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.
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