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Introduction

The advent of new technologies is makingour specialty far more complex than it was acenturyago.Clearly,theapprenticeshipmodeloftraining and educating new generations cannotbefurtherappliedinanarrowsense.Inthefirstdecadeofthiscenturywelookedatthevariabilityon neurosurgery certification across the world(1–5). Among the conclusions found in thisseriesofmanuscripts,itwasnotedthatalthoughsuccessfulcertificationprocessesexistworldwide,thevariabilityinsuchprocessispronounced,bothwithin and across continents. This was furtherreaffirmedbyotherauthors(6–8).

Training Methodology and Subspecialty Correlation

Neurosurgery training could be definedas the period during which a trainee will beexposed to all technical and cognitive aspectsof both surgical and non-surgical treatmentsof neurological disease, focusing in the mostprevalent and relevant aspects of brain, spine,and peripheral nerve pathology and becomingcompetent in the unsupervised practice of suchtechniques.However,inpracticaltermstherearetwochallengeswiththisconcept. Thefirstchallengeistofitallthesubspecialtiesin the specific time that a society considersneeded,whichvariesbetween5andover10years

Editorial

dependingonthecountryandthesecondchallengeis how to verify that competency indeed hasoccurred.Wehavetotakeintoconsiderationthatourfieldisnowexpandingatanexponentialrate.The advances made in specialties that considerminimal access (endoscope, interventionalneuroradiology, minimally invasive spine, andfunctional neurosurgery) make it virtuallyimpossibletomakesomeonecompetentinallofthem. Therefore,theideaofestablishingashorter“core training” of three years followed by adedicatedtwotothreeyearspecialisationinoneor two areas becomes not only appealing, butprobably necessary. It is naive to think that allneurosurgeonshavetobecompetentinallareasof our field. This goal, at the present time, isprobablynotrealistic,evenmoreso,inasocietywhere good outcomes are demanded of us. Forinstance, while learning the basics of proximaland distal control or microsugical anastomotictechniques is probably part of that abovereferenced “core training”, being able orwillingtoincludeaneurysmsurgeryinourroutinedailypracticemaynotbepracticalduetolimitationsofour environment, hospital support, or training.The only caveat to this is that it will require amaturity on the part of the trainee to declarehim/herselfdevotedtoarestrictedpracticefromearly on in their training. Potential solutions to

Present and Future of Neurosurgery Training and Education

Jaime Gasco

Assistant Professor Director of Resident Education, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, United States of America

1Malays J Med Sci. Jan-Feb 2014; 21(1): 1-3

Abstract Multiple challenges are faced by educators and trainees. These challenges aremultidimensionalandpertaintoascenarioinwhichtraineeshavetobecomeinashortperiodoftime competent technical neurosurgeons, while at the same time conscious of economic andprofessionalfactorsthatwillinfluencetheirpractice.Itisthedutyofsocietiesandleadingeducatorstocometogetherindevelopingcontinentalmethodsoftrainingaimedtowards“organisedlearning”.Thegoalshouldstrictlybetheeducationofourresidents,notjusttheutilisationoftheirmanpowerforanumberofyears.

Keywords: certification, competency, education, neurosurgery, training

Submitted:17Dec2013Accepted:23Dec2013

2

Malays J Med Sci. Jan-Feb 2014; 21(1): 1-3

thisshouldtheychangetheirminds lateronareadditionalfellowships.Credentialedpostgraduatesubspecialty training therefore becomes moreimportant than ever, since we will be publiclyclaimingthatthosegraduatescanpracticeinsuchsubspecialty in a competent and unsupervisedfashion.

Certification of Competency

Most countries test neurosurgery traineeswith cognitive examinations during residency,and rely on internal evaluations of technicalcompetency during training. Additionally, somecountries expand their examination into thepostgraduate period by means of implementingoral examinations in which cases are typicallypresented but it remains a cognitive test, nota technical one. Measuring the complexity ofthe certification systems, the organisation ofthe leading boards and the components of theexaminationprocesses,intheWorldFederationofNeurosurgical(WFNS)studyseriesweidentifiedleadingcertificationsystemswithintheirspecificcontinent (1–5). In Asia, the processes offeredbyMalaysiaandRepublicofKoreawerehighest,followed by the Hong Kong/Singapore jointexamination system (5). The intention of suchranking system was to take a snapshot of thecomplexity anddiversity of itemsutilised in thedifferent countries. The correlation betweenoverall quality and ranking scorewas not done,norimpliedinthisstudyseries,socautionshouldbe taken in the interpretation of such results.Equally, it became apparent that there was anexisting lackofhomogeneityacrosstheworld inthe way neurosurgeons are tested and becomecertified. Cognitive competency evaluation bymeansofonlineassessmentcanbecomeasimplemethod of sharing a similar evaluation systemacrosstheworld(9,10).Currently,thisislimitedtomaintenanceofcertificationintheUnitedStatesbutthiscouldbeutilisedworldwideasamethodofassessment. A databank of questions couldbe created under the scope of the WFNS, withability to distribute online protected cognitiveevaluations across the world. The examinationsshouldbedesignedwithcapabilitytodiscriminatelevelsofcompetencyrangingfromunsatisfactory,early learner, competent, proficient, and expert,equivalent to the physician diagnostic inventoryscale.Theideaofaworldwidecertificationsystemunder the scopeof theWFNS isboth intriguingand appealing, and it could easily openbarriersto competent neurosurgeons in this era ofglobalisation.

The Future Role of Simulation in Training

Recently, neurosurgery has been able todevelop adjuvants for learning that are startingto appear in our academic institutions with theintention to decrease the steep learning curvetowards competency level (11–13). Simulators,under the scope of an organised curriculumsystem(11)offerapracticalsolutiontoindividualadjuvant training in areas of weakness,new technologies andhave a future role in pre-operative rehearsal to decrease real errors insurgery.Similarlytopilots,neurosurgerytraineesin the future will probably have a logbook ofsimulated emergencies and case modules.If countries utilise comparable simulatorsand evaluation methods, this could provide asolution to the current challenge of evaluating“technical competency”. Limitations on costand implementation under individual hospitalsare still major challenges. It will be thereforeimportant to produce science that proves howthis technology indeeddeliverswhat itpromisesi.e. shorter learning curve, less errors, betteroutcomes,highercompetencylevelsoftrainees.

Socio-economic and Ethical Aspects of Professional Education

In this era of restricted funding, limitedresources and accountability of individualexpensestoachieveoursurgicalgoalswemustnotforgetourobligationtoteachresidentsawarenessregardingcostcontainmentandproperresourceutilisationwithoutcompromisingthecareofourpatients. In addition, we must also not forgettheboundarythatshouldexistbetweenindustrycollaborationandneurosurgeons,sincethisareacaneasilyblurourcapabilitytodistinguishwhenour field is being advanced rather than just theinterestsofafew.Weshouldteachourresidentstotreattheirpatientsasfamilymembers.Iftheywould do different surgeries to a patient thantheywouldtoa familymember,canwesaythatwe succeeded in our goal to educate them asphysiciansurgeons?

Acknowledgement

The author would like to thank ProfessorJafri Abdullah for his educational leadership inMalaysia and his international collaboration intheWorld Federation of Neurosurgical (WFNS)study.

Editorial |Neurosurgerytraining:Presentandfuture

www.mjms.usm.my 3

Correspondence

DrJaimeGascoMBBS(UniversidaddeValencia)DivisionofNeurosurgeryUniversityofTexasMedicalBranch301UniversityBlvdGalveston,TX77555UnitedStatesofAmericaTel:+4097721550Fax:+4097721742Email:jagascot@utmb.edu

References

1. Gasco J, Barber SM, McCutcheon IE, Black PM.Neurosurgery certification in member societies ofthe WFNS: Africa and the Middle East. World Neurosurg.2011;76(1–2):18–27.doi:10.1016/j.wneu.2010.09.006.

2. Gasco J, Barber SM, McCutcheon IE, Black PM.Neurosurgery certification in member societies ofthe WFNS: Europe. World Neurosurg. 2010;74(4–5):375–386.doi:10.1016/j.wneu.2010.03.019.

3. Gasco J, Barber SM, McCutcheon IE, Black PM.Neurosurgery certification in member societies ofthe WFNS: global overview. World Neurosurg.2011;76(3–4):231–238. doi: 10.1016/j.wneu.2010.10.036.

4. GascoJ,BarberSM,Rangel-CastillaL,McCutcheonIE,BlackPM.Neurosurgerycertificationinmembersocieties of the World Federation of NeurosurgicalSocieties(WFNS).TheAmericas.World Neurosurg. 2010;74(1):16–27.doi:10.1016/j.wneu.2010.01.012.

5. Gasco J, Braun JD, McCutcheon IE, Black PM.Neurosurgery certification in member societies ofthe World Federation of Neurosurgical Societies:Asia.World Neurosurg.2011;75(3–4):325–334.doi:10.1016/j.wneu.2011.01.001.

6. Burkhardt JK, Zinn PO, Bozinov O, Colen RR,BertalanffyH, Kasper EM.Neurosurgical educationin Europe and the United States of America.Neurosurg Rev.2010;33(4):409–417.doi:10.1007/s10143-010-0257-6.

7. Trojanowski T. Certification in neurosurgery-worldwide perspective. World Neurosurg. 2013;80(5):e159–160.doi:10.1016/j.wneu.2010.11.030.

8. Trojanowski T. Certification of competence inneurosurgery--the European perspective. World Neurosurg. 2010;74(4–5):432–433. doi: 10.1016/j.wneu.2010.04.012.

9. Sheehan J, Starke RM, Pouratian N, Litvack Z.Identification of knowledge gaps in neurosurgeryusing a validated self-assessment examination:differences between general and spinalneurosurgeons.World Neurosurg.2013;80(5):e27–31.doi:10.1016/j.wneu.2012.09.007.

10. Sheehan J, Starke RM, Pouratian N, Litvack Z,Asthagiri A. Identification of Knowledge Gaps inNeurosurgeryThroughAnalysisofResponses to theSelf-Assessment in Neurological Surgery (SANS).World Neurosurg. Forthcoming2012.doi:10.1016/j.wneu.2012.05.033.

11. GascoJ,HolbrookTJ,PatelA,SmithA,PaulsonD,MunsA,etal.Neurosurgerysimulationinresidencytraining: feasibility, cost, and educational benefit.Neurosurgery. 2013;73(1Suppl):39–45.doi: 10.1227/NEU.0000000000000102.

12. Gasco J, Patel A, Luciano C, Holbrook T, Ortega-Barnett J, Kuo YF, et al. A novel virtual realitysimulation for hemostasis in a brain surgicalcavity: perceived utility for visuomotor skills incurrent and aspiring neurosurgery residents.World Neurosurg.2013;80(6):732–737.doi:10.1016/j.wneu.2013.09.040.

13. Roitberg B, Banerjee P, Luciano C, MatulyauskasM, Rizzi S, Kania P, et al. Sensory andmotor skilltesting in neurosurgery applicants: a pilot studyusingavirtualrealityhapticneurosurgicalsimulator.Neurosurgery. 2013;73(1 Suppl):116–121. doi: 10.1227/NEU.0000000000000089.