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What makes a neurosurgeon?

By CareerNo Comments

“Excellence is a continuous process and not an accident.”
P. J. Abdul Kalam

When I was in medical school, a question frequently asked by friends and family was, “How do you decide what kind of doctor to become?” I eventually developed an answer in the form of a metaphor: imagine you are at a gourmet ice cream shop. There is a wide variety of amazing flavors to choose from. The shopkeeper is very generous and gives you the opportunity to sample every flavor. However, at the end of this sampling, you can only leave the store with one flavor. And you have to eat that flavor of ice cream for the rest of your life.

Reactions to this metaphor vary — it may seem exciting to try the samples. It may seem fraught to make such a lasting decision based on a small sample size. It may seem like a very arbitrary way to determine a future career course in a highly specialized profession. Whatever the strengths or weaknesses in the decision to become a neurosurgeon, the process of becoming a neurosurgeon has, especially in recent years, not been left to chance.

Historically, surgical training was an advanced, multi-year apprenticeship. Trainees would identify a mentor from whom they would master the art and skill of surgery. Many surgical training programs were set up as a ‘pyramid’ with multiple trainees beginning a residency but only 1-2 completed, as the grueling nature of the work would naturally create attrition. This often inculcated a cutthroat culture where one ‘fatal’ mistake would result in dismissal. It’s no wonder that many surgeons developed an unrelenting mentality and personality that often endured long after they finished training.

The process of training neurosurgeons today has changed dramatically. Medicine, more broadly, and neurosurgery, in particular, have co-opted techniques from various industries to make residency a much more predictable, measurable and just educational experience. It is no longer sink-or-swim. Residency program directors have adopted innovations from education and quality science and industrial processes to create a more holistic training rubric that prepares neurosurgical trainees to thrive in 21st-century health care delivery systems. Surgeons can no longer be lone wolves doing their own thing; they must be captains of health care teams where teamwork and a just culture are the touchstones of patient care.

The training of neurosurgeons is not the only aspect of the process that has changed dramatically. The substrate of neurosurgical training is transforming as well. Returning to our ice cream metaphor, the ingredients of neurosurgical training are changing to reflect more completely the society in which we practice medicine. Neurosurgery has made it a key priority to recruit a more diverse body of trainees from a variety of cultural backgrounds. Because we work in teams and care for patients across the spectrum of society, our team members should more closely mirror that spectrum.

If I asked you to close your eyes and think of a neurosurgeon, you would probably conjure up a certain mental image (and please don’t tell me it’s Dr. McDreamy!). However, the old image reflects a way of training that is impractical and non-viable. Neurosurgery has rapidly adapted over the past few decades to create a new process to train the next generation of neurosurgeons. No process is perfect, but neurosurgical leaders realize that and so this process continues to evolve. Perfecting this process will never be completed, but the practice of reviewing and improving the process improves us not only as physicians and educators, but even more as people.

Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.

Kristopher T. Kimmell, MD, FAANS
Rochester Regional Health
Rochester, N.Y.

Mark J. Kubala, MD, FAANS(L) Awarded TMA Foundation “Heart of Gold” Award

By Career, TraumaNo Comments

The Texas Medical Association Foundation (TMA Foundation) recently awarded neurosurgeon Mark J. Kubala, MD, FAANS(L) their highest honor, the Heart of Gold Award. The foundation presents the award to outstanding individuals who embody a “gold standard” of volunteerism and have made a measurable impact on the foundation’s mission through gifts and leadership. Read More

Cross-Post: First Female Neurosurgeon to Become a Medical School Dean: Julie G. Pilitsis Shares Her Path to Success

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Our current series on Making and Maintaining a Neurosurgeon discusses how one transitions from student to resident to practicing neurosurgeon. This cross-post highlights the second chapter after practicing neurosurgery. Eleven years ago, Julie G. Pilitsis, MD, PhD, FAANS, set a goal to become a dean for a college of medicine.

To achieve this goal, Dr. Pilitsis worked toward gaining experience in the clinical, educational and research aspects of medicine at Albany Medical College. After a national search, she became the chair of The Department of Neuroscience and Experimental Therapeutics. Subsequently, she obtained additional leadership training through the Harvard course for chairs, Executive Leadership in Academic Medicine and earned a Masters in Business Administration. To help garner institutional budget experience, she joined the system’s finance committee. To gain philanthropy experience, she obtained formal training and worked closely with her institutional foundation.

In 2022, Dr. Pilitsis became the dean and vice president of medical affairs at Schmidt College of Medicine at Florida Atlantic University (FAU). She is the first female neurosurgeon to become a medical school dean. “A community is essential for all of us to get to where we are going. The central tenet of my time at FAU will echo that spirit of developing a health care workforce ‘of the community, for the community.’ I am proud to be a part of the neurosurgical community,” states Dr. Pilitsis.

Click here to read the full article in the AANS Neurosurgeon.

Editor’s Note: Effective Jan. 8, Dr. Pilitsis is now the of the Department of Neurosurgery at the University of Arizona College of Medicine.

We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.

Embracing Innovation: Adapting to New Surgical Technologies

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During my residency training at the University of Pennsylvania, M. Sean Grady, MD, FAANS, repeatedly counseled that residency is intended to teach us how to incorporate innovations in neurosurgery into our practice. Then, we can keep up with the pace of research and technology and, thus, always offer our patients the cutting-edge. My first year out of training was at Stanford University, and I was asked to take on a neurosurgical leadership role in the transcranial focused ultrasound program. I had come from a background where the reversibility and adjustability of deep brain stimulation would always supersede the permanence of an ablation technique.

However, when I saw the magic of focused ultrasound showing immediate relief of tremors following a real-time thalamotomy under magnetic resonance imaging guidance, I knew the field would never be the same. I then embraced this new technology, as Dr. Grady would have insisted. I was privileged to continue to lead this program at Stanford during my time there and work with terrific colleagues such as Pejman Ghanouni, MD, PhD; Jaimie M. Henderson, MD, FAANS; Kim Butts-Pauly, PhD and an international team of experts to get this treatment FDA-approved.

Now, we are using this method to treat Parkinson’s disease and contralateral tremors. We have even applied this incredible technology to temporal lobe epilepsy and hypothalamic hamartoma, though much work is needed to develop these indications. Patients travel to my clinic from far and wide for this therapy, and the outcomes speak for themselves.

Deep brain stimulation remains commonplace in my practice, but offering treatment options is key to program-building and patient care. I liken this optionality to brain aneurysm management. There was a time when neurosurgery could have lost control of this space due to interventional radiology’s offering of incisionless coil procedures. However, the sub-specialty of endovascular neurosurgery was created, and our necessary role in both the angiography suite and operating room was solidified. Stereotactic and functional neurosurgeons must embrace ablation techniques using focused ultrasound in much the same way. Patients want options, and finally they have them.

Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.

Casey H. Halpern, MD, FAANS
Penn Medicine
Philadelphia, Pa.

Evaluating Professionalism and Self-reflection in Neurosurgery

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As neurosurgeons, continuous improvement is essential to our growth. Self-reflection and self-improvement are core tenets instilled in us throughout training. During residency, this is built into our education, with discussions of quality, service and opportunities for improvement at the forefront.

But what about after residency? As we transition, we continue to refine what we do and how we practice, often adding new techniques to our repertoires. Residency and fellowship provide the framework to continue to grow, but the educational environment of practice may differ drastically depending on the practice setting. As of 2020, more than 50% of board-eligible candidates reported being in a non-academic practice setting.

To this end, the American Board of Neurological Surgery (ABNS) fosters excellence in patient care and supports our evolution in practice while maintaining high professional standards. The mission of the ABNS is to encourage the study, improve the practice, elevate the standards and advance the science of neurological surgery, thereby serving the cause of public health. There are three main areas where the ABNS continues to evolve to meet the needs of the field: primary examination, oral examination and continuous certification.

  1. Primary examination. The ABNS continues to work towards evolving the primary exam to a mastery exam with clinically relevant questions that reflect current basic knowledge. In 2019, the neuroanatomy “mastery” module was introduced. Residents have four attempts to master the material, which is available for advance study. In the spirit of self-evaluation, residents and program directors are being surveyed for feedback to the ABNS about this module, and the ABNS is planning to closely follow primary examination anatomy scores for impact, with the anticipation that this module will help drive learning.

As of fall 2022, there were 118 Accreditation Council for Graduate Medical Education-accredited programs and 1,629 neurosurgery residents. In March 2023, a record 887 residents took the primary exam, of whom 249 took it for credit and the remainder were for self-evaluation. Question stems are released each year to support studying. The passing score (72% in 2023) is slowly increasing, and the ABNS directors and the National Board of Medical Examiners are completing more frequent standard setting for the exam.

  1. ABNS Practice and Outcomes of Surgical Therapies (POST) and the Oral Examination. ABNS POST continues to evolve in response to current needs and feedback about the process. Current graduates now register and enter 10 cases into POST within the first six months of graduation for the ABNS to provide feedback and help track the transition to practice.

In response to the global pandemic, the oral examination changed to a virtual format for candidates. This was very well received and will continue with guest examiners traveling to pre-exam enrichment activities and conducting exams virtually. The ABNS surveys candidates and examiners for feedback about the exam process. In May 2023, 58% of candidates responded, of whom over 99% felt the application and registration process were clear and transparent, 98% felt the pre-exam session and materials were helpful, and 100% felt the exam was conducted professionally.

One candidate said, “The ABNS staff — along with the entire board certification application process — has been remarkably efficient, clear and professional. It is reassuring to see this kind of professionalism from the board, which represents our field. Overall, it was more impressive than I expected, and the level of professionalism of the staff and examiners made me proud to be in the field. Great work to the team(s) that put this together and make it possible.” Other suggestions for clarification and improvement are reviewed to help improve the oral examination process.

  1. Continuous certification. Formerly known as maintenance of certification, the ABNS uses continuous certification to help assist diplomates in lifelong learning and self-assessment by encouraging, stimulating and supporting continued education in the practice of neurosurgery. Professionalism and participation in quality improvement are also assessed. The program is designed to allow diplomates to meet requirements, comply with state and hospital regulations, and reassure patients, families, payers, funding agencies and the public that ABNS diplomates continually improve their knowledge and practice in core neurosurgery. The ABNS has strongly advocated for continued learning instead of a high-stakes exam to better support the specialty’s needs.

Neurosurgeons continue to evolve and adapt to changes in our field, health care and the needs of our patients. Continuous improvement, self-reflection and self-improvement are essential. The ABNS aims to serve the cause of public health by our mission and values and by continually improving how we serve the field and our patients.

Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.

Marjorie Wang, MD, MPH, FAANS
Froedtert & the Medical College of Wisconsin
Milwaukee, Wis.

 

The Pros and Cons of Pursuing a Fellowship

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After fast-paced, rewarding, but often exhausting years of completing highly technical neurosurgical training as a resident, the decision to pursue an additional one to two years of fellowship training is ultimately highly personal. As a mid-level resident, I weighed the pros and cons of this path after graduating in the context of my professional and personal goals.

Among the pros:

  • Greater job opportunities for those who have completed advanced subspecialty fellowship training;
  • Marketing opportunities in areas with significant market competition;
  • Exposure to and education on new procedures;
  • Refining surgical technique and learning variation in management;
  • Opportunities to educate residents; and
  • Expanding your professional network of mentors and advocates.

Among the cons:

  • The opportunity cost of delaying attending level salary;
  • Delaying building of your neurosurgical practice; and
  • Potential for another relocation following fellowship.

As a spine-focused neurosurgeon, I decided to pursue fellowship training at the Society of Neurological Surgeons Committee on Advanced Subspecialty Training-approved Stanford University School of Medicine program. I felt very fortunate to have worked with excellent spine faculty during my residency at the University of Michigan. I viewed the fellowship as adding to that foundation, particularly regarding the evaluation and decision-making for outpatients. As a resident, we would typically enter the elective spine care timeline near the end, with a pre-op patient ready to undergo a defined surgical procedure. The resident focused on the procedure’s safe and effective performance and high-quality immediate post-operative care. Time spent in the clinic can be variable and limited, particularly with a high-volume inpatient service. Yet, most spine operations are performed on patients who were referred to and evaluated in the clinic, and the vast majority of referred patients do not ultimately have surgery. It is paramount for the spine surgeon to identify who needs surgery to help them accomplish their goals, which operation is best suited to that objective, and how to maximize benefit while mitigating risk.

My fellowship, with equal time under the mentorship of Jon Park, MD, FAANS, FACS, and John K. Ratliff, MD, FAANS, FACS, was well-structured to address these topics and more. Following an attending meant following an attending’s schedule, providing a window into how independent practice feels over the course of a week, and an education on how to run a successful practice. We would typically spend two days per week in the clinic and two days in the operating room, with the fifth day available for add-on cases or academic work. Each of my mentors worked with talented advanced practice providers, so I gained insight into how this physician-led team-based approach made patient care more efficient. An efficient clinic means improved patient wait times and access. I saw how to communicate with referring physicians to coordinate care and develop professional relationships.

Perhaps most importantly, I learned a great deal about how to methodically evaluate the patients in the clinic to determine if they would benefit more from surgical or non-surgical care. It is helpful to remember that you can always bring patients back to the clinic to evaluate the results of additional testing or treatments. It is also useful to remember that there is almost always more than one reasonable surgical strategy if surgery is best suited to treating the situation. I developed new scripts to facilitate informed, shared decision-making regarding treatment options, elicit patient perspectives and address concerns. That has proven immensely valuable in independent practice.

The operative experience was valuable in learning new ways to accomplish operations I had seen or done before. For components of procedures that were already very familiar, fellowship affords more autonomy and a preview of what being an independent surgeon is. That made scrubbing into my first genuinely independent cases less stark of a difference. I had opportunities to “moonlight” on call, which also provided glimpses of independent practice. I also enjoyed operating with residents and learning how to teach in the operating room, which requires its own skillset. In weighing the pros and cons of fellowship, I can confidently state that the pros were undoubtedly more numerous. I will continue to benefit from a rewarding experience over the rest of my neurosurgical career.

Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.

Jay K. Nathan, MD
Trinity Health IHA Medical Group
Livonia, Mich.

Neurosurgery Blog Featured on Medscape’s List of Medical Blogs Physicians Love

By Health ReformNo Comments

On Feb. 16, Medscape published an article, “‘Blog MD’: Medical Blogs That Physicians Love,” including Neurosurgery Blog on their list of 10 medical blogs for physicians. The article states, “the blog authored by the AANS and CNS tackles topics beyond brain surgery. Physicians and other specialists could learn from writings about a neurosurgeon’s approach to mentorship, artificial intelligence in the treatment of stroke patients, and creating a pathway for the next generation of neurosurgeons.”

In the last 12 years, the Neurosurgery Blog has published nearly 550 blog posts. The article notes that the blog’s mission is to investigate and report on how health care policy affects patients, physicians and medical practice and to illustrate that the art and science of neurosurgery encompass much more than brain surgery. Its health policy reporting efforts include multiple topic months and guest blog posts from key thought leaders and members of the neurosurgical community.

Click here to read the article.

We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery.