Identification of knowledge gaps in neurosurgery using a validated self-assessment examination: differences between general and spinal neurosurgeons

Longitudinal Analysis of Peripheral Nerve Surgery Training: Comparison of Neurosurgery to Plastic and Orthopedic Surgery

BACKGROUND

Residents in multiple surgical specialties are trained to perform peripheral nerve surgery (PNS), but the extent of exposure to this field varies among specialties. This study evaluates trends in volume of PNS performed during residency for neurologic surgery trainees compared to those in plastic and orthopedic surgery between 2009 and 2019.

METHODS

We queried ACGME for neurologic, plastic, and orthopedic surgery resident case-logs and compared mean number of PNS between graduating residents of each specialty using a one-way analysis of variance test. Linear regression was utilized to determine trends within and across the specialties over the study period.

RESULTS

Neurosurgery residents (24.76 ± 3.41) performed significantly fewer PNS than their counterparts in orthopedic (54.56 ± 6.85) and plastic surgery (71.96 ± 12.20), P < 0.001. Residents in neurologic surgery reported over 1.5-fold as many cases as their ACGME-required minimum, in contrast to plastic (2.5-fold) and orthopedic (5-fold). Plastics residents (3.46 cases/year) demonstrated the greatest longitudinal increase in PNS, followed by neurosurgery residents (0.81 cases/year). PNS accounted for a mean of 5.81% of neurosurgery resident cases, 4.20% of plastic surgery resident cases, and 2.98% of orthopedic surgery resident cases (P < 0.001).

CONCLUSIONS

Neurosurgery residents exceeded the required minimum number of PNS and were increasingly more exposed to PNS. However, compared with their counterparts in orthopedic and plastic surgery, neurosurgery residents performed significantly fewer cases. Exposure for neurosurgery residents remains unchanged over the study period while plastic surgery residents experienced an increase in case volume. The deficiency in exposure for neurosurgical residents must be addressed to harness interest and proficiency in PNS.

Underutilization of epilepsy surgery: Part I: A scoping review of barriers

One-third of persons with epilepsy have seizures despite appropriate medical therapy. Drug resistant epilepsy (DRE) is associated with neurocognitive and psychological decline, poor quality of life, increased risk of premature death, and greater economic burden. Epilepsy surgery is an effective and safe treatment for a subset of people with DRE but remains one of the most underutilized evidence-based treatments in modern medicine. The reasons for this quality gap are insufficiently understood. In this comprehensive review, we compile known significant barriers to epilepsy surgery, originating from both patient/family-related factors and physician/health system components. Important patient-related factors include individual and epilepsy characteristics which bias towards continued preferential use of poorly effective medications, as well as patient perspectives and misconceptions of surgical risks and benefits. Health system and physician-related barriers include demonstrable knowledge gaps among physicians, inadequate access to comprehensive epilepsy centers, complex presurgical evaluations, insufficient research, and socioeconomic bias when choosing appropriate surgical candidates.

Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review

Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.

Management of Adolescent Idiopathic Scoliosis: Institutional Experience, Integration into Neurosurgical Practice, and Impact on Resident Training

OBJECTIVE

Management of adolescent idiopathic scoliosis (AIS) in neurosurgery residency training may have a significant impact on resident experience, even though few trainees are likely to pursue careers in the field of AIS. The impact of this exposure on resident knowledge in adult spinal disease management is the subject of our retrospective analysis.

METHODS

An analysis was performed of all adolescent patients undergoing surgical correction of spinal deformity between 2006 and 2016. Patient characteristics, including age at operation, Cobb angles, length of stay, operative time, blood loss, and complications, were collected. Objective benchmarks were created for resident education in the management of AIS. A survey was sent to the last 7 years of graduates to assess the impact of exposure to AIS during neurosurgery training on their current practice.

RESULTS

Nine male and 37 female patients ages 11 to 22 years were identified. Neurosurgical residents assisted in all procedures without fellows or surgical assistants. Average operative time was 336 minutes (range, 215-575 minutes), and blood loss per procedure was 603 mL (range, 200-4000 mL). The average Cobb angle correction was 72.2% (range, 35.3%-90.9%). Zero of the past 7 graduates currently treat AIS surgically. All 7 graduates agreed that exposure to AIS during residency enhanced their knowledge of adult spinal disease management.

CONCLUSIONS

Treatment of AIS by surgeons with specialized training can be effective and safe. Resident exposure to these patients enhances their understanding of spinal biomechanics and deformity correction, which is applicable to treating AIS and adult spinal deformity.

Can Maintenance of Certification Work? Associations of MOC and Improvements in Physicians' Knowledge and Practice

PURPOSE

To summarize the findings of studies, conducted by individuals both internal and external to the American Board of Medical Specialties (ABMS) Member Boards, of the associations of Maintenance of Certification (MOC) and improvements in physicians' knowledge and patient care processes or outcomes.

METHOD

The authors conducted a narrative review of studies identified by searching PubMed and Web of Science for English-language articles from the United States published between 2000 and May 2017. To be included, articles had to examine the relationship of MOC to physician knowledge, clinical practice processes, or patient care outcomes. The initial search yielded 811 articles. After two rounds of review and excluding those articles that did not fit the study criteria, 39 articles were included for analysis.

RESULTS

The 39 included studies were conducted by or included diplomates of 12 ABMS Member Boards. Twenty-two studies examined MOC processes that were developed by an ABMS Board; 17 examined interventions that were developed by nonboard entities but accepted for MOC credit by an ABMS Board. Thirty-eight studies examined a single component of MOC; 24 studied the improvement in medical practice component. Thirty-seven studies reported at least one positive outcome.

CONCLUSIONS

Most of the studies included in this review highlighted circumstances in which MOC was associated with positive impacts on physician knowledge and patient care processes or outcomes. Future collaborative research is needed to improve the relevance, helpfulness, and generalizability of continuing certification to different physicians across specialties and practice settings.

Stereotactic Radiosurgery for Neurosurgical Patients: A Historical Review and Current Perspectives

Today, stereotactic radiosurgery is an effective therapy for a variety of intracranial pathology that were treated solely with open neurosurgery in the past. The technique was developed from the combination of therapeutic radiation and stereotactic devices for the precise localization of intracranial targets. Although stereotactic radiosurgery was originally performed as a partnership between neurosurgeons and radiation oncologists, this partnership has weakened in recent years, with some procedures being performed without neurosurgeons. At the same time, neurosurgeons across the United States and Canada have found their stereotactic radiosurgery training during residency inadequate. Although neurosurgeons, residency directors, and department chairs agree that stereotactic radiosurgery education and exposure during neurosurgery training could be improved, a limited number of resources exist for this kind of education. This review describes the history of stereotactic radiosurgery, assesses the state of its use and education today, and provides recommendations for the improvement of neurosurgical education in stereotactic radiosurgery for the future.

Training Neurosurgery and Radiation Oncology Residents in Stereotactic Radiosurgery: Assessment Gathered from Participants in AANS and ASTRO Training Course

OBJECTIVE

Stereotactic radiosurgery (SRS) represents an expanding approach for neurosurgeons and radiation oncologists. We evaluate educational gaps of senior residents drawn from each specialty as part of a focused SRS course. We also evaluate the strengths and limitations of SRS training in current residency programs of the course residents and faculty.

METHODS

The American Association of Neurological Surgeons and American Society of Radiation Oncology jointly held a senior resident course in SRS. Residents were nominated by program directors from across the United States. Thirty residents were chosen to participate in the course. The residents were surveyed before and after the course. Faculty (n = 14) were also surveyed to ascertain their perspectives on current training in SRS.

RESULTS

Most (96.7%) of the residents planned to perform SRS when finished, and 94% anticipated SRS indications to expand. Regarding SRS technique, 47% reported average/above average understanding of intracranial SRS; only 17% expressed similar understanding of spinal SRS. Before the course, 76.6% noted below average/average ability to recognize and manage SRS complications. Twenty-three percent of the faculty indicated that graduating residents from their programs were unprepared to perform radiosurgery. Residents' self-assessed understanding of brain SRS indication (P = 0.000693), SRS techniques (P = 0.000021), spinal SRS indications (P = 0.000050), spinal SRS techniques (P = 0.000019), and complication recognition and management (P = 0.00033) significantly improved following the course.

CONCLUSIONS

Knowledge and training gaps in SRS appear evident to the senior residents and faculty of both specialties. We believe that other educational opportunities for SRS experience are necessary to optimize clinical competency, as well as meet future clinical staffing needs for this expanding, multidisciplinary approach. Further evaluation of gaps in SRS is necessary through a larger, nationwide survey of U.S. neurosurgeons, program directors, and residents.

Results of the AANS membership survey of adult spinal deformity knowledge: impact of training, practice experience, and assessment of potential areas for improved education

Object

Adult spinal deformity (ASD) surgery is increasing in the spinal neurosurgeon's practice.

Methods

A survey of neurosurgeon AANS membership assessed the deformity knowledge base and impact of current training, education, and practice experience to identify opportunities for improved education. Eleven questions developed and agreed upon by experienced spinal deformity surgeons tested ASD knowledge and were subgrouped into 5 categories: 1) radiology/spinopelvic alignment, 2) health-related quality of life, 3) surgical indications, 4) operative technique, and 5) clinical evaluation. Chi-square analysis was used to compare differences based on participant demographic characteristics (years of practice, spinal surgery fellowship training, percentage of practice comprising spinal surgery).

Results

Responses were received from 1456 neurosurgeons. Of these respondents, 57% had practiced less than 10 years, 20% had completed a spine fellowship, and 32% devoted more than 75% of their practice to spine. The overall correct answer percentage was 42%. Radiology/spinal pelvic alignment questions had the lowest percentage of correct answers (38%), while clinical evaluation and surgical indications questions had the highest percentage (44%). More than 10 years in practice, completion of a spine fellowship, and more than 75% spine practice were associated with greater overall percentage correct (p < 0.001). More than 10 years in practice was significantly associated with increased percentage of correct answers in 4 of 5 categories. Spine fellowship and more than 75% spine practice were significantly associated with increased percentage correct in all categories. Interestingly, the highest error was seen in risk for postoperative coronal imbalance, with a very low rate of correct responses (15%) and not significantly improved with fellowship (18%, p = 0.08).

Conclusions

The results of this survey suggest that ASD knowledge could be improved in neurosurgery. Knowledge may be augmented with neurosurgical experience, spinal surgery fellowships, and spinal specialization. Neurosurgical education should particularly focus on radiology/spinal pelvic alignment, especially pelvic obliquity and coronal imbalance and operative techniques for ASD.