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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.

AANS Neurosurgeon Spotlight: The State of Neurosurgical Education

By AANS Spotlight, Burnout, COVID-19, GMENo Comments

Recent global circumstances have had considerable effects on neurosurgery. In the latest articles from AANS Neurosurgeon, the official socioeconomic publication of the American Association of Neurological Surgeons (AANS), authors discuss the state of neurosurgical education. Practices have taken steps to not only adapt to a multitude of changes due to the COVID-19 pandemic, but to thrive among them, while helping their patients do the same. Browse the Education issue for a scientific, artistic and realistic view from those tasked with providing and navigating valuable educational experiences during a time when there is no such thing as “normal.”

Article Spotlight

This Crisis is an Opportunity
Lola B. Chambless, MD, FAANS

Dr. Chambless explains how the pandemic has provided an unprecedented opportunity to study, learn and reform.

A Combined Spine Surgery Fellowship
Jason Savage, MD ꟾ Michael P. Steinmetz, MD, FAANS

Discover the makings of a successful spine fellowship – strong leadership, constant re-evaluation and a collaborative surgeon group.

Pen versus Penfield: A Proposed New Training Modality for Neurosurgery Residents
Erin N. D’Agostino, MD

Dr. D’Agostino describes how art “can serve a role in surgical skill building, learning and teaching of anatomy, patient education and combating burnout.”

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Follow @aansneurosurg on Twitter, Instagram and like AANS Neurosurgeon on Facebook!

AANS Neurosurgeon Spotlight: Winter 2020 – The Mind of a Neurosurgeon Part III

By AANS Spotlight, Career, Faces of Neurosurgery, Food for thoughtNo Comments

From training appraisal to relocation, authors explore the neurosurgeon perspective in AANS Neurosurgeon’s The Mind of a Neurosurgeon. Prominent neurosurgeons discuss their unique experiences in a field in which few have the opportunity to work and thrive.

Changing Gears: Mid-Career Relocation as a Catalyst for Better Patient Care
Daniel Orringer, MD, FAANS

  • Inspirational leadership; state-of-the-art facilities; a cumbersome electronic medical record; affiliation with a top-notch medical school; and a culture and history of excellence.
  • Navigating geographic change – from Ann Arbor to New York.
  • Navigating institutional change – evaluating essential components of a routine.
  • A new team – leading with the patients’ interest in mind.

The Mindful Neurosurgeon and the Art of Doing What’s Right
Edward C. Benzel, MD, FAANS

  • The desire for personal gratification, professional advancement and monetary gain can lead one to their neurosurgical calling.
  • The mindful neurosurgeon does not look at a job from the perspective of the job being a commodity generator, but from the perspective of the job as a calling.
  • Good leaders are selfless guides, reflective and empathetic.
  • The truly mindful neurosurgeon values doing what is right over all else.

Building the Neurosurgical Mind: Critical Appraisal in Neurosurgical Training
Beverly C. Walters, MD

  • Neurosurgical training goals focus on specialty knowledge acquisition, development of technical skills involving eye-hand coordination, learning how to collect important patient data and enhancement of critical thinking ability.
  • Look at the structure of research that tries to promote changes in practice to develop skills in evaluation of data and to be able to decide, factually, whether the ideas are worthy of inclusion in clinical practice – or, more importantly, if they are not worthy.
  • This basic concept of understanding the successes and failures of clinical research in our specialty and development of the ability to use data in the treatment of patients became known at the end of the twentieth century as evidence-based medicine.

Read More from The Mind of a Neurosurgeon.

A Year in review: Making Progress on Neurosurgery’s Legislative and Regulatory Agenda

By Advocacy Agenda, Congress, Health Reform, Medical Innovation, Medical Liability, Prior Authorization, UncategorizedNo Comments

As we come to the end of a decade and head into 2020, it is fitting to reflect on the progress that the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) have made in advancing organized neurosurgery’s legislative and regulatory agenda to ensure that neurosurgical patients have timely access to quality care. At the beginning of 2019, we set forth an ambitious agenda, and throughout the year, the AANS and CNS continued to make progress on achieving our health policy goals.

Some highlights:

  • Protect Patients’ Timely Access to Care. Prior authorization is a cumbersome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. To protect patients’ timely access to care, as leaders of the Regulatory Relief Coalition, the AANS and the CNS collaborated with key champions in Congress — Reps. Suzan DelBene (D-WA); Mike Kelly (R-PA); Roger Marshall, MD, (R-KS); and Ami Bera, MD, (D-CA) — to introduce H.R. 3107, the Improving Seniors’ Timely Access to Care Act. With 156 sponsors at year’s end, this bill would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program.
  • Improve the Health Care Delivery System. Narrow insurance networks restrict patient access to the physician of their choice and leave patients vulnerable to unanticipated medical bills. Working to improve the health care delivery system, the AANS and the CNS successfully advocated for the introduction of legislation to protect patients from unanticipated medical bills. The Protecting People from Surprise Medical Bills Act (H.R. 3502), and the Stopping The Outrageous Practice (STOP) of Surprise Medical Bills Act (S. 1531), would hold patients harmless and ensure that they would only be responsible for in-network cost-sharing amounts when out-of-network providers take care of them. Patients would also be kept out of the middle of payment disputes between health plans and providers, and a process for fairly reimbursing providers for their services would be established.
  • Support Quality Resident Training & Education. An appropriate supply of well-educated and trained physicians — both in specialty and primary care — is essential to ensure access to quality health care services for all Americans. Looming physicians shortages — by 2032, the nation faces a physician shortfall of between 46,900 to 121,900 — threaten this access to care. To help ease this shortage and to support quality resident training and education, the AANS and the CNS successfully advocated for legislation to increase the number of Medicare-sponsored residency training positions. The Resident Physician Shortage Reduction Act ( 348 / H.R. 1763), with a total of 185 cosponsors, would increase the number of available medical residency positions by 15,000 over five years.
  • Continue Progress with Medical Innovations. America has a long tradition of excellence and innovation in patient care, and neurosurgeons have been on the cutting edge of these advancements. However, due to the medical device excise tax, American medical innovation and patient care have been at risk. Working with our partners in the medical technology industry for the past decade, the AANS and the CNS have been advocating for Congress to repeal this tax. This year, with the passage of H.R.1865, the Further Consolidated Appropriations Act, 2020, Congress demonstrated its commitment to continuing progress with medical innovation by repealing this tax. President Trump signed the legislation into law (P.L. 116-94). This bill also included increased funding for biomedical research in the neurosciences. Finally, Reps. Diana DeGette (D-Colo.) and Fred Upton (R-Mich.) released their initial vision for their Cures 2.0 initiative, which aims to modernize insurance coverage policies and improve access to life-saving cures. Cures 2.0 would build on the original 21st Century Cures Act (P.L. 114-255), which aspires to advance medical research and foster a new era of medical innovations.
  • Fix the Broken Medical Liability System. Medical lawsuit abuse is driving up health care costs, and driving good doctors out of the practice of medicine, leaving patients without the care they need when they need it. Many doctors — particularly in high-risk specialties like neurosurgery — are cutting back on high-risk and life-saving services, relocating to states with more patient-friendly liability laws, retiring early or leaving the practice of medicine altogether. To help fix the broken medical liability system, as a leader of the Health Coalition on Liability and Access, the AANS and the CNS worked with leaders in Congress to introduce H.R. 3656, the Accessible Care by Curbing Excessive LawSuitS (ACCESS) Act, which is modeled after proven reforms that are in place in California and Texas. In addition, legislation to help ensure that physicians are available to take care of patients with medical emergencies is pending before the House and Senate — the Good Samaritan Health Professionals Act (S. 1350) and the Health Care Safety Net Enhancement Act (H.R.3984).

We still have our work cut out for us to continue advocating for sound health policy that improves patient care, but 2019 will go down as a year in which the AANS and the CNS made significant positive strides.

          

 

 

AANS and CNS Release 2017 Legislative and Regulatory Agenda

By Access to Care, Antitrust, Coding and Reimbursement, Congress, Drugs and Devices, Emergency Care, GME, Health, Health Reform, Healthcare Costs, HIT, IPAB, MACRA, MedEd, Medical Innovation, Medical Liability, Medicare, Quality ImprovementNo Comments

On February 14, 2017 the AANS and CNS released their 2017 legislative and regulatory agenda, which includes action items such as improving the health care delivery system, abolishing the Independent…

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