## Abstract

The purpose of neurosurgical education is to teach the clinical knowledge and surgical skills necessary to become a neurosurgeon. Another goal is to inculcate the principles of the scientific method. However, increasing expectations about attending involvement during surgery, duty hour requirements, and new curricular mandates have put programs under stress to ensure adequate training, in less time, in an environment of limited resident independence. More recently, the Accreditation Council for Graduate Medical Education has developed a new tracking process based on “milestones” or defined educational outcomes. At the same time, our healthcare system is undergoing a rapid socioeconomic transition in organization and payment models, which traditionally has not been a focus of formal teaching. A 2008 survey conducted by the Council of State Neurosurgical Societies found that graduating residents felt inadequately prepared in areas like contract negotiation, practice evaluation, and management.

### ABBREVIATIONS

ABBREVIATIONS
• ACGME

Accreditation Council for Graduate Medical Education

• PSU

Pennsylvania State University

• SNS

Society of Neurological Surgeons

• UCSF

University of California at San Francisco

• UTH

University of Texas at Houston

In this consensus statement, we share the perspective and experience of 6 neurosurgery programs: the University of California at San Francisco (UCSF), Washington University, Indiana University, Pennsylvania State University (PSU), the University of Texas at Houston (UTH), and Columbia University. This paper defines challenges, including (1) the need for progressive resident independence in a regulatory environment that mandates attending involvement; (2) the balance between teaching neurosurgery and research with other mandates (such as patient safety and quality requirements); (3) the adequate preparation of our trainees to evaluate practice opportunities and thrive in a changing healthcare system. This paper provides descriptions of best practices and suggests improvements to ensure the future of neurosurgery.

The purpose of neurosurgical education is to teach the clinical knowledge and surgical skills necessary to become a competent neurosurgeon. Another goal is to inculcate the principles of the scientific method as applied to clinical medicine, so that our graduates can evaluate published findings and, in the best-case scenario, advance the field through new knowledge and innovation. Through the 20th century, neurosurgical education evolved from initial apprenticeships to formal residency programs, now numbering over 100 in the United States.1 Compared to today, there was considerably less regulation and oversight over training; despite this, or because of this, our field has thrived and progressed, greatly expanding our numbers and advancing both the science and our capabilities.2

The 21st century has seen major changes due to changing expectations about resident oversight, particularly during surgery, and mandates from the Accreditation Council for Graduate Medical Education (ACGME). The 2002 definition of the 6 core competencies and the 2003 implementation of duty hour requirements have put neurosurgical programs under stress to meet new curricular demands, in less time, while ensuring adequate training. Simultaneously, more stringent application of regulations mandating attending presence in “critical portions” of every operation has limited the independence of resident action.3 More recently, the ACGME has developed a new resident tracking process based on the “milestone,” a defined educational outcome. A comprehensive set of milestones is intended to provide a framework to assess, on a continuous basis, the development of the resident physician in medical knowledge and patient care as well as competencies like professionalism and practice-based learning.4, 5

The milestones are designed to achieve several goals. For programs, they are to guide curriculum development and support better assessment practices. They are also to enhance opportunities for early identification of struggling trainees. For residents, they are to provide explicit and transparent expectations for performance, aid in self-assessment and learning, and increase feedback. Furthermore, the milestones are intended to provide continuous monitoring and enhance public accountability. Currently, decisions about readiness for graduation remain the purview of the program director. However, milestones performance data will be collected and analyzed to determine whether they can be used for promotion and graduation decisions.

Implementation of the Milestone Project will significantly change neurosurgical education. No longer is it sufficient to show that a resident has the opportunity to learn in a given training environment; now, the program directors must show that a resident has learned. Adequate training is no longer defined in terms of time served as a resident, but rather by the attainment of specific skills and knowledge. In addition, the American Board of Neurological Surgery has adopted other requirements, such as a minimum case requirement involving most subspecialty areas.

At this same time, our healthcare system is undergoing a rapid socioeconomic transition in organization and payment models. Traditionally, there has been little formal teaching of the practical aspects of practice, such as management, billing and contracting, or evaluating opportunities and options. A 2008 survey conducted by the Council of Neurosurgical Societies queried all graduating residents about their perceived readiness for practice.1 Of 233 respondents (30%), neurosurgical training was felt to be generally adequate with 2 exceptions: training in subspecialty areas such as radiosurgery and inadequate preparation in contract negotiation, practice evaluation, and management. It is unlikely that there has been significant change since the survey.6

In this paper, we share the perspective and experience of the Program Directors and Chairs of 6 neurosurgery residencies: The UCSF, Washington University, Indiana University, PSU, the UTH, and Columbia University. This consensus statement focuses on current challenges, descriptions of best practices and possible improvements, and the likely future of neurosurgical education.

### General Perspective

While those of us involved in the training of neurosurgeons must respond to regulatory requirements and changes in the overall healthcare environment, we can only determine the necessary skills and competencies required to complete that training. Therefore, we must maintain the core values of our specialty and preserve the important elements that have brought us to where we are today. In the past, trainees could be more independent and could spend more time in the hospital and operating room. Increasing oversight with less time for training represents a challenge for all programs, compounded by the requirements of additional curricular topics that are not central to the teaching of neurosurgery.7-15 Another concern is the need to preserve and enhance our research mission. Only neurosurgeons have a deep understanding of the clinical challenges faced by our patients, and are, therefore, the most qualified to direct necessary research on those conditions.

Fundamentally, the transmission of neurosurgical knowledge and skill occurs in daily, personal interactions from faculty to trainees, and from more senior to junior residents. Much of what we learn about competencies like professionalism and leadership is most strongly taught by informal processes like observation and role modeling. Now, with a defined curriculum, and milestones to meet, more formal processes will have to be established. We can work together to ensure that this is a positive process, enhancing our programs while maintaining core values.

Perhaps the most important change lies in the need to assess progress for each resident at regular intervals, with specific milestones to address and results being forwarded biannually to the ACGME. At UTH, it was decided to have a premeeting to discuss the goals of each rotation, a mid-rotation assessment, then a postrotation session. Because we have many 3-month rotations, this format necessitated a monthly meeting. We have now set aside a standard time where all faculty and residents gather specifically for this purpose. Each rotation has a designated faculty leader who oversees the discussion with the resident and all involved faculty. This has already had a significant impact; residents more clearly understand what they need to learn during a rotation, and the formal and frequent feedback is beneficial.

The milestones clearly and comprehensively encapsulate the skill sets desirable in our graduates. The following is our summary:

1. How to be a good doctor first, then an excellent surgeon able to perform the basic operations required of all in the specialty. The milestones specify basic competencies to attain in medical knowledge and patient care for subfields of neurosurgery. Meeting these requirements will necessarily involve residents having direct patient care experience and caseloads in each area, not just didactic exposure. Furthermore, the milestones state that the graduate must be able to “independently perform a complex procedure.”

2. How to demonstrate continuous self-improvement, manage resource utilization, and live in a world of data and performance measurement. Many milestones involve safety and quality improvement processes and learning to work in a larger healthcare environment with an understanding of resource utilization and system errors.

3. How to be professional and ethical, communicate effectively, work in teams, manage other people, and develop leadership. The milestones specify becoming a leader, even a mentor during training, and developing educational activities for those coming after them. They also specify learning to communicate effectively with compassion, respect for others, and cultural sensitivity.

4. How to learn concepts in clinical epidemiology and biostatistics, do research, and contribute to the literature. There are specific competencies related to the assessment and incorporation of scientific findings into practice at both the individual and service level, with an understanding of the mathematical tools that are prevalent. Further, a level 4 milestone is “formulates hypothesis, designs investigation, executes project, and reports results.”

5. How to have a successful career after graduation in the healthcare system of the future. The milestones now promote the understanding of the following topics: the principles of ethical and accurate coding of diagnoses and procedures; US health payment systems; a successful transition to practice; and the ability to work effectively in various healthcare delivery settings and systems. There are also significant changes occurring in our overall healthcare system and our graduates need to understand these trends and acquire the skills to thrive in the new environment.

### Clinical Independence and Maturity

All programs have been teaching neurosurgery residents to be doctors and surgeons since inception, and those processes do not need to be addressed here. The effect of duty hours has also been well documented and is beyond the scope of this paper.9-18 Just as problematic have been changing expectations in relation to trainee supervision. The requirement that the attending physician be “present” during all critical portions of an operation has changed the teaching dynamic. Even senior residents who have acquired considerable skill and earned trust must have more supervision than was thought appropriate in the past.

Training has been hampered significantly. Independence is required to develop critical skills and maximize the impact of faculty observation and teaching. After working on their own, residents learn much more from subsequent instruction and assisting a senior surgeon. Even if a resident is manually completing all the steps of an operation, having someone constantly present does not adequately prepare a trainee to be on their own. Furthermore, the lack of independence diminishes the sense of responsibility and commitment that is so central to an excellent neurosurgeon. When one was mostly an assistant during a case, how much responsibility is there for the surgical outcome? Even with inpatient care, duty hours have created teams of physicians working in shifts, further diminishing a sense of ownership and accountability.

The result is that surgical maturation may occur more slowly and the resident may not be fully prepared for independent practice upon graduation. At UTH, one response was to allow more time in surgery and less time on menial activities that can be performed by physician extenders. We have also structured our services so that the care of our emergently admitted patients (eg, with subarachnoid hemorrhage or brain injury) is delivered primarily by 1 of 3 teams staffed by a neurocritical care attending, working mostly with anesthesia, emergency medicine, and neurology residents and neurocritical care fellows. This means that on a daily basis, each neurosurgery resident is primarily taking care of fewer patients than in the past, almost all of them electively admitted. While less than ideal, this may be a realistic option in light of duty hours and the requirements for them to acquire nonclinical skills. Our residents are part of the neurocritical care teams during their first training year and become proficient in the basics of critical care, including intubations and ventilator management. But they become consultants for these patients afterwards.

However, such measures alone are probably unable to fully overcome training deficiencies arising from limited independence.19 At Washington University, a 6-month international rotation provides a more autonomous training environment, and the opportunity to compare national health systems. This may be one solution, but it is doubtful that most programs, particularly those with a complement of 1 resident per year, can afford such rotations. Furthermore, regulations and training environments may be changing internationally as well.

### Quality Improvement in a Data-Driven World

The concepts of quality improvement are not new, going back to 1918 when Ernest Codman published A Study In Hospital Efficiency: As Demonstrated By the First Five Years of a Private Hospital.20 He outlined in bold detail more than a 100 errors that had occurred in the care of 337 patients and started the morbidity and mortality process, tracking complications and outcomes. This has been a time-honored tradition in neurosurgery, and one to be continued. For us as surgeons, direct complications resulting from surgery have much emotional impact and high educational value.

However, the tracking of individual complications is no longer sufficient. The overall performance and outcomes of both the individual and the entire service have become important with added consideration for cost, efficiency, and value. For our trainees, the milestones specify that they utilize morbidity and mortality and program-level outcome data to institute systematic clinical practice changes; improve care systems to achieve optimal care; participate in clinical outcomes data gathering and analysis; and describe the cost impact of practice variation in the context of system and national health resource utilization. This means that they have to be involved in gathering and analyzing data, that they understand the data, and work to increase quality, safety, and value.

According to Parker et al,21 there are 3 principal reasons for including quality improvement and patient safety initiatives into resident education:

1. Patients expect safe, efficient, equitable, patient-centered, and effective care.

2. Accreditation agencies such as ACGME mandate inclusion of quality improvement and safety training into residency curricula.

3. The next generation will encounter a quality-driven consumer market, with open access to data, and increasingly be asked to prove the quality and clinical outcomes of their practice.

Practice-based learning, which should be a lifelong process, includes 3 elements:

1. Continuous and systematic collection of data related to all clinical activity.

2. Continuous analysis of these data for surveillance and immediate, real-time practice management.

3. Generation of new knowledge and innovation to improve our specialty.19,22

Currently, most programs expose residents to some quality data with discussion of its import. Most residents are present at institutional report card reviews and/or required to attend regular quality sessions, sometimes even hospital-based committee meetings.

Direct involvement of residents in quality programs has become a best practice. The direct analysis and execution of quality programs, complemented by didactic sessions, is the most effective method of skill acquisition. By helping to gather data, residents will understand how input affects the output and how to deal with pitfalls and biases. Participating in analysis will naturally increase understanding of clinical epidemiology and biostatistics.

At PSU, Washington University, and UCSF, residents are already involved in quality improvement by designing their own interventions. These projects are initiated, led, and executed by entirely by the resident (see Table 1 for a list of examples from the neurosurgical resident education program at PSU). At Washington University, there is an annual award for the best resident quality project. At UCSF, residents develop proposals that are evaluated by a committee of representative program directors and leadership from the medical center, the Graduate Medical Education office, and the Resident and Fellow's Council. At the end of the academic year, if the proposed quality goal is met, the resident is awarded a $400 bonus. Past projects have focused on reducing patient wait times and improving on-time operating room starts, documentation and communication, and patient satisfaction. One project aimed at reducing the utilization of clinically unnecessary lab tests led to a 47% reduction in testing, leading to$1.7 million in cost savings over 1 year. The results of this project were published in the neurosurgical literature.23

TABLE 1.

PSU Neurosurgical Resident Quality Projects

Penn State Neurosurgical Resident Quality Projects 2015-2016
Randomized clinical trial—complication rates in central line vs peripheral intravenous central catheter lines Advanced directive discussion
Urinary tract infection reduction efforts Anticonvulsant selection in patients with seizures
Improved screening technique for detection of urinary tract infection with automated microscopic sediment analysis Diagnosis and screening for pulmonary emboli
Calcium and vitamin D to prevent fractures in patients on corticosteroids Postoperative MRI within 48 h of nonbiopsy brain tumor surgery
Diagnosis and screening for deep venous thrombosis Reversal of coagulopathy in patients with intracranial hemorrhage
Screening for depression Discontinuation of perioperative prophylactic anticonvulsants in patients without seizures
Penn State Neurosurgical Resident Quality Projects 2015-2016
Randomized clinical trial—complication rates in central line vs peripheral intravenous central catheter lines Advanced directive discussion
Urinary tract infection reduction efforts Anticonvulsant selection in patients with seizures
Improved screening technique for detection of urinary tract infection with automated microscopic sediment analysis Diagnosis and screening for pulmonary emboli
Calcium and vitamin D to prevent fractures in patients on corticosteroids Postoperative MRI within 48 h of nonbiopsy brain tumor surgery
Diagnosis and screening for deep venous thrombosis Reversal of coagulopathy in patients with intracranial hemorrhage
Screening for depression Discontinuation of perioperative prophylactic anticonvulsants in patients without seizures

At UTH, it was decided several years ago that all residents, like the faculty, would receive report cards. Given that hospitals, insurers, and ranking and regulatory agencies track and use these data, we felt that it was important for trainees to become familiar working in this environment. We decided that we would report individual data, along with service data, and that there would be an annual bonus tied to performance whereby each resident could earn up to $8000 per year (data assessed and bonuses awarded quarterly, up to$2000 per resident).

As with all such programs, attribution is difficult. As residents form part of a team, can outcomes be attributed solely to them? There is no perfect answer. With the faculty, patients are assigned to the discharging attending of record, but this cannot be done for residents. One solution was to use a mix of individual data (when available) with overall service data, depending on rotation.

One component of UTH metrics was “good citizenship,” aspects of practice that they directly control and not related to a performance outcome. Each resident could earn up to $1000 per quarter for such qualitative criteria as good behavior and reasonable clinical documentation (faculty members review a sampling of resident notes monthly as part of the rotation discussion mentioned above). It also includes quantitative data like meeting attendance, completing rounding notes, and writing discharge orders by a certain time (see Table 2). A second component consisted of clinical outcomes. We tracked surgical cases in which they were involved for infections. For other outcomes such as mortality, length of stay, and patient satisfaction, they were given service-level scores based on their rotation. Each resident could earn another$1000 per quarter based on performance metrics. These data are publicly shown and reviewed on a monthly basis. We found that the residents were all able to increase their performance to meet good citizenship criteria, and that individual performance variability became minimal (see Table 2).

TABLE 2.

Good Citizenship Criteria

Resident
Metric Benchmark Max payout
Timeliness of discharge (service) > 40% $1000.00 Timeliness of notes (service) > 75% Quality of documentation Pass/fail Overall good citizenship Pass/fail UHC mortality O/E < 0.80$200.00
UHC LOS O/E < 0.80 $200.00 Patient satisfaction (service) > 75%tile$200.00
SSI Crani (service) < 0.5% $200.00 SSI VPS (service) < 3% SSI spine Lami (service) < 0.5% SSI spine fusion (service) < 0.5% EVD infection (service) < 4% SSI Crani (individual) SSI VPS (individual) SSI spine Lami (individual) SSI spine fusion (individual) EVD infection (individual) Infections cumulative (individual) < 5%$200.00
Neurocore notes volumes

Total potential payout  $2000.00 Resident Metric Benchmark Max payout Timeliness of discharge (service) > 40%$1000.00
Timeliness of notes (service) > 75%
Quality of documentation Pass/fail
Overall good citizenship Pass/fail
UHC mortality O/E < 0.80 $200.00 UHC LOS O/E < 0.80$200.00
Patient satisfaction (service) > 75%tile $200.00 SSI Crani (service) < 0.5%$200.00
SSI VPS (service) < 3%
SSI spine Lami (service) < 0.5%
SSI spine fusion (service) < 0.5%
EVD infection (service) < 4%
SSI Crani (individual)
SSI VPS (individual)
SSI spine Lami (individual)
SSI spine fusion (individual)
EVD infection (individual)
Infections cumulative (individual) < 5% $200.00 Neurocore notes volumes Total potential payout$2000.00

SSI, surgical site infection; EVD, external ventricular drain.

Most programs have access to institutionally provided programs involving compliance to regulations like patient privacy and the triage of emergency patients. A challenge is to provide this teaching most efficiently, without encroachment into needed time for core teaching (the Discussion below provides suggestions). The more important process is to impart the tenets of true professionalism, involving ethics and the needs of our patients over self-interest. As quoted by Benzel2:

The most important human endeavor is the striving for morality in our actions. Only morality in our actions can give beauty and dignity to life. To make this a living force and bring it to clear consciousness is perhaps the foremost task of education.

– Albert Einstein

Such teaching is most effectively imparted by the daily example set by the faculty, and the expectation of high standards for our successors.

The development of leadership skills, however, may be another matter. For many of us, our first leadership or managerial experience comes during residency. Our trainees come to us after many, often very successful, years in school but usually with little real-world experience working in teams, working for others, or having others work for us. As we ascend the ranks to a chief residency, we are expected to supervise students and junior residents, run a service and schedule, mediate conflicts and solve problems. After training, neurosurgeons need skills in business and finance, organizational team building, managing partners and staff, and engaging in strategy and negotiations.

While these are skills we learn “on the job,” often with mentorship from the faculty and particularly the program director, a formal leadership development program can be beneficial. One example is the program at the University of Iowa, where a resident who had such training through the military suggested a program for their residents. To that end, they formulated the following goals24:

1. Each resident will have gained knowledge and acquired tools related to leadership.

2. Each resident will understand the role of a leader in general and specific to the department.

3. Each resident will be better prepared to lead peers and junior residents.

4. Each resident will acquire leadership knowledge and skills that will be applicable to future stages of his/her career.

5. Each resident will gain a better understanding of his/her leadership style and abilities.

This program included a monthly session on topics including leadership styles, conflict management, effective feedback, team building, team leadership, motivation, and transitioning from peer to leader. They also used established assessments tools to gauge leadership, conflict management, and communication styles. The authors report significant enthusiasm for the program, with further enhancement of coaching sessions for incoming chief residents.

At UTH, there is similar program for faculty taking on leadership positions but not currently for trainees. This process is most useful when there has been some experience, coupled with a forum for discussion and advice. Honest, constructive feedback is also critical and the 360 instrument when done well can be a great help. A coach was hired to gather feedback and work individually with each leader to improve self-awareness and performance.

Currently, there are detailed 360 evaluations for our residents, from faculty, coresidents, nurses, and staff. Patient comments are also provided when available, but this only occurs when residents are specifically mentioned by name in a survey (because they are not the attending of record). However, such feedback is generally geared toward behavior and personal interactions, not toward leadership characteristics.

The plan is to implement a program similar to the University of Iowa, in tandem with the program for faculty. This will be particularly helpful approaching chief residency, which occurs in the sixth year of our program.

### Research

Most trainees will not pursue research in their careers, but a basic understanding of the process of scientific investigation is still important. For a lifetime, they will need continuous self-learning, reading and assessing new findings to incorporate into practice. Doing research is the best way to understand how bias may be introduced, how experiment design influences the outcome, and how data can be interpreted in different ways.

The milestones specify “contributes to the peer-reviewed neurological surgery literature” and “formulates hypothesis, designs investigation, executes project, and reports results.”3 This means that each resident must have conducted at least 1 research project, and have written at least some papers.

Is academic productivity an important goal on its own right? Learning how to write a paper suitable for our literature is a specific skill, attained only by repeated practice. As we write more, we get better at the process and become more efficient. We learn that we can make a contribution to the literature, and that a paper may foster discussion or even change.

There is also evidence that the writing of papers during residency influences career direction and success. Crowley et al25 looked at neurosurgery graduates from 1985 to 1990, with information available on 717 of the 720 residents. More than half the graduates had no publications (30.5%) or 1 paper only (21%). Total and first author publications were both independent predictors of holding an academic position and becoming a professor or chair/chief.23 These findings represent associations, and it is likely that those who wanted to be in academics in the first place wrote more papers. However, it is also likely that the lack of papers hampers the chance of getting a faculty position. Furthermore, writing is a skill that could be important in any career path. Fostering some academic writing in all residents is a worthy goal even aside from the milestone requirements.

Different programs have different approaches, with some instituting minimum paper requirements. Perhaps what is the most important factor is faculty example and participation. Residents require appropriate projects to become involved, and mentorship to make progress. In the programs participating in this article, all allowed up to a year of resident research, with 1 (Washington University) allowing 18 months. Most program directors reported that their residents were permitted to do supplemental clinical training during this time, particularly in areas like endovascular neurosurgery. Some programs also use this year for remedial education if needed. In any event, the resident should undertake a substantive project. This can be incorporated into their clinical training, but must include a hypothesis, data to be gathered and analyzed, conclusions drawn, and results prepared for presentation or publication.

Some programs like UCSF mandate the writing of a training grant, such as an National Institutes of Health F32 award as a precondition for going into a laboratory year (although funding is not required). UTH has instituted the same process for all research-year projects. The review of literature and formulation of a plan, which is vetted by the program director, chair, and the direct supervisor, is important to the maximal utilization of the short time available for research.

Currently absent from most programs are formal education sessions on the practical aspects of the postgraduate career, such as how to evaluate practice opportunities, the basics of contracting and negotiation, and changes in the payment models of the overall system. Most programs have informal discussions but some have monthly sessions devoted to such topics, and others have various practitioners come and describe the pros and cons of their situations (such as in private practice). Some programs have rotations in various settings like a community hospital; others offer experience only in tertiary academic settings.

The milestones facilitate resident understanding of coding, the basics of the US Health payment systems, and a plan for transition to practice. Already, most residents feel that they lack sufficient understanding of practice management and understanding socioeconomic factors upon graduation.1 They also need to understand the changes occurring in our healthcare system and how it is likely to affect them (reviewed in the paper “Neurosurgery in Transition” in this Supplement). Our graduates need the information required to accurately evaluate a practice or employment opportunity, with insight into how ongoing changes will make each position more or less viable.

For each program to add formal sessions covering these topics would further reduce teaching time that is already burdened by multiple requirements. While informal career counseling and mentoring should always occur, this is an area where a national resource through a structured series of online courses or another Boot Camp could help all residents (see Discussion below).

## DISCUSSION

While there are strong market forces mandating change in our profession as well as how we train the next generation, we must maintain the positive aspects of the clinical and research education that created our field as we know it. Only we know how to do neurosurgery, our expertise will remain in demand, and we must take the initiative in both shaping neurosurgical practice and our education programs for the future.

The introduction of milestones, a defined set of educational outcomes, will be a positive development. But there will be challenges to implementation, and we must ensure that core neurosurgical teaching is not compromised. Each program must work out a method to ensure adequate independent learning and experience, so that our residents are well prepared in 7 years.

In this paper, we suggest the following:

1. The major challenge is to increase independence for each resident throughout training, leading to a graduate who is able to do all expected cases alone. However, this may not be possible in the current regulatory environment. Our training goals and stated milestone outcomes require independent practice toward the end of residency, but government regulations and patient safety mandates also require attending involvement. The latter involves a federal statute with criminal and financial penalties.

One solution is for most trainees to undergo fellowship training. This would allow continued work with senior mentors, but as a fully trained attending, they can be more independent. However, neurosurgery training is already among the longest, with all programs recently extended to 7 years. This may already be a deterrent to medical students choosing specialties, and many residents needing to do a fellowship is undesirable.

A better solution would require regulatory changes. Government agencies would need to recognize a new category, of a doctor in “transition to practice.” This category would be above a trainee but below an attending, and could apply to the last year of residency. This category would allow that physician to independently care for patients under the overall supervision of the program. Regulations regarding billing processes, patient consent, and liability protection would have to be specified. This would be a major undertaking, involving change at a federal level, but would provide a solution most likely to restore the independence of action required to complete training. We suggest that neurosurgical organizations, in collaboration with other surgical specialties, should strive for such a designation.

2. Another challenge is to balance the teaching of neurosurgical excellence with proliferating mandates and requirements. As with the acquisition of clinical skills, other competencies, such as familiarity of quality processes, require participant-driven implementation. While didactic teaching is important, such skills cannot be learned just by reading, listening to a lecture, or taking an online tutorial. Direct action and incorporation into the daily clinical routine is most likely to be effective. This paper shares specific examples of resident-led quality projects in neurosurgical programs. We can also utilize the ideas and experience emanating from other specialties. The American Medical Association has created the Resident and Fellow Quality Improvement Forum and Project Database,26 a site containing introductory modules with explanations of how to initiate and conduct such initiatives, with descriptions of actual projects undertaken by other trainees.

3. Only neurosurgeons have a deep understanding of neurosurgical problems. We can answer important questions or guide other investigators to perform relevant studies. When it comes time to translate new knowledge, only we can conduct neurosurgical trials. Therefore, we must maintain environments where aspirational trainees can learn the basic skills of the scientific process and be inspired to innovate. Furthermore, each resident, regardless of career goals, should undertake a substantive research project. This project can be incorporated into their clinical training, but must include a hypothesis, separate data to be gathered and analyzed, conclusions drawn, and results prepared for presentation or publication. As mandates increase and time available for training becomes constrained, we must maintain an adequate research component.

4. For incoming residents, in 2010 the Society of Neurological Surgeons (SNS) launched the Neurosurgery Boot Camp courses designed to instruct residents on psychomotor skills and the components of all 6 ACGME core competencies.27,28 Based at 6 locations across the country, these “boot camps” involve faculty lectures, clinical scenarios and group discussions, manual skills stations, online modules, and pre- and postcourse evaluations. Early published data from the first years of the Boot Camp courses demonstrate broad acceptance and early effectiveness.29 This initial positive feedback led the SNS to expand the program in May 2013 to include a second set of annual Boot Camp courses for upcoming PGY-2 junior residents.

This joint effort addresses a common requirement for all programs, became a shared resource, and established neurosurgery as a leader in GME reform. Perhaps another Boot Camp can be established to address professionalism and leadership, career development, practice types and opportunities, contract evaluation, and understanding socioeconomic changes. Such a program could prepare our residents for managerial responsibility, provide insight into career options, and stimulate early preparation to reach career goals. This might occur at the end of the fourth year, when the resident has had some experience, but with enough time to affect their remaining training. An alternative approach would be to create a series of online resources, perhaps sponsored by the SNS, which would be available to every program and trainee.

### Disclosure

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

## REFERENCES

1.
Mazzola
CA
,
Lobel
DA
,
Krishnamurthy
S
,
Bloomgarden
GM
,
Benzil
DL
.
Efficacy of neurosurgery resident education in the new millennium: the 2008 Council of State Neurosurgical Societies post-residency survey results
.
Neurosurgery
.
2010
;
67
(
2
):
225
-
232
;
discussion 232-233
.
2.
Benzel
EC
.
Neurosurgery education: the pursuit of excellence
.
Clin Neurosurg
.
2010
;
57
:
49
-
55
.
3.
Teaching Physician Guidelines FAQ
.
American College of Emergency Physicians
. .
4.
Selden
NR
,
Abosch
A
,
Byrne
R
et al
Neurosurgery milestones
.
.
2013
;
5
(
1 Suppl 1
):
24
-
35
.
5.
Swing
SR
,
Beeson
MS
,
Carraccio
C
et al
Educational milestone development in 7 specialties entering the Next Accreditation System
.
.
2013
;
5
(
1
):
98
-
106
.
6.
Maniker
AH
.
Regarding efficacy of neurosurgery resident education
.
Neurosurgery
.
2011
;
68
(
3
):
E883
;
7.
Lunsford
LD
,
Kassam
A
,
Chang
YF
.
Survey of United States neurosurgical residency program directors
.
Neurosurgery
.
2004
;
54
(
2
):
239
-
245
;
discussion 245-247
.
8.
MS
,
Batjer
HH
,
Dacey
RG
.
Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery
.
J Neurosurg
.
2009
;
110
(
5
):
828
-
836
.
9.
Bina
RW
,
Lemole
GM
Jr
,
Dumont
TM
.
On resident duty hour restrictions and neurosurgical training: review of the literature
.
J Neurosurg
.
2015
;
16
(
3
):
1
-
7
.
10.
Babu
R
,
Thomas
S
,
Hazzard
MA
et al
Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions
.
J Neurosurg
.
2014
;
121
(
2
):
262
-
276
.
11.
Jagannathan
J
,
Vates
GE
,
Pouratian
N
et al
Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity
.
J Neurosurg
.
2009
;
110
(
5
):
820
-
827
.
12.
Idema
S
,
Buis
DR
,
Idema
AJ
,
Vandertop
WP
.
Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107000 neurosurgical trauma patients in the nationwide inpatient sample database
.
Neurosurgery
.
2013
;
72
(
1
):
E142
-
E143
.
13.
Norby
K
,
Siddiq
F
,
MM
,
Haines
SJ
.
The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes
.
J Neurosurg
.
2014
;
121
(
2
):
247
-
261
.
14.
Hoh
BL
,
Neal
DW
,
Kleinhenz
DT
,
Hoh
DJ
,
Mocco
J
,
Barker FG 2nd. Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample database
.
Neurosurgery
.
2012
;
70
(
6
):
1369
-
1381
;
discussion 1381-1382
.
15.
Fargen
KM
,
Dow
J
,
Tomei
KL
,
Friedman
WA
.
Follow-up on a national survey: american neurosurgery resident opinions on the 2011 accreditation council for graduate medical education-implemented duty hours
.
World Neurosurg
.
2014
;
81
(
1
):
15
-
21
.
16.
Dumont
TM
,
Rughani
AI
,
Penar
PL
,
Horgan
MA
,
Tranmer
BI
,
Jewell
RP
.
Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction
.
J Neurosurg
.
2012
;
116
(
3
):
483
-
486
.
17.
Fargen
KM
,
Chakraborty
A
,
Friedman
WA
.
Results of a national neurosurgery resident survey on duty hour regulations
.
Neurosurgery
.
2011
;
69
(
6
):
1162
-
1170
.
18.
Dacey
RG
Jr
.
Resident work hours
.
J Neurosurg
.
2012
;
116
(
3
):
475
-
476
;
discussion 476-477
.
19.
Toyota
BD
.
The impact of subspecialization on postgraduate medical education in neurosurgery
.
Surg Neurol
.
2005
;
64
(
5
):
383
-
386
;
discussion 386-391
.
20.
Codman
EA
.
A Study in Hospital Efficiency: As Demonstrated by the Case Report of the First Five Years of a Private Hospital
.
Boston
:
Thomas Todd
;
1918-1920
.
21.
Parker
SL
,
McGirt
MJ
,
Asher
AL
,
Selden
NR
.
Quality improvement in neurological surgery graduate medical education
.
Neurosurg Clin N Am
.
2015
;
26
(
2
):
231
-
238
.
22.
Lohr
KN
,
Schroeder
SA
.
A strategy for quality assurance in Medicare
.
N Engl J Med.

1990
;
322
(
10
):
707
-
712
.
23.
Han
SJ
,
Saigal
R
,
Rolston
JD
et al
Targeted reduction in neurosurgical laboratory utilization: resident-led effort at a single academic institution
.
J Neurosurg
.
2014
;
120
(
1
):
173
-
177
.
24.
Pettit
JE
,
Dahdaleh
NS
,
Albert
GW
,
Greenlee
JD
.
Neurosurgery resident leadership development: an innovative approach
.
Neurosurgery
.
2011
;
68
(
2
):
546
-
550
;
discussion 550
.
25.
Crowley
RW
,
Asthagiri
AR
,
Starke
RM
et al
In-training factors predictive of choosing and sustaining a productive academic career path in neurological surgery
.
Neurosurgery
.
2012
;
70
(
4
):
1024
-
1032
.
26.
Resident and Fellow Quality Improvement Forum and Project Database
.
American Medical Association
.
27.
Selden
NR
,
Origitano
TC
,
Burchiel
KJ
et al
A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses
.
Neurosurgery
.
2012
;
70
(
4
):
971
-
981
;
discussion 981
.
28.
Selden
NR
,
Anderson
VC
,
McCartney
S
,
Origitano
TC
,
Burchiel
KJ
,
Barbaro
NM
.
Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training
.
J Neurosurg
.
2013
;
119
(
3
):
796
-
802
.
29.
Fontes
RB
,
Selden
NR
,
Byrne
RW
.
Fostering and assessing professionalism and communication skills in neurosurgical education
.
J Surg Educ
.
2014
;
71
(
6
):
e83
-
e89
.

## Acknowledgments

The authors thank Joanna O’Leary, PhD, medical editor, in preparation of this manuscript, and Teodoro Forcht-Dagi, MD, for review and comments.

A group of senior US neurosurgery educational leaders wrote this consensus opinion statement on behalf of 6 leading ACGME-accredited residency programs. The statement expresses a very important and commonly held perspective that neurosurgical training depends on direct educational mentorship, adequate time to engage in clinical care, and progressive independence, all of which have been threatened by recent regulatory reforms of health care and of graduate medical education.

The authors identify one important positive development amongst these regulatory challenges: a shift from accreditation based on educational process to one based on educational outcomes. One key component of this shift is the definition and tracking of individual educational outcome ‘milestones’.1, 1,2 The authors enumerate 5 important ways in which “the milestones clearly and comprehensively encapsulate the skill sets desirable in our graduates.”

For example, they call for the provision of service-wide and individual resident quality data to drive both clinical and educational outcome improvement. Teaching residents the fundamentals of quality science with hands on, project-based experience will drive immediate system improvements as well as create a generation of engaged leaders.

The authors also note the importance of progressive independence in neurosurgical training. At face value, delaying any independent practice until after residency training, when a young surgeon no longer has help immediately available, is risky. Again, the milestones may offer a valuable tool to align regulatory and educational goals. Validated milestone achievement could form an objective, granular basis for progressive independence. For example, a resident, after completing appropriate milestones, could be allowed to place a ventriculostomy, or complete a trauma craniotomy, with indirect supervision.

As the authors state in their discussion, “The introduction of milestones, a defined set of educational outcomes, will be a positive development. But there will be challenges to implementation, and we must ensure that core neurosurgical teaching is not compromised.” Indeed, a balance between curriculum-driven and outcomes-validated neurosurgical education, and one-on-one traditional mentoring, is key to successfully training skilled and compassionate neurosurgeons in the modern era.3

The authors conclude with a carefully considered and cogent set of recommendations for neurosurgical educational reform. Indeed, similar measures would likely benefit most or all interventional medical specialties.

Nathan Richard Selden

Portland, Oregon

1.
Selden
NR
,
Abosch
A
,
Byrne
R
et al
Neurosurgery Milestones, Journal of Graduate Medical Education, March, 2013, supplement, 24-35
.
2.
Swing
SR
,
Beeson
MS
,
Carraccio
C
et al
Educational milestone development in 7 specialties entering the Next Accreditation System. Journal of Graduate Medical Education, March 2013, 98-106
.
3.
Selden
NR
. (
2016
)
Mentorship: Service, education, progress - The 2015 CNS presidential address. Journal of Neurosurgery, DOI: 10.3171/2016.2.JNS152606
.