Neurosurgical training and evaluation – Need for a paradigm shift
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.193841
Source of Support: None, Conflict of Interest: None
Neurosurgical education and training has been my interest for a long time. A meeting at AIIMS, New Delhi, convened by us in 1986, of Indian centers involved in neurosurgical training, along with representatives of the Medical Council of India (MCI) and National Board of Examinations (NBE) led to an increase in the duration of the M. Ch. Neurosurgery course (post MS) from 2 years to 3 years. Similar changes were accepted by the NBE. The duration of the post MBBS course was increased to 5 years with further one optional additional, in-service year, where the resident worked as the chief resident. These changes were formally approved by both the organizations, MCI as well as NBE.
To answer the question as to why there is a pressing need for a reassessment of the neurosurgical training program, the following facts may serve as an explanation. In the last decade, there has been an attempt to stop the 5-year course by the MCI to bring it in line with other surgical superspecialties, despite the fact that Neurosurgery has its own special needs. Some major institutions in India have taken a variable stand on training. Management of acute neurosurgery, so vital for neurosurgical training on a continuing basis, is not a part of the training curriculum in a few important institutions of long standing. Is it required to continue the 3 years post MS (Surgery) program? These aberrations need to be addressed for the greater good of the future of Indian neurosurgery. Having had a ring-side view of the neurosurgical training and evaluation scenario all over India for a considerable period of time makes me suitable to share my views on this subject.
In the 1940s, the American Association of Neurological Surgeons first formalized a training program which started the American Board of Certification in Neurosurgery. The two largest US based neurosurgical societies, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, have continued to play an important role, both advisory and supervisory, in implementing and standardizing the protocols for the training programs, which are flexible and depend on the needs of the time. Incidentally, the course duration in the USA is different in various specialties. Both these principles need to be adopted by the MCI and the NBE, as all specialities cannot be equated. Both the MCI and NBE, the main regulatory bodies of medical education in India, have no liaison with any national medical professional association/society. Note should be taken of this anomaly and steps should be undertaken to rectify the situation. The MCI and NBE should also activate the practice of periodic reaccreditation for existing centers. Incidentally, several centers of repute in USA, have on occasions, been derecognized by their respective boards for a variety of reasons.
Formal neurosurgery practice in India was started in 1949 at Vellore by Dr. Jacob Chandy, followed by Dr. B. Ramamurthi in Madras in 1950, and Dr. R.G. Ginde at Bombay in 1951. The earlier years had only a clinical apprenticeship program at Vellore and Madras (Chennai), which trained Drs. S. Balaparmeswara Rao, R.N. Roy, R. S. Dharkar and Gajendra Sinh, who went on to establish reputed clinical services in the cities of Vizag, Calcutta, Gwalior and Bombay, respectively. It was Dr. Jacob Chandy who had the vision to anticipate the future manpower needs that would mandate the emergence of degree-holding specialists, not only in Neurosurgery but, indeed, in all surgical and medical superspecialties, which developed in India over the subsequent years. The joining of hands of Dr. Jacob Chandy and Dr. B. Ramamurthi, who otherwise were professional rivals, was a great event of that era that shaped the future of Indian Neurosurgery. A wise Vice-chancellor of Madras University, the late Dr. Lakshmanswamy Mudaliar, reputed to be an unparalleled medical statesman, made it possible to start the M.S. (Neurosurgery) two-year program, at Vellore and Madras. The first two graduates were Dr. K.V. Mathai and Dr. V. Balasubramaniam, both of whom became outstanding neurosurgeons and teachers. The nation owes a great debt to Dr. R. G. Ginde of Bombay who possessed an incisive, methodical mind and compassionate approach for setting efficient protocols for conducting evaluation systems.
A few words about Dr. Baldev Singh are in order. By the time that I joined Christian Medical College, Vellore in 1962, Dr. Baldev Singh had already left. However, he had left behind him a tremendous legacy that is unimaginable in the present era. The senior nurses shared with us the scientific methods involved in nursing of unconscious patients, Ryle's tube feeding, and in many other areas related to nursing, which were personally taught by Dr. Baldev Singh. His emphasis on the importance of history taking and physical examination established this as a continuing practice in this institution. A teacher like him, who leaves an imprint on several generations of clinicians, is impossible to find today. He was affectionately named 'Papa Neuron' (the missionary hospital influence!), a name that stuck with him till the very end. I had the privilege to work with him at AIIMS in 1965, as I joined the institution a few months after he did. An American neurosurgeon, Dr. Harvey Gass, met Dr. Baldev Singh at Tirath Ram Shah Hospital in Delhi, after hearing a lot about him. He wrote a short pamphlet on the biography of Dr. Baldev Singh from which I recount a few highlights. After doing MRCP, he joined as a senior houseman at Royal Infirmary, Edinburgh, U.K. It is here that he was accosted one day by Mr. Norman Dott (one of the pupils of the famous Dr. Harvey Cushing). He was searching hard for someone to assist him in his new job as a consultant in Neurosurgery. Dr. Baldev Singh agreed to join him and remained with him for a short time. After this stint, he purchased neurosurgical instruments and returned to Amritsar to open the very first neurosurgical clinic of India. Unfortunately for Neurosurgery, shortly after he arrived in India, he developed viral myocarditis, for which he was asked to undertake strict bed rest and advised not to resume any strenuous activity in the future. He later became a very prominent physician after his recovery. A few years later, in the early 1950s, he joined Dr. Jacob Chandy at Christian Medical College, Vellore. This collaboration became legendary, possibly never to be repeated. It laid the foundation of Neurosciences in Vellore as a collaborative discipline. At AIIMS, New Delhi, which he joined in 1965, he led a very active life in establishing the department of Neurology and in helping the Department of Neurosurgery to gain its feet. His clinics were a treat to attend, to which MD students would also flock. After the completion of the clinical rounds, going to the staff canteen and eating 'gulab jamuns' and continuing the discussion on clinical cases there, was an unforgettable experience. After retiring from Neurology, he joined the Physiology department at AIIMS, New Delhi, which was devoted to Neurophysiology. Subsequently, he became an ascetic figure, absorbed in his work and reading. During his last few years of stay at AIIMS, after his retirement, he was devoted to developing Neurophysiology and in helping young people like me in diverse endeavors. Visual difficulties eventually led him to go back to his hometown of Amritsar, where he spent his last years being lovingly cared for by his widowed daughter-in law.
There have been major changes between the late 50s and the present times. It is important to take note of these changes before we plan a roadmap for the future. Apart from the university/institute training programs leading to the issuance of M. Ch degree, the NBE also started the DNB stream. Furthermore, for students pursuing their MCh course, a 3-year (post M.S) and a 5- and 6- year (post MBBS) courses are on offer. AIIMS New Delhi has a five-year course, leading to the final examination, followed by one year of chief residency, after which the degree is awarded. In most other places, it has become a 5 year course with the degree being awarded at the end of the examination. The sixth year is optional only at NIMHANS, Bengaluru. The pressure of the long hours of duty for the in-service trainees compromises the available time for training, which is further affected by centers having a busy clinical service, where there is no time for a collective assembly of the faculty and trainees for the pursuit of academic programs. Ever-increasing distractions like television, internet, mobile phones as well as other avenues of leisure time activities have further significantly compromised quality time for neurosurgical training. Added to this is the enormous burden of new information coming every day. It is almost a wonder that the system is able to produce neurosurgeons.
There are less than 2000 neurosurgeons in India. This is far less than the requirement for a 1.2 billion plus population. The matter is further compounded by clustering of neurosurgeons in the metropolitan and larger cities. Out of the more than 550 districts of India, about 200 have neurosurgeons. In some areas, the nearest hospital with a neurosurgeon could be 500 km away, or even more. The government hospitals, the mainstay of majority of patients who are poor, have neurosurgeons only in larger cities, in inadequate numbers. They are, in many instances, understaffed and poorly equipped. The state of Medical Colleges with regard to neurosurgery is, by and large, sad. Most state run medical colleges do not have a Neurosurgery department or section. Neurosurgery forms a small part of the undergraduate curriculum and often taught by general surgeons unfamiliar with the specialty. There is a lack of appreciation at the political level of the rapidly increasing number of road traffic accidents causing head injuries, requiring neurosurgical intervention. The spread of information regarding neurological illnesses even among the rural poor people bring them to larger cities and metros in large numbers every day. This produces severe strain even on the best run existing facilities, which obviously can meet the problem only marginally. The sad part is the ever growing waiting list becomes irrelevant as many may have to wait well after their expected survival, or worse, develop permanent neurological damage.
Increasing the production of the number of neurosurgeons in India is not only important from the public service front of view but also for the development of the speciality. We have to make inroads into the sleeping public sector and the private sector, which is largely inactive in training aspects.
It is important to cultivate M.P's and M.L.A's at the centre and the state. They could lobby our causes, which could be prioritized by our professional societies. This is in line with the practice of US Neurosurgical Societies. In India, all industries have their own agencies who lobby with M.P.'s M.L.A.'s and government, and get things done. At the level of the centre, our pressing need is for our societies to have a say in neurosurgical education. At the state level, the priority is development of Neurosurgery departments in Medical Colleges, both public and private. The often pathetic state of neurosurgical services in state medical colleges, which are often the largest public hospital in the city catering to the needs of the economically weak, has to be highlighted. The need for reviving the system of honorary consultants, prevalent in all metro cities earlier, needs to be considered particularly in specialities like Neurosurgery, where creation of posts may be a major problem. It may also solve the problem of the young neurosurgeon who is eager to establish a foothold in a new city. Teaching is quite addictive, and many would continue on the same position, as has been the earlier experience. The government expenditure would be limited to providing infrastructure. An out-of-the-box approach like this is required if Neurosurgery has to progress and public services improved.
How long should the training be and should there be two streams, i.e., 3 years and 5/6 years. We have 3 decades of experience with both the systems. The 5/6 years stream certainly is far better than the 3 year one. A post M.S. (Surgery) candidate does not have any advantage. On the contrary, unlearning attitudes and skills of general surgery takes time which eats into the 3 years of training. Incidentally, some institutions of repute, e.g., PGIMER Chandigarh still have not changed from their present 2 ½ year course. The same institute, even after 3 decades has not started the 5/6 years MCh. Both need to be addressed to bring uniformity. It stands to reason as to how can the course be of 3 years for post M.S. (Surgery). This has no advantage over the training of a MBBS candidate going for a direct MCh course. Thus, the two courses cannot be equated. An uniform 6 years M. Ch course should be introduced with an end of course evaluation. The 3 year course should be phased out. The proposed 6 year course would not confirm to MCh courses in other specialities. The needs of Neurosurgery are different. I have already mentioned that Neurosurgery uses very little of General Surgery attitudes and skills. Further, microneurosurgery and neuroendoscopy are skills required to be learnt in laboratories and on cadavers. Learning cerebral angiography would require a few months of training. The total period of training of 6 years in just about enough with an evaluation at the end of the course. The AIIMS New Delhi experience of a 5 year course with an examination at the end of it, and a further year of chief residency has not been fruitful, as the last year is not utilized properly. It is time that AIIMS revisits its programme to make the required course correction. The minimum eligibility should be M.B.B.S. with six months of work experience in a neurosurgical set up, before a candidate appears for the entrance examination. This is to ensure that the candidate has an idea of the rigors of the discipline. Encountering seriously ill patients could be shocking experience for a novice joining Neurosurgery training with romantic notions.
The aim of a neurosurgical training program is to produce a person with reasonable competence in clinical diagnosis, interpretation of diagnostic procedures, with adequate microsurgical skills, and the ability to manage patients.
The training in MCh should only be in a well-equipped general hospital having multiple specialties with emergency and outpatient services. This will allow exposure to a wide variety of both elective and emergency cases, which are essential for developing a wide range of experience in clinical management. A good department of Neurology is essential to imbibe the essentials of clinical Neurology as well to expose the candidate to the management of “grey zone” diseases, which may require collaboration between the two disciplines. The hospital should have at least a computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) facility, with preferably a neuroradiologist at the helm of affairs. The department should have at least one operating microscope and an endoscope. There should be microsurgical instruments and aneurysm clips apart from the usual neurosurgical operating sets. A dedicated intensive care unit for the patients, to be shared between the specialties of Neurology and Neurosurgery, is essential. There should be at least 500 neurosurgical operations conducted every year including emergency surgeries by the department. Management of head and spinal injury is a significant part of the future clinical practice of the trainees; hence, management of these cases should form a continuing part of the training program.
Hospitals, both public and private, with 500 beds or more, could form the nucleus for the development of future training centers, where any hospital with a minimum of 3 staff members, and with honorary/regular neurosurgeons with more than 5 years post MCh/DNB experience on their rolls, could apply for recognition by NBE for DNB Neurosurgery, provided that the total number of neurosurgical operations being conducted by them is at least 500 per year, they possessed an in-house CT scan machine, and access to a MRI machine. An additional advantage would be the coexistence of the department of Neurology. Starting such programs would facilitate the development of a manpower bank, and in addition, provide valuable public services, which are sorely lacking today.
MCh services would require a higher standard of training than DNB. Without changing the existing structural requirements, we should increase the present intake of trainees by at least 20%. The faculty requirement needs modifications. Professors/Additional Professors, and, Readers/Associate Professors should be clubbed together and each faculty member would have the same number of candidates.
The study course has to be tailored to the current developments that have taken place in the field of Neurosurgery. The potentially weak areas during a candidate's neurosurgical training include applied Anatomy, surgical Physiology, basic Neuropathology and clinical Neurology. These form the basis of clinical management, which has become dysfunctional, leading to the irrational use of expensive and often unnecessary diagnostic procedures. A radical revamping of the training program is warranted. For too long, we have endured the growing slide downwards of academic standards, without any intervention, in the hope that candidates will attain maturity on their own.
A brief roads map follows. The first six months should be spent in Neurology. During this period and in the following 6 months, two hours of every week should be spent in structured learning exercises in applied Neuroanatomy, Neurophysiology and Neuropathology. The next 6 months should be spent in casualty/emergency services with the aim of learning resuscitation, evaluation and primary management of polytrauma and polysystem medical diseases. The present system of spending time in General Surgery, Pediatric Surgery and Orthopedic Surgery for a full year is a waste of time for the neurosurgical trainees. This is because the teachers of these departments where the Neurosurgery residents are posted, often lack interest in training residents from other departments who have come on a temporary rotation to their department. Half a working day per week should be devoted to exclusive academic activities with the faculty and residents.
Of the remaining 5 years, three months should be spent in Neuroradiology with the aim of learning cerebral angiography and to familiarize oneself with the basics of the CT/MRI scans. This period should also be spent in the clinical evaluation and management of pre- and post procedural status of patients requiring neuro-interventional procedures. Clinical management of patients who have undergone Neuroradiology interventional procedures is a grey zone today at most centers and this protocol would automatically rectify it. Centers not having an active Neuroradiology unit should outsource the procedure to other facilities. Concurrent clinical responsibility for patients would ensure continuing application to the clinical aspects.
Training in a skills laboratory should be mandatory to learn microsurgery, spinal instrumentation and endoscopy. The trainee should attend atleast one conference and one Continuing Medical Education programme every year from the second year onwards. The highlights of these should be discussed in the teaching sessions.
It is important to profile the average neurosurgical trainee including his attitudes before any training schedule is formulated. There is an undeniable lack of continued application, and this coupled with overconfidence, is a dangerous combination. Further, the tendency to leave everything for the last moment is very often seen. This translates into doing the least amount of work in the quickest possible time, which just allows one to swim on the surface without actually savouring the waters of knowledge and training. Transformation of information into knowledge requires thinking which, sad to say, is generally lacking. If we add to this the inordinate passion of the trainees to moisten their hands with the patient's blood in the operation room, unfortunately again mechanically, it completes the vicious cycle. The answer to this is continuing evaluation every 3 months which should form 50% of the total evaluation. In this context, I must confess my last two decades of close interaction with students of management, IITs and Law schools has changed my perception that the neurosurgical trainee is the most hard working student among trainees in all professional training programs. The projects that these students do requires intense studying and writing and is subjected to the process of a continuous evaluation.
What drives the average trainee to perform? Peer pressure is nonexistent. Teachers as role models are few and far between. The only stimuli that could serve as performance enhancers are periodic evaluations. An end-of-the-term examination, as is prevailing now, is too short and selective to comprehensively cover all aspects of Neurosurgery. Most trainees are well armed with yesteryears examination papers, know the general trend and limit their study to the likely questions. Regarding the practical examinations, many candidates do not fare satisfactorily, particularly in the clinical examinations.
Within one year of entering the course, the candidate should chose a subject for his//her dissertation assisted by the faculty mentor. The subject could be either a clinical one or a laboratory-based project. Once the project is chosen, it should be a prospectively conducted with the posing of a proper scientific question. It should be written in the format of a paper based upon the requirement of any standard Indian neurosurgical journal, where it should have been sent for publication at least 6 months before the end of the term examination. The faculty mentor would be responsible for a quarterly monitoring of the progress of the candidate followed by annual review by the entire faculty.
It should be mandatory for the resident to record all activities that he/she has participated in. This should be recorded briefly on a daily basis, and wherever required, the activity should mention the name of the instructor. Every month, the logbook should be checked by the faculty mentor, who should be assigned to the candidate at the beginning of the training. Preferably, the same mentor should continue till the end of the course. It will be the duty of the mentor to establish personal rapport with his/her candidate and act as a guide in all academic as well as social and personal matters, much like a tutor at the old universities of U.K. The mentor has to be a friend and not merely a critic. Calling the trainee home and helping him/her establish contact with the mentor's family should also be the aim. This would be an invaluable addition to the present system as a stress relieving procedure during the prolonged training program.
The questions appearing in the final examination should be a reasonable scatter of as many items as possible. They should relate to the practice of day-to-day Neurosurgery. Terms like 'describe, discuss, manage' should be used with caution in questions, as often, they require essay type, relatively non-specific answers. It should be possible to complete the answers to the questions asked in the examination within the time frame available. The NBE had a good practice of having a moderator scrutinize the question paper separately from the paper-setters. The other good practice that they have continued has been the model answer or the salient points desirable in the answer that the paper-setter has to submit prior to the checking of the answer sheets. I think this practice should be put in place for all MCh examinations also.
The MCI and NBE could play a major role by setting the same question paper for all centres. This would mean obtaining uniformity of examination calendar in all institutions which is not a difficult task. The examination can be held at the same time in different centres through an online process. The evaluation of the answer papers could continue as is being done now. However, MCI/NBE could randomly check answer sheets to avoid any wide variability, which could be brought to the attention of the examiners and institutions. This would be a step towards standardisation. Only those who pass the theory examination should be permitted to appear for the practical examination.
Actual operative neurosurgery on a patient should preferably be a part of the examination. A number of institutions have expressed grave reservation regarding this practice as the candidate is under stress and any untoward complication could open one to public criticism. I must say that over the years that I have been an examiner, there has always been a faculty member assisting the candidate and I have not seen any problem occur. In case live surgery is not possible, then live filming of the entire surgery, including filming of the use of operating microscope by the candidate, duly certified to be that of the candidate by the Head of the concerned department, may be submitted by the candidate in a compact disc format. The other parts of the examination should include: (a) One long case and atleast two short cases; (b) ward rounds, to include neurotrauma and intensive care unit rounds; (c) radiology; (d) a general viva voce, that includes the history of neurosurgery, clinical decision making, choice of investigations, newer developments, information published in current neurosurgical journals, and presentation in conferences and publications.
The aim of the evaluation system is to pick up persons of average competence who would be capable of doing day-to-day Neurosurgery specially related to trauma and common tumors of the spine and brain. The candidates should show a progressive ability to improve their clinical and surgical skills. The changes in the evaluation system should be carried out to change the mindset of the examiners from the existing one, to produce a good neurosurgical manpower force. The emphasis on only memory recall should be reserved for the basic facts. The ability to find out where and how one can access new information should be an essential component of the training program. For the examiner, there are a few words of caution. The exercise is to find what a candidate knows and not what he doesn't. With regard to what he does not know, does he have the capability of finding out the facts and is also able to determine the source of these facts. In the final analysis, the question that needs to be asked is whether he/she is capable of joining as a junior member of the exclusive club of neurosurgeons.
The DNB programs have inherent problems e.g., lack of hands-on surgical experience. The use of skills laboratories would be of great help. By and large, the training format should be the same as that of MCh. The periodic inspection of training centres by inspectors of NBE is a good practice which could be considered by the MCI.
The equalization of MCh and DNB for joining service is not fair because the systems of training are quite different. A one year advantage to a person having an MCh degree should be given.
The conclusions of the proposals presented in the current article are as follows:
(1) A six month residency tenure in Neurosurgery should be an essential eligibility requirement to apply for the MCh (Neurosurgery) program; (2) Phasing out of post M.S. 3-year course needs to be done; (3) A single MCh course of 6 year duration has been proposed; (4) Mandatory postings in Neuroradiology and skills laboratory has been recommended; (5) Active mentoring of each trainee should be done; (6) The practice of a 3 monthly evaluation with 50% weightage leading to the final examination at the end of the term, should be introduced; (7) the MCI and NBE should collaborate with professional societies, to set up a revised training curriculum that may be updated from time to time; and, (8) only general hospitals with active Neurosurgery departments should conduct training; (9) the MCI should take the lead to start the process of standardization of examinations.
This article is based on the Dr. Baldev Singh Oration of the National Academy of Medical Sciences -2014 given by the author.