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Neurosurgeons as Neurointensivists

harbGuest post from Robert E. Harbaugh, MD, FAANS
AANS Past President
SNS President
Director, Institute of the Neurosciences
Distinguished Professor and Chair, Department of Neurosurgery
Professor, Department of Engineering Science & Mechanics
The Pennsylvania State University
Milton S. Hershey Medical Center
Hershey, PA

Neurocritical care is part of the continuum of neurosurgical care and neurosurgeons are trained to care for their patients in a critical care setting. Despite this, neurosurgeons in the United States were at risk of losing their role as neurointensivists. This report will review the accomplishments of organized neurosurgery regarding certification of neurosurgeons as neurointensivists.

The American Board of Neurological Surgery (ABNS) Certification
The American Board of Neurological Surgery (ABNS) defines the scope of neurosurgical practice; sets the standards of neurosurgical education, training and practice; defines the requirements for training; develops and administers a primary examination; evaluates the credentials of candidates for certification, including professional practice; develops and administers an oral examination; issues board certification certificates; and defines requirements for maintenance of certification (MOC) in neurological surgery.

Clearly, the evaluation and management of neurosurgical patients in critical care settings is explicitly articulated as being within the scope of neurosurgical practice by the ABNS. As such, ABNS certification alone is sufficient for neurosurgeons to care for their own patients in a critical care setting. However, additional training and/or certification in neurocritical care, for those neurosurgeons who make neurocritical care a major part of their practice, can be obtained as described below.

SNSThe ABNS/SNS CAST Process for Certifying Neurosurgeons as Neurointensivists
The Society of Neurological Surgeons’ (SNS) Committee on Advanced Subspecialty Training (formerly the Committee on Accreditation of Subspecialty Training), or CAST, was formed in 2001 to offer accreditation of subspecialty training programs in neurosurgery. Training standards were established by the subspecialties through the Joint Sections of the American Association of Neurological Surgeons and Congress of Neurological Surgeons, with specifications for facilities, faculty, affiliated services, patient care, and procedural volumes. Since its inception, the CAST process has been based on the principle that subspecialty recognition should be based on proficiency, which may occur during or after residency.

In its effort to certify and standardize subspecialty training in neurological surgery, the SNS CAST is working closely with the ABNS to make sure that there is agreement across our neurosurgical organizations. Until recently, CAST accredited subspecialty training programs did not issue certificates to individuals. During his tenure as SNS President, Ralph G. Dacey, Jr., MD, FAANS, created the CAST Task Force to consider expanding the role of CAST to include subspecialty certification of neurosurgeons. Other members of the task force included:  Arthur L. Day, MD, FAANS; Stephen L. Giannotta, MD, FAANS; Robert E. Harbaugh, MD, FAANS; and Volker K.H. Sonntag, MD, FAANS. Neurocritical care was the first subspecialty that the CAST Task Force was neurocritical care.

The SNS Executive Council approved CAST Task Force recommendations for the program requirements for CAST accreditation of neurocritical care training programs, as well as the criteria for CAST certification of neurosurgeons and other specialists with subspecialty expertise in neurocritical care. These requirements include a “Practice Track” pathway for neurosurgeons and others who had already completed subspecialty training in neurocritical care prior to the availability of CAST accredited training programs, or who already have a subspecialty practice in neurocritical care. The requirements for accreditation of programs and certification of individuals, including the criteria for both post-graduate and enfolded fellowships, can be found on the SNS website. CAST is working with the ABNS to grant certificates to neurosurgeons who have completed a CAST accredited fellowship. The group is also collaborating with the Accreditation Council for Graduate Medical Education (ACGME) to allow data sharing, which will help CAST in its role of accrediting programs. A CAST process that partners with the ACGME for accreditation of fellowship programs, and with the ABNS for subspecialty certification of neurosurgeons, is a great accomplishment for our specialty and for patients with neurocritical care needs.

frogLeapfrog Group Recognition
Finally, The Leapfrog Group now recognizes the CAST process as equivalent to the United Council for Neurologic Subspecialties (UCNS) process for accrediting neurocritical care fellowships and certifying neurointensivists. On May 15, 2015, the Leapfrog Group updated its “Fact Sheet: ICU Physician Staffing” to define neurointensivists as one of the following:

  1. Board-certified physicians who are additionally certified in the subspecialty of Neurocritical Care Medicine. Certification in Neurocritical Care Medicine is awarded by the United Council for Neurologic Subspecialties (UCNS) or through completion of the Society of Neurological Surgeon’s CAST fellowship, with subsequent passage of the associated ABNS exam.
  2. Physicians board-certified in their specialty who have:
  • completed the CAST fellowship prior to the availability of the associated ABNS exam; and
  • provided at least six weeks of full-time ICU care annually.

Because of the work of organized neurosurgery, neurocritical care — an important and integral part of neurosurgery — will remain a field open to present and future generations of neurosurgeons. This is beneficial for neurosurgeons and neurosurgical patients alike.

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