28(part 2):$7-S 114. 5. Ojemann GA: The role of research training in a neurosurgical residency. Neurosurgery 1985;17:138-9. 6. Petersdorf RG: Some issues in graduate medical education. Surg Neurol 1991;35:8-13. 7. Rossi, GF: A view from Europe: subspecialization in neurosurgery. Surg Neurol 1990;33:154-6.
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Training the Neurosurgeon for the Twenty-first Century Robert G. Ojemann, M.D. Department of Surgery, Harvard Medical School, and Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts
In January 1992 the next neurosurgical resident match will be held. Under the current requirements of the American Board of Neurological Surgery (ABNS) the earliest any of the applicants accepted in that match would complete their neurosurgery residency is in June 1998. None of these applicants will be eligible to take the Oral Examination of the American Board of Neurological Surgery until after the year 2000. Many factors will influence the training of the neurosurgeon for the twenty-first century. At the 1990 Society meeting Robert Petersdorf, M.D., president of the American Association of Medical Colleges (AAMC), outlined eight issues in graduate medical education he said required sustained effort from all parts of the academic community [6]. I will summarize his comments and relate them to neurosurgery. The issues were the following: 1. Innovation in education. He discussed the problems of the fourth-year medical school curriculum and the suggestions that have been made to radically alter the structure of this training. This Society [of Neurological Surgeons] will need to follow developments in this area closely, since many residency programs place considerable weight on the performance of the student during a rotation on neurosurgery. 2. New clinical settings for clinical education. The problem of less exposure to inpatients and the changing patient population in some institutions with fewer routine cases was reviewed. For neurosurgery one of the problems is the increasing same-day admissions for most spine and some cranial operative procedures. How many programs have developed a way to involve the resident who will participate in the operation in the preoperative evaluation of such patients ? Another problem for some neurosurgical programs is the difficulty in providing the senior
The presidential address given to the Society of Neurological Surgeons at its 82nd annual meeting, Charleston, South Carolina, May 8-11, 1991. Address reprint requests to: Robert G. Ojemann, M.D., Massachusetts General Hospital, Boston, Massachusetts 02114. Received August 27, 1991; accepted August 30, 1991. © 1992 by Elsevier Science Publishing Co., Inc.
resident with enough experience in managing inpatient surgical cases. 3. Assuring competency (selection and evaluation). The evaluation of residents during the training program was discussed. What was not mentioned was the problem of resident selection. This Society believes that these two issues, selection and evaluation, are interrelated, and this subject has been the focus of a hard-working committee. I would use the title "selection and evaluation of residents" rather than "assuring competency." 4. Residency accreditation. Dr. Petersdorfdiscussed the views of the AAMC and referred to problems related to the functioning of the Residency Review Committee (RRC). The relationship of the RRC and the neurosurgical training programs was the topic of an extended discussion at this meeting. 5. Working conditions. This has been the subject of numerous public and professional discussions. This is another area in which major restrictions could have a significant impact on neurosurgical training programs. 6. Financing graduate medical education. With changing patterns in reimbursement and reduced support from the federal government, this topic will be of increasing concern, particularly for our specialty, in which the training program is longer than most. The Washington Committee for Neurological Surgery is monitoring this issue. 7. Autonomy of the specialty boards. The tendency to issue more and more certificates of special or added competence, which he termed "certificamania," was deplored. Fortunately, our specialty has resisted this tendency. 8. Manpower distribution. The overproduction of specialists and subspecialists at the expense ofgeneralists was discussed. We need to continually review our personnel needs. Are we training enough neurosurgeons to meet the replacement needs for disability and retirement, to meet the needs of an increasing elderly population, to provide enough neurosurgeons for academic programs, to take advantage of expanding opportunities in areas such as epilepsy, and to regain our leadership role in areas such as the treatment of spinal disorders? 0090-3019/92/$5.00
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A major issue that Dr. Petersdorf did not specifically mention is the structure of the training program; this is the subject that I will review in some detail. Periodically we should reevaluate our training programs to see if we will be adequately meeting the needs of future neurosurgeons. Do changes need to be made to adapt to the development of subspecialization, the treatment of traditional neurosurgical problems by other specialists, and the need for more sophisticated research to advance our field? Or is the present system still the best? We should ask several questions. Are the required 36 months of general neurosurgery appropriate? Are 3 months of neurology just right, too much, or too little? Should time on neuroradiology still be recommended? What are programs doing with the elective period of 21 months in the 5-year and 33 months in the 6-year programs? Is the time allotted for research being used wisely? With problems of funding longer training programs, should there be an opportunity for subspecialization within the residency program, or should more fellowships be developed for the neurosurgeon who has completed a residency program, or should both be encouraged?
History of the Requirements
of the ABNS
To have more understanding of why we have the present training requirements, I reviewed the ABNS minutes in relation to the times when major changes in these requirements were made. I am indebted to David Kline, former secretary of the ABNS, who had summarized many o f these changes; to Julian Hoff, the current secretary; and to his staff in the A B N S office, Mary Louise Davis and Elsie Ford, who retrieved the appropriate information. In 1940 individuals were granted certification without examination if they held the following credentials: 1. Practice in the United States or Canada 2. Professional rank of neurosurgeon 3. Practice limited to neurosurgery for 10 years prior to 1/1/40 4. Satisfactory moral and ethical standing 5. Membership in AMA or equivalent Canadian society or a society recognized by the AMA Council on Medical Education and Hospitals Training for these individuals had for the most part been by preceptorship. The operative experience was usually opening and closing the operative incisions and observation during the intracranial or intraspinal part of the procedure.
The initial training requirements for examination were as follows: 1. Graduation from a medical school in the United States or Canada recognized by the AMA Council on Medical Education and Hospitals or a foreign medical school acceptable to the A B N S 2. Surgical internship o f not less than I year in an approved hospital 3. Three years of neurosurgical training emphasizing the basic sciences related to neurosurgery 4. Two years of practice In 1950 the ABNS stated that the training in clinical neurosurgery must be progressive-at least two years of this training must be in one institution. This period of special training shall be of such a character that the relation of the basic sciences of anatomy, physiology, pathology, bacteriology and biochemistry is emphasized--the Board will not credit periods of study limited to the basic sciences of longer than six months. In 1954-1955 there were apparently long discussions at the board meeting about changing the length o f the training program to 4 years after the year o f general surgery. Some members thought that another year of general surgery should be added because o f the lack of knowledge of general surgical principles displayed by the candidates. Others thought the extra time should be spent in neurology, but several seemed to feel that it was more important to allow more flexibility in the program. In April 1955 the program was lengthened to 4 years with the stipulation that at least 30 months must be devoted to clinical neurosurgery. In addition it was stated for the first time that the candidate must be prepared to pass examinations in general surgery, organic neurology, neuropathology, neuroanatomy, neurophysiology, neuroophthalmology, and neuroradiology. Over the next decade the training requirements remained unchanged. T h e r e were more discussions about adding another year of general surgery. In 1965 the bylaws were amended as follows to meet a presumed need at that time: The residency period must be chiefly clinical and not didactic, and there should be continuous concurrent instruction in the basic neurological sciences and medical neurology, particularly as they relate to neurosurgery. There must be training in the surgical performance of contrast studies and the indication for these studies, as well as pre and postoperative care of such patients subjected to the various procedures. The training must also include the evaluation of such contrast studies.
Training the Neurosurgeon--21st Century
In 1968 another change was made in the bylaws, reflecting the changing background of the board. No longer was there the perceived need for additional general surgical training. It was stated that "at least 30 months of this period (4 years neurosurgical residency) must be devoted to clinical neurological surgery and the remaining 18 months should be devoted to some aspect of the neurological sciences." In the early 1970s the subcommittee on graduate medical education of the Education Committee of the American Association of Neurological Surgeons (AANS) became concerned about the fact that the requirements for neurosurgical training had not significantly changed in many years and were not in keeping with the thoughts of many program directors. Suggestions were developed and Dr. Robert King, chairman of the Education Committee, made a presentation to the ABNS, where, I understand, there was considerable skepticism. Nevertheless, the ABNS asked the Society of Neurological Surgeons to appoint a task force on graduate medical education to review this issue. The task force was charged with developing recommendations for upgrading the quality of training in neurological surgery. In May 1975 the task force reported to this Society. The chairman was Dr. Robert King. The members were Drs. Chou, Desaussure, Goldring, Langfitt, and Meagher. They proposed a minimum of 12 months of fundamental clinical skills related to surgery and a minimum of 60 months in the neurosciences to include the following: 1. 2. 3. 4.
Basic neuroscience--optional time Research--optional time Neuroradiology and neuropathology--optional time Neurology--3 months minimum (6 months recommended) 5. Clinical neurosurgery--36 months minimum (12 months as senior resident)
These recommendations were eventually accepted and have been the requirements for training since 1979. It has been 16 years since the report of the task force was made. To prepare the neurosurgeon for the twentyfirst century it is time to review these guidelines and to decide if any changes should be recommended in relation to the questions I have raised. Essential to this review was the question of data on how the neurosurgical programs were using the elective time--21 months for the 5-year program and 33 months for the 6-year program. Some information was available in the 1988 summary of individual resident programs published in Neurosurgery, but more details were needed [3]. Therefore, a survey was undertaken to supplement the published information.
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Table 1. Neurosurgical Training Beyond the Mandatory
36 Months Number of 5-year programs
Number of 6-year programs
Required Option to extend Elective None
30
28
7 14
10 4
Total
51
42
10
2
Results of Survey In the fall of 1990 a survey was sent to all the neurosurgical program directors in the United States asking about the use of the elective time. Replies were received from 86 programs. In March 1991 an updated summary of neurosurgical residency programs was published in Neurosurgery [4]. Information from this summary was used to supplement the survey results. The information from 93 neurosurgical programs forms the basis for the following summary. There were 51 5-year programs and 42 6-year programs. Five programs had the option to extend the program from 5 to 6 years, usually by adding 1 year of research. These are included with the 5-year programs. Three programs usually extended the residency to 7 years. This was either additional research or subspecialty training. I have included them with the evaluation of the 6-year residencies.
Neurosurgery The number of programs having required and elective time on neurosurgery beyond the mandatory 36 months is listed in Table 1 for the 5-year and 6-year programs. In 58 of the 93 programs additional neurosurgical rotations were required. In 12 of these 58 programs more neurosurgery could be elected beyond the additional required rotation. In 17 of the other 35 programs neurosurgical rotation could be elected beyond the required 36 months. In 16 programs the resident who did not wish to do research or only wanted 1 year instead of 2 years of research could elect other rotations. Several of the 29 programs with elective time allowed the resident to take specialized training in a neurosurgical area. The options included epilepsy, pediatrics, oncology, spine, stereotactic, trauma, and vascular. The amount of additional time spent on neurosurgery is recorded in Table 2. In the 5-year programs, eight had additional time in pediatric neurosurgery that ranged from 3 to 6 months, one program required a spine and vascular rotation, and one program sent the resident to
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T a b l e 2. Time Spent Beyond the Mandatory 36 Months in Neurosurgical Training
Additional time
Number of 5-year programs
Number of 6-year programs
3 months 6 months 12 months 3-24 months
9 11 4 13
0 8 15 15
Total
37
38
another institution for 6 months of neurotrauma. In the 6-year programs subspecialty-required training included 6 months of pediatric neurosurgery and 6 months of posterior fossa surgery in one, 6 months of pediatric neurosurgery and 6 months of spine surgery in one, 6 months of pediatric neurosurgery and 6 months of stereotactic surgery in one, 6 months of epilepsy in one, and 6 months of spine surgery and 6 months of stereotactic surgery in one. Several of the programs mentioned the opportunity for elective subspecialty training. Six of the 5-year programs provided time for the resident to go to another program for 3 months to 1 year in a number of different rotations. Four 6-year programs offered the option of going to another program for specialized training.
T a b l e 4.
Time in Neuropathology Training
Training time
Number of programs
Required 1-2 months 3 months 4 months 6 months Combined Elective None
81 9 56 4 6 6 2 10
or a research rotation. Several of the program directors mentioned weekly neuropathology conferences.
Neuroradiology In 41 of the 93 programs a full-time rotation of 1-3 months on neuroradiology was required (Table 5). In 19 other programs time on neuroradiology was combined with some other rotation. Several program directors emphasized that neuroradiology was an integral part of the teaching during the entire residency program.
Other Clinical Rotations
In 52 of the 93 programs there was additional time on neurology beyond the required 3 months (Table 3). In six programs the resident could elect to take from 1 month to 3 months of additional neurology or electrodiagnostic studies.
In three 5-year programs 1 month of neuroophthalmology was required, and in four this rotation could be elected at the resident's discretion. One program required 3 months of basic science. Two 6-year programs required neuroophthalmology as a planned rotation, and in one this was elective. Four had rotations on the intensive care unit for 3 - 6 months and in two others it was an elective. Two had a designated basic science rotation.
Neuropathology
Research
In 81 of the 93 programs neuropathology was required as part of the residency program (Table 4). In six programs this rotation was combined with neuroradiology
All of the programs provided time for research. In a number of programs basic science training and microsurgical laboratory experience were part of this rotation. In a few programs other areas, such as neuroradiology and neuropathology, were taken during this time. Research
Neurology
T a b l e 3.
Time in Neurology Training
Training time Required 3 months 4 months 6 months Additional elective 1-3 months
Number of programs 41 7 45
6
T a b l e 5.
Time in Neuroradiology Training
Training time Required 1-3 months Required in combination with another rotation Elective None
Number of programs 41 19 2 31
Training the Neurosurgeon--21st Century
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Table 6. Time in Research, 5-Year Program Time in researcha,b 6 9 12 15 21
months months m onth s m onths months
Total
No clinical duties
Clinical duties
6 3 13 1 1
5 4 17 1 0
24
27
Option to extend time: 2 programs. Not required: 14 programs.
time with no clinical duties was provided in 53 of 93 programs (Tables 6 and 7). In 41 of the 53 the time allotted was 12 months or longer. In 40 programs the research time was combined with clinical duties, usually night and weekend call or vacation coverage. In 31 of these 40 programs the time was 12 months or longer. In summary, 72 of 93 programs are providing research periods of at least 12 months. In 16 of these programs the time spent for research is 18-24 months and eight other programs have an option to lengthen the time to 18-24 months. However, in at least 16 programs the resident could elect a clinical rotation instead of research.
Discussion What conclusions and recommendations can we draw from this review in regard to the structure of the neurosurgical training program?
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could provide a maximum of only 4 months. Program directors seem to agree with the need for sound neurology training. More than half require some additional time and 45 of 93 programs require 6 months of neurology. Is it important to continue devoting 6 months to neurology? The basic skills of the neurologic examination are no less important now than they were in the days before computed tomography and magnetic resonance scans. The importance of an adequate history and examination in making difficult decisions in neurosurgical problems cannot be overemphasized. However, owing to the increased numbers of neurologists available, no longer are most neurosurgeons required to see a large number of neurology patients in their practice. In addition the problems of differential diagnosis have been considerably lessened. The ABNS is considering modification of the neurology portion of the oral examination. The answer to this question is not easy, because the quality and content of neurology rotations is quite variable. Perhaps a review of the neurology portion of the written examination with a comparison of those who had 3 and those who had 6 months of neurology would be useful. I would also recommend that guidelines for training require the neurology rotation within the two first years, preferably the first year of the residency. In a few programs it comes later, and residents do not have the benefit of using this knowledge as they learn to care for neurologic problems.
Neuropathology Neurology In the recommendations of the 1975 task force a minimum of 3 months of neurology was required and 6 months recommended. It is my understanding that 6 months of neurology was the original recommendation of the task force, but the required time was reduced to 3 months because several program directors said they
Program directors believe a neuropathology rotation is important, with 81 of 93 programs requiring this rotation. Three months was the usual time. I do not have details of what the resident actually does during this rotation, but a number of programs include basic science training as part of this rotation.
Neuroradiology Table 7. Time in Research, 6-Year Program Time in research"b 6 12 18 21 24
mo nths months months months mo nths
Total
No clinical duties
Clinical duties
3 17 2 1 6
0 7 3 1 2
29
13
~Option to extend time: 10 programs. b Not required: 2 programs.
Several programs mentioned that neuroradiology was best taught in the day-to-day activities of the service, and 33 programs had no designated training in neuroradiology. There is a great variation among programs in the involvement of the neurosurgical resident with the neuroradiology department. For the most part neurosurgical residents no longer participate in the performance of diagnostic tests. Because of this, consideration should be given to recommending that for most programs neuroradiology is no longer appropriate as a separate rotation.
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Research W h e r e does research stand in the planning of the neurosurgical program? All programs had available a research rotation, and in 72 it was at least 12 months. It has been said that any time period of less than a year of research is probably not productive, and with the complexity of research 1 8 - 2 4 months is preferable. Some have stressed that m a x i m u m benefit is achieved if there are no clinical duties during the research time. Some program directors stated that not every resident needs a research rotation. I believe this rotation is important for several reasons. G e o r g e Ojemann, writing in 1985 on the role of research training in a neurosurgical residency, said The essential features of research are making systematic observations and organizing these into hypothesis and written documents. Often, but not always, this is done in planned experiments. With this definition research training has a place in every neurosurgical residency program regardless of the trainees' ultimate career goals. For opportunities to make new observations--of unique cases, the effects of therapy, pathophysiology of neurosurgical diseases, or the function of the nervous syst e m - w i l l occur in every neurological career [5]. H e went on to say that research training for the majority of residents who will follow a practice career should have two major goals. The first is to develop skills necessary to evaluate the effectiveness of therapy, and the second is to acquire techniques for systematic observation. These skills will improve the trainee's clinical abilities and provide the basis for critical evaluation of reports in the literature. Similar thoughts were expressed by Ralph Dacey, writing in 1991 on the research training component of a neurosurgical residency [1]. Another reason for this rotation is that while only about 15 % of neurosurgical residents end up in predominantly academic positions, many trainees are unsure of their interest at this stage of their career [5]. Recently I was chairman of a Harvard committee to evaluate a m e m ber of another clinical department for promotion to the rank of professor. As part of the extensive evaluation that Harvard does, former trainees were interviewed. One, now the chairman of a clinical department in another institution, said, " H e is an exceedingly committed t e a c h e r - - I had originally planned to go into private practice but he turned me on to academics." In 1982 T o m Langfitt [2] also considered the topic of research training in the neurosurgical program. As he pointed out, there is not one structure for this training that is necessarily better than others. In some programs the research is done under the guidance of the neurosurgical faculty m e m b e r s who are trained in basic or clinical
Ojemann
research disciplines, and in others the training is in the laboratory of a basic scientist within the department, in another department in the university, or in another institution. The important point that he stressed, however, is the quality of the research program. Doing only one or m o r e retrospective clinical studies is usually p o o r use o f the time. I believe we must have some guidelines for research training to ensure this quality just as we do for clinical training. Those programs providing less than 1 year of research should carefully assess the value of that time.
Clinical Neurosurgery H o w was the period of 36 months selected by the task force as the required m i n i m u m time for neurosurgical training in the residency? T h e r e does not appear to be any scientific basis for this figure. As one might expect, the details of what are referred to as "spirited discussions" in the A B N S meetings are not recorded in the minutes. H o w was the original period o f 3 years of training decided in 1940? Mary Louise Davis, o f the A B N S Office, was able to provide the following information: The reason 3 years was originally set for the residency requirement in 1940 was that it was the minimum time stipulated by the Advisory Board of Medical Specialties, a standard accepted by the various medical specialties already organized in the 1930s. This was actually rather hard for neurosurgery to adhere to because most of its programs offered only 2 years. In fact, at the time that 3 years became an accrediting requirement, although many programs professed to have 3-year programs, very few actually offered that. The result was that most of the neurosurgeons initially certified by the ABNS had done their training in more than one place in order to come up with 3 years. During the 50-year history of the A B N S the m i n i m u m requirement for clinical neurosurgical training within the residency was never less than 30 months. Talking to many of my colleagues turned up a sense that on balance it takes about 36 months to train a neurosurgeon in all of the basic disciplines of neurosurgery. In the survey 35 of the 93 programs provided only the required 36 months of neurosurgical training. T h e n why do the other 58 programs require more? In some programs it is the need to provide adequate clinical coverage. In some the program director believes 42 or 48 months is needed for adequate training. H o w e v e r , in several programs time is required for training in a subspecialty, and others provide considerable flexibility in allowing the resident to choose a specialized area of clinical training in elective time. We already have more than 20 programs that are
Training the Neurosurgeon--21st Century
providing the opportunity for some subspecialty clinical training within the residency program. I would recommend that the minimum neurosurgical training period be left at 36 months. It is important to acquire the broad base of knowledge and experience that is built up over this period of time. Our specialty has resisted the trend to give special certificates for every possible subspecialty area. Our primary certificate implies that the neurosurgeon is trained in a broad base of surgical knowledge covering infection, pain, pediatrics, spine, trauma, tumor, and vascular problems. This will continue to be the basis for certification. Dr. Petersdorf said in referring to a proposal for a subspecialty certificate in orthopedic trauma, "One may question, if the orthopaedic surgeon does not know how to take care of trauma, what does the initial certificate mean?" [6]. While I believe we should maintain the basic definition of our primary certificate, we cannot stand idly by and expect the status quo will persist. Other specialties are giving or preparing to give certificates of special competence in clinical areas that have traditionally been in the neurosurgical field. We must recognize that some areas in neurosurgery have become highly specialized and require unique training that only a small percentage of the neurosurgeons will want to pursue. Examples are epilepsy surgery, focused stereotactic radiation therapy, some aspects of skull base surgery, and interventional neuroradiology. There are also residents who want more focused training in one of the primary components of neurosurgery. Many residents have a clear idea of a subspecialty early in the residency. H o w can we provide this training? We should not continue to lengthen the training program without careful consideration. Most of our residents are in their 30s before they finish and there is the increasing problem of the cost of training. I believe that for many residents part or all o f a subspecialty training program can be provided as part of the planned residency. Through careful planning this time might be provided by considering the following recommendations: 1. Giving more credit for related work done in the past, particularly to those who already have a PhD or have had specialized training in another related discipline. I believe we need to be a little more flexible. 2. Eliminating the full-time rotation on neuroradiology and emphasizing the integration of this training in the day-to-day care of the patient. 3. Better utilizing the time already being used for neurosurgery beyond the 36 months. There are already 75 programs with either required or elective neurosurgical rotations in the time beyond the basic requirement that could be used for this training. What other issues does this recommendation for sub-
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specialty training as part o f the residency program raise ? We need to develop minimum training requirements for the subspecialty areas. The institution can give a certificate that says the individual has taken the specialized training program just as certificates are given by hospitals now for fellowships taken after the training program. But the specialized training will not have much meaning and may not be adequate unless guidelines are set for that training. Another consideration will be the timing of the training. Just before or just after the chief resident year would seem the appropriate time. It will also be important that the programs that provide specialized training not detract from their own basic residency programs. This would have to be carefully monitored. What if the resident develops an interest in an area not available in his or her program? At the present time there are only a small number of residencies offering their trainees the option o f taking specialized training in another residency during the training period. Mechanisms will need to be developed by this Society to facilitate these opportunities. Dr. Gian Franco Rossi [7], writing from Italy in Surgical Neurology on subspecialization in neurosurgery at Dr. Eben Alexander's invitation, also made the point that subspecialization has to stem from a solid basis o f knowledge of neuroscience. However, he thought that a period of practical experience in the most common fields should be undertaken and that subspecialization should follow certification. This might be ideal but from a practical standpoint would be difficult to follow in this country. It seems to me that the trend will be to subspecialization within the residency that is combined in some cases wtih one extra fellowship year. An example of what might be worked out comes from a proposed program that evolved out o f the discussions between the AANS Task Force on Neuroradiology and a group of interventional neuroradiologists appointed by their society to consider training in the latter subspecialty. Two avenues o f training, one for those coming from radiological and the other for those from a neurosurgical background, were developed. T h e r e were four important considerations: 1. Individuals must receive minimum training to obtain board certification in their primary specialty. 2. The overall program for both specialities would be 7 years after medical school. 3. Adequate training in radiological interventional neuroradiology must be achieved by individuals in both specialities. 4. The neuroradiologist would receive up to 1 year o f training on a neurosurgical service. The joint program for the radiologist would be as follows:
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1. 2. 3. 4. 5.
Ojemann
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PGY I Radiology: 36 months Neuroradiology: 12 months Neurosurgery: 12 months Endovascular: 12 months (minimum 80 cases)
The joint program for the neurosurgeon would be as follows: 1. 2. 3. 4. 5.
PGY I Clinical neurosurgery training: 36 months Neurology: 3 months Neuropathology or other electives: 3 months Basic radiology and neuroradiology skills and related research: 18-21 months 6. Endovascular: 12 months (minimum 80 cases)
In a 5-year program only one extra year of fellowship would be required. In a 6-year neurosurgical program it would be possible to acquire nearly all of the specialized training during the neurosurgical residency. This plan is under consideration by both specialities. A program for specialist training in pediatric neurological surgery for 24 months has been proposed. The suggested curriculum would include 12 months in clinical pediatric neurological surgery, 3 months in pediatric neurology, and the remaining 9 months in related disciplines and research. Guidelines for minimum number of patients and procedures for a training program are to be determined. With careful planning most of this training could be made part of the full residency program. For epilepsy the minimum requirements might include 6 months in a program that does a significant number of therapeutic operations for epilepsy yearly and provides sufficient experience in medical management and the clinical, electroencephalographic, and imaging evaluations of patients with difficult seizure disorders. The minimum number of patients required for a training program would need to be determined. This program could be easily planned as part of a residency program.
Recommendations In summary, I have recommended that the following proposals be considered: 1. Guidelines be established for subspecialty training within the residency program.
2. Mechanisms be developed to help the resident seeking such training. 3. The time now devoted to neurosurgery beyond the 36 months be carefully evaluated by each program director. 4. Neuroradiology as a separate rotation be carefully evaluated and eliminated when it is not an important part of the training program. 5. The length of training in neurology be reviewed and this training be given within the first two years of the residency, preferably the first year. 6. More credit be allowed for past work in related fields. 7. Guidelines or review mechanisms be established to ensure the quality of the research experience. I would propose that the ABNS consider these issues and if they deem it appropriate, appoint a task force, as was done 20 years ago, to review the structure of the training program in light of the information gained in this survey, the proposals I have made, and the needs of our specialty for the twenty-first century. Undoubtedly additional recommendations would be developed. The charge would be the same as recorded in the first paragraph of the preamble of the report: The Task Force was charged with developing recommendations for upgrading the quality of training in neurological surgery so that training programs might better prepare men (and women) for the practice of neurological surgery. We recognize fully that the recommendations which we propose for adoption at this time will require further modification in the future. I believe it is again time to consider modifications of these recommendations.
References 1. Dacey RG Jr: The research training component of a neurosurgical residency. Neurosurgery 1991;28(part 2):$3-$4. 2. Langfitt, TW: Research and training in the neurosurgical sciences: with comments on some key issues that confront neurosurgery. J Neurosurg 1982;57:733-8. 3. Neurosurgical residency training programs in the United States and Canada. Neurosurgery 1988;22:177-283. 4. Neurosurgical residency training programs in the United States and Canada. Neurosurgery 1991;28(part 2):$7-S 114. 5. Ojemann GA: The role of research training in a neurosurgical residency. Neurosurgery 1985;17:138-9. 6. Petersdorf RG: Some issues in graduate medical education. Surg Neurol 1991;35:8-13. 7. Rossi, GF: A view from Europe: subspecialization in neurosurgery. Surg Neurol 1990;33:154-6.
