NEUROSURGICAL EDUCATION Roberto C Heros M D Can

NEUROSURGICAL EDUCATION Roberto C. Heros, M. D.

Can the Current Neurosurgical Residency be Improved? YES, But not too much and not too fast

Well Known Challenges • ACGME standardized requirements • Compliance issues • Curriculum-based residency • More to learn, less time to do it • Reimbursement pressures interfere with our ability to train our residents • Work hours regulations

“The test of the people is what they can do when they are tired. ” - Winston Churchill (1874 -1965)

More Subtle Challenges • Physicians no longer seen as “priests”. • We are only “doctors” – need real “professionals” to teach us and our residents about ethics, honesty in research, domestic violence, recognition of sleep deprivation, informed consent, end of life decisions, etc. • Privacy issues - Patients have right to privacy, physicians do not. Patients can read our notes, radiology reports, medical records, etc. • IRB regulations obstruct clinical research • Residents frequently seen as hospital employees • Nurses and other paraprofessionals work for the hospital and not for the doctors • Role of the Program Director but

Suggestions for Change - I Network with other surgical subspecialties to gain more independence of our RRC from ACGME • Independence from ACGME dictated “competencies”. • Flexibility on “work hours”. • More dependence on faculty based ecletic education rather than lecture and courses by “professionals”. • More dependence on faculty assessments rather than computer-based standardized ACGME criteria. • RRC review visits jointly by an ACGME professional and a senior neurosurgeon.

Suggestions for Change - II Develop Task Force of the ABNS, RRC & SNS to consider restructuring of residency One model: • Divide between “junior” and “senior” residency. • “Junior” (minimum of four years): Core curriculum including Neurology and basic surgical skills and one or two years of basic or clinical research. • “Senior” years divided into two years of “chief residency” (cranial, spine, pediatrics, etc. ) and one year of sub-specialization. • Different considerations for junior and senior years

“Senior Residency” • Collegial respect • No “scut” work • No “in-hospital” call • Intensive surgical experience • Progressive “real” responsibility • Significantly increased salary

Suggestions for Change - III Subtle changes in attitude in faculty-resident relationship: • Mentor-partner concept • Maintain role of Program Director (“Chief Mentor”); preferably but not always Chairman but always senior, respected faculty. • Elevate the position of Program Coordinator • Incentivize ($) chief residents to help Coordinator • “Family” concept. More social interaction: Sporting events, parties, informal journal clubs, etc • Invite criticism and solicit input: “What do you think we should do”, not as a “test” but as an honest question to improve patient care.

“Every act of conscious learning requires the willingness to suffer an injury to one’s self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily; and why older persons, especially if vain or important, cannot learn at all. ” - Thomas S. Szasz, 1920 - , Education, The Second Sin, 1973.

“To educate the person in mind and not in morals is to educate a menace to society. ” - Theodore Roosevelt (1858 -1919)

Thank you

The Neurosurgeon as a Professional Definition of Professionalism (after Linda de Cossart; Moynihan Lecture, Royal College of Surgeons of England, 2005) - An occupation exercising “good” in the service of others - Specialized work that cannot be entirely understood by the layman - Not measured by financial reward only - Has an esoteric and complex knowledge base - Depends upon professional judgment - Is ethically and morally based

ACGME “COMPETENCIES” • Patient care • Medical knowledge • Practice-based learning and improvement • Interpersonal and communication skills • Professionalism • Systems-based practice

The Other Competencies AANS Presidential Address, 2003 • Intellectual honesty • Scholarship-science and art • Practicing in a hyperlegalistic society • Time and cost effective practice patterns • Approach to patients • The Pride of Being a Neurosurgeon

Intellectual Honesty • • Recognizing our frailties Take ownership of our mistakes Avoid false rationalization The three levels of discussion of complications • Discuss openly your limitations • Acknowledge ignorance • Encourage respectful disagreement

Intellectual Honesty Our trainees will forgive almost any of our weaknesses, but they will not respect us as mentors if they perceive us as being intellectually dishonest.

Scholarship – Science and Art • Discuss and grade the level of evidence • Evidence-based medicine • Guide or Dictator? • Practicing by protocol • Should not trump common sense or clinical judgment • Encourage exploration and innovation • Demand self-assessment

Scholarship – Science and Art Our challenge as mentors is to instill in our trainees a commitment to ever enhancing the scientific foundation of our profession without becoming enslaved by the scientific method.

Practicing in a Hyperlegalistic Society • • Can too much of a good thing be bad? Effect on the physician-patient relationship Informed consent Be flexible. What is best for this patient? Whose choice is it anyway? “Always do what is best for the patient” Can the medicolegal implications be ignored? The neurosurgeon as expert witness

Practicing in a Hyper-Legalistic Society The worst consequence of the medico-legal crisis is the deterioration of the physicianpatient relationship. It is our responsibility to prevent this.

Time and Cost-Effective Practice Patterns • Our time and resources are limited • Unnecessary tests and procedures • Do not lose sight of the “main complaint” • Do not let the trees obscure the forest

Time and Cost Efficient Practice Patterns Our resources and our time are limited and it is our responsibility to conserve both and serve better our patients, by doing for them only what they need…and no more.

Approach to Patients • Always treat the patient as you would if he/she were not sick • Become a zealous upholder of the patient’s dignity • Reinforce positive gains rather than persistent deficits • Listen to the patient. He/she will let you know when he is ready to hear it. • Be authoritative. The patient wants it! • Be positive. It will enhance the patient’s confidence in you • “It is okay to wear your emotions on your sleeve”

Approach to Patients We should teach, by verb and example, that being a patient does not reduce one’s level of dignity and, therefore, we should relate to our patients as we would if they were not sick.

Being a Neurosurgeon As neurosurgical mentors, we should instill in our trainees the same pride and sense of elitism that has made us so satisfied with our career choice. This they can have without arrogance … and they should also understand that this pride is not an entitlement, but rather is earned through hard work and sacrifice.

One Scheme for a Longer Residency • “Junior” residency-5 years - One year of general competency including Neurology; under neurosurgical control - Two or three years of clinical neurosurgery - One to two years of research

One Scheme for a Longer Residency • “Senior” residency-3 years - Two years of clinical neurosurgery - One year of chief residency • Fellowship; elective - Status of temporary junior faculty/partner with time-limited contract

The Pride of Being a Neurosurgeon • Elitism is appropriate. Just don’t flaunt it! • Respect other neurosurgeons a priori…. until they lose your respect. • The “other” neurosurgeon was right… until proven wrong. • Work hour limits are for others. Neurosurgeons choose their own hours. • The self-knowledge of our sacrifice is the necessary base for enjoyment of our rewards. • The best example of “The Joy of Being a Neurosurgeon”: Peter Jannetta

Neurosurgical Education Further thoughts and opinions - How and by whom should “ethics” be taught - The ethics of referral - Advertising and self-promotion - Evidence-based neurosurgery - Bureaucratic hijacking of education - Hyperlegalistic interference - Medico-legal testifying - The pride of being a neurosurgeon

NEUROSURGICAL EDUCATION Roberto C. Heros and Jacques J. Morcos

Demands, Challenges and Opportunities • Radiosurgery • Endovascular surgery • Functional neurosurgery • Complex spinal surgery • New technology • Research • And yet…. less work hours!

Research Some areas we cannot abandon: - Neuro-Oncology - Vasospasm - Endovascular techniques - Gene therapy and stem cell research - Neurotransplantation - Spinal biomechanics - Neuroprotection - Embryology and in-utero treatment of congenital disorders - Physiologic basis of neurostimulation - Physiology and treatment of pain - Robotics and neuroprosthetics

Possible Changes in Residency • Curriculum-based residency • Preceptorship • Core years + subspecialization • Longer residency