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Evaluating Professionalism and Self-reflection in Neurosurgery

By CareerNo Comments

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.

 

April 12, 2024
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The Pros and Cons of Pursuing a Fellowship

By CareerNo Comments

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.

April 3, 2024
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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.

April 1, 2024
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M&M Conference: A Better Process for Better Outcomes

By Career, Quality ImprovementNo Comments

Morbidity and mortality (M&M) is a common conference across medical specialties. It originated in the early 1900s when a surgeon named Ernest A. Codman, MD, attempted to create a systematic way of reporting errors and standardizing practices and procedures. Back then, error tracking and reporting were not the norm, and he lost privileges at his hospital for trying to introduce any evaluation of surgeon competence. He persevered in his work and is now recognized as the founder of the M&M conference. This conference allows surgeons to reflect upon their performance and receive invaluable feedback from their peers on preventing future adverse outcomes. It is (generally speaking) a medicolegally protected peer-review conference to discuss complications and undesired outcomes and is an invaluable tool in resident education. Beyond individual surgeon performance, discussion of cases identifies systemic problems and errors that can be changed to create a more sustainable solution.

In neurosurgery, where the stakes of brain surgery or a complex spinal surgery are high, the complications can result in life-altering injury or even death. When people hear the name “Dr. Death” (Christopher D. Duntsch, MD), they probably think of the podcast about a neurosurgeon who was sentenced to life in prison after seriously injuring or killing 33 patients. While this represents an extreme outlier in our profession, these types of complications are precisely what we hope to identify through discussion with our colleagues. Common cases presented in M&M include any patient death surrounding the time of surgery, new neurological deficit, unplanned return to the operating room, readmission to hospital, deviation from the expected post-operative clinical course, wrong-site surgery or post-operative complication.

M&M conference is one of the best opportunities to provide high-yield teaching to residents and faculty regarding delivering safe, high-quality care. Everybody can learn from their mistakes — and M&M is the vehicle used in the medical setting to ensure that we continuously learn and improve what we do. There are many examples of topics discussed in M&M that subsequently spearhead a quality improvement (QI) project.

I was fortunate to be a part of one of the first cohorts of the Program Directors in Patient Safety and Quality Educators Network (PDPQ), working with the Accreditation Council for Graduate Medical Education (ACGME) to create a sustainable quality improvement and patient safety (QIPS) curriculum in neurosurgery. Neurosurgery was one of three pilot specialties involved in this program, which is now going on its fifth year and has expanded to 11 specialties. We met weekly for six months with leaders within neurosurgical programs across the country and other specialties to develop a clear plan for improving resident learning in QIPS. One area that would always come up in our breakout discussions was how M&M was foundational in all programs and thus could be used as an excellent educational tool.

If all neurosurgery programs standardize the M&M process, we discussed how this could allow for national patient safety metrics and process improvements that can be applied across many institutions. After the second cohort of PDPQ participants, two colleagues and I spearheaded our ”M&M Optimization Project,” in which we asked participants to utilize a new standardized M&M format (based on published literature). We recruited 15 programs to use the new format, which categorized the specific concern in each case; our hypothesis was that the standardized format would lead to more discussions, improved education, and more identifiable actionable items and interventions.

The outcome of our pilot was favorable, as indicated by the participants’ survey responses. Since implementation at my institution, I have seen more structured changes come out of our M&M discussions in the past year. The faculty and residents have noted more engagement and education, and many resident QI projects and departmental QIPS initiatives have stemmed from this new format. It is clear that M&M is a necessary tool for checks, balances and accountability and a powerful educational tool for patient safety and quality improvement. It fosters lifelong learning and improvement science in our specialty.

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.

Christina M. Sayama, MD, MPH, FAANS
Oregon Health & Science University
Portland, Ore.

March 18, 2024
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Neurosurgery: Critical Resident Education in Quality Improvement and Patient Safety

By CareerNo Comments

There is nothing more important to a neurosurgeon than patient safety. We strive daily to provide the right care to the right patient at the right time and place in the best possible way. Beyond each individual encounter, achieving this requires constant assessment and reassessment of all aspects of care delivery — a process called quality improvement. For decades, medicine and neurosurgery addressed quality improvement and patient safety (QIPS) but not in a focused, scientific way. Today, however, this represents one of the fastest-growing areas of investigation and implementation in almost every hospital and healthcare system. In response, the American Council for Graduate Medical Education (ACGME) launched the Clinical Learning Environment reviews (CLER) to achieve an optimal clinical learning environment to achieve safe and high-quality patient care. Early work with CLER led to another program, the Program Directors Patient safety and Quality improvement (PDPQ) program.

Program Goal: To create a learning community that fosters best practices in educating residents throughout their training on key aspects of patient safety and quality improvement.

Neurosurgery was one of just three specialties selected for the initial pilot of the ACGME PDPQ program. Cormac O. Maher, MD, FAANS and Deborah L. Benzil, MD, FAANS, helped craft the original curriculum and subsequent revisions as the program grew by adding additional specialties every year. Ultimately, the goal is for all residents in all medical specialties to have this education. Practically, each training program will deploy didactic and experiential elements that imbed in all physicians the critical importance of the science and practices that ensure optimal patient safety and approaches that achieve the greatest benefit in quality improvement.

To date, neurosurgery has participated in five cycles of the PDPQ program (see box for complete program listing). In addition, a group spearheaded by Kushal J. Shah, MD, FAANS;  Christina M. Sayama, MD, MPH, FAANS and Justin G. Santarelli, MD conducted a project designed to optimize morbidity and mortality conferences for neurosurgery departments to make them a more valuable QIPS learning experience. The new model was incredibly successful based on evaluations of the first residencies involved.

As part of the next steps for this important endeavor, the Society of Neurological Surgeons (SNS) Committee on Resident Education has established a QIPS subcommittee. When initially formed, the goals of this subcommittee were:

  • Work closely with the ACGME to implement the PDPQ throughout the specialty of neurosurgery;
  • Seek to accelerate the rate of participation until all programs have participated;
  • Work to improve existing platforms for quality improvement and safety training within the specialty, such as SNS-sponsored boot camps and explore new ways of helping programs achieve their training goals in this area through program directors and department quality officers; and
  • Coordinate with the ACGME to implement a set of ongoing program director quality and safety communities for those programs that have completed the initial phase of the PDPQ project.

The SNS also plans support for expanding this knowledge base to all program directors with a feasible and neurosurgery-focused curriculum rooted in the foundations of the comprehensive ACGME curriculum and experiential work. While the details of this next phase are still a work in progress, it is hoped that the new format will have the added benefit of providing a forum for program directors to share best practices and discuss common challenges on a timely and ongoing basis. At present, this happens exclusively on an “ad hoc” basis. Currently, all academic medicine faces significant challenges and the complexities of regulatory requirements (ACGME, Review Committee for Neurological Surgery, American Board of Neurological Surgery, health care systems, etc.) have all training programs, program directors and administrators. It is hoped that this planned opportunity will help alleviate this. Potential topics for open discussion and sharing of best practices include:

  • Best resources for available QIPS didactic material; and
  • Mechanisms to optimize resident participation in and completion of meaningful quality improvement projects.

Neurosurgery has long been a strong proponent of QIPS. Like many efforts to optimize resident education, neurosurgery leads the way with its early and influential involvement in the ACGME PDPQ program.

Neurosurgery Programs Participating in the ACGME PDPQ Program

Program Lead Participants
University of Michigan Cormac O. Maher, MD, FAANS; Jason A. Heth, MD, FAANS
Cleveland Clinic Edward C. Benzil, MD, FAANS; Benjamin B. Whiting, MD; Vikram  Chakravarthy, MD
Oregon Health & Science University Christina M. Sayama, MD, MPH, FAANS; Seunggu J. Han, MD, FAANS
University of Minnesota Matthew A. Hunt, MD FAANS
Rush University R. Webster  Crowley, MD, FAANS
University of Utah Randy L. Jensen, MD, PhD, FAANS
New York Medical College Carrie R. Muh, MD, FAANS; Justin G. Santarelli, MD
Allegheny Health Network Jody  Leonardo, MD FAANS
Atrium Health Scott D. Wait, MD, FAANS
Case Western Reserve Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
Mayo Clinic Michelle J. Clarke, MD, FAANS
University of Kansas Kushal J. Shah, MD, FAANS
Medical University of South Carolina Libby M. Kosnik-Infinger, MD, MPH, FAANS
Oklahoma University Andrew Bauer, MD, FAANS
Ascension Providence (Michigan State University) Doris Tong, MD

 

If there are any other programs that are interested in participating in the next round, please contact Cormac Maher ( comaher@stanford.edu) or Deborah Benzil ( BENZILD@ccf.org ).

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.

Deborah L. Benzil, MD, FAANS, FACS
Cleveland Clinic
Cleveland, Ohio

March 6, 2024
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The Future of Neurological Surgery: Adapting to GME Changes

By CareerNo Comments

Until the 19th century, surgical training was haphazard with no standardization. The surgical trainee learned through observation of a mentor and finished training when the mentor decided it was time. As surgery evolved from a trade to a profession, surgical training also evolved, pioneered by William S. Halsted, MD. Dr. Halsted’s principles of surgical training included the need to understand the scientific basis of disease, provide supervised care of surgical patients and gain increasing responsibility during training, leading to independent practice.

The last 25 years have been a time of dramatic change in neurosurgical education. The Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Neurological Surgery, which is responsible for determining the standards used to accredit neurosurgical residency programs, has been at the forefront of conceiving and instituting changes. During this brief period, we have established a standard of seven years of training for all neurosurgery programs, instituted duty hours restrictions, incorporated the first year of graduate medical education into the neurosurgical residency, created a standard residency curriculum working with the Society of Neurological Surgeons (SNS) and American Board of Neurological Surgery (ABNS), established case minimums for all neurosurgeons in training and increased the oversight of fellowship training through our collaboration with the SNS Committee on Advanced Subspecialty Training (CAST).

Changes in neurosurgery resident training have been driven by advancing technology, elevated patient expectations and the rapidly growing scope of neurosurgical practice. Advances in technology allow neurosurgeons today to perform a much wider range of procedures with better outcomes. At the same time, this increase has made mastering all aspects of neurosurgery untenable. So, while the scope of global neurosurgical procedures has increased, the individual neurosurgeon’s practice has become more focused. This creates a challenge for neurosurgery: how do we continue to have our trainees identify as neurosurgeons when they have widely varying practices?

A key step in assuring the public that a neurosurgeon who completes an ACGME-accredited training program and is certified by the ABNS is well trained is defining “core neurosurgery.” The ACGME Milestones 2.0 Work Group that developed our neurosurgical Milestones 2.0 concluded that core neurosurgery is defined by the cognitive and technical skills that each neurosurgeon must master to care for neurosurgical patients until a subspecialist can see them. These Milestones, along with determining the minimum number of cases that each graduating resident must perform in various neurosurgical subspecialty areas, help ensure that all neurosurgery residents have had excellent training.

Addressing the issue of neurosurgical subspecialization has required the collaboration of the ABNS, the ACGME and CAST. Along with defining core neurosurgery, the ability to obtain accredited subspecialty training during the neurosurgery residency has helped to assure that residents can not only obtain competence in all areas of core neurosurgery but excellence in those subspecialties in which they focus their practice.

Significant accomplishments in the last three years include:

  • Transition to a single GME accreditation system, whereby many of the formerly American Osteopathic Association-approved programs became ACGME-accredited;
  • Changes to case log required minimum numbers;
  • Creation of new dedicated time requirements for program leadership, program coordinators, and core faculty;
  • Design of a subspecialty-specific block diagram; and
  • Creation of a multi-disciplinary ACGME-accredited neurocritical care fellowship.

The current membership of the ACGME Review Committee remains committed to neurosurgical research. We have always expected each neurosurgeon in training to be able to form a hypothesis, test it, analyze the results and present their findings to the neurosurgical community. Every neurosurgeon should have these skills, and the ACGME Review Committee requires that neurosurgical residents be trained in these skills and that the residents and faculty demonstrate academic achievement each year.

In summary, neurosurgery has always welcomed and often led necessary change while adhering to our founding principle that we exist to take care of our patients and to participate in the research and educational efforts that assure better care for patients in the future.

Disclaimer:  Dr. Harbaugh has served as a director of the ABNS, a member of CAST, a past president of the SNS and is presently chair of the ACGME Review Committee for Neurological Surgery. The opinions in this post are his and do not represent the position of any organization.

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.

Robert E. Harbaugh, MD, FAANS, FACS, FAHA
Penn State Hershey Medical Center
Hershey, Pa.

February 26, 2024
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Cross-Post: Neurosurgery’s glass ceiling: Addressing the gender imbalance in the field

By Career, Cross Post, Women in NeurosurgeryNo Comments

Our current series on Making and Maintaining a Neurosurgeon discusses how one transitions from student to resident to practicing neurosurgeon. In particular, we highlight what our field is doing to improve diversity and the importance of mentorship to those considering neurosurgery. How impactful can mentorship be? Incredibly.

This cross-post highlights the recent article in The Varsity, the University of Toronto’s Student Newspaper by Parsa Babaei Zadeh, Veronica Papaioannou, Zahn Bariring and Lauren Shaw titled, “Neurosurgery’s glass ceiling: Addressing the gender imbalance in the field.” The authors discuss how mentorship is crucial for guiding prospective applicants to competitive specialties and fostering an inclusive space where applicants do not feel alienated.

The authors interview neurosurgeon Gelareh M. Zadeh, MD, PhD, FAANS, FRCS, an advocate for change, actively engaged in mentoring young women. “A lack of mentors, role models, and the sense of having allyship and having people that are similar to you in the field… is one of the biggest factors [preventing women from pursuing neurosurgery], so increasing [the] number of people from diverse backgrounds whether it’s females or others is really important,” Dr. Zadeh states.

Click here to read the full article published by The Varsity.

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.

February 14, 2024
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