Widening the circle of service: The gift of academic neurosurgery
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.232297
Source of Support: None, Conflict of Interest: None
The quantum of professional service that a neurosurgeon carries out is essentially linked to the surgery he/she does. This imposes a limit on the number of patients that a neurosurgeon can benefit in his/her lifetime. This number may vary anywhere between 6000 (200 surgeries per year × 30 years of active service) to around 15000 (500 surgeries per year × 30 years of service). While there may be outliers who perform more or less surgeries than the given numbers, the point being made is that this number is finite. Let us consider a lifetime average of about 10,000 patients. Most neurosurgeons, like all surgeons, love to operate and would invariably want to operate on more than their fair share of patients. After all, this is one of the main reasons that they have chosen a surgical specialty. So let us consider a neurosurgeon who wants to operate on a million patients. You would probably call this a preposterous target, maybe even one generated by “greed”. But could there be a justification for this desire to “operate” on this humongous number of patients, and, more importantly, is it achievable?
Only 6% of the 300 million surgical procedures done worldwide every year are done in the Low and Middle Income Countries (LMIC). The Lancet Global Commission on Surgery has estimated that nearly 5 billion people worldwide, almost all in the LMIC, lack access to surgical care and anesthesia services. India firmly belongs in this category of countries. One of the reasons for this is the relative paucity of funding from government and other donor agencies to improve surgical services. Most of the healthcare funding is funneled into tackling the “big three” diseases namely HIV/AIDS, malaria and tuberculosis. It was estimated that, worldwide, these three diseases combined led to the death of nearly 4 million people in the year 2010. But in the same year, nearly 16 million people died of surgically remediable diseases including neurosurgical disorders. Just a few neurosurgical disorders are disproportionately responsible for mortality and morbidity in a large number of patients. These disorders include congenital and post-infectious hydrocephalus, myelomeningoceles and head injury.
It is obvious from the above statistics that there is a tremendous shortfall in personnel (and other resources) who can deliver neurosurgical and other surgical services in LMIC. It is in this context that the “greed” of neurosurgeons to do more surgery should be viewed. When viewed with this perspective, this almost insatiable desire thus becomes a virtue.
So how does an academic neurosurgeon fulfill this societal need for more neurosurgical services? The obvious answer to this question is by teaching and training a large number of neurosurgeons. The number of patients an academic neurosurgeon can operate upon is limited as mentioned above. However, the number of patients who can be benefited by the knowledge and skill of an academic neurosurgeon is far higher if those who are operated upon by his/her colleagues, trainees, alumni of the parent institution and trainees of alumni are included in the figure. These patients will number several times more than the number operated upon directly by the academic neurosurgeon.
Academic neurosurgery is in a great churn. The lines separating the roles of neurosurgeons in public teaching hospitals and those practicing in corporate or private hospitals are blurring. The former are being allowed to pursue private practice in a number of institutions while the latter are increasingly involved in training neurosurgeons. Therefore, the earlier definition of an academic neurosurgeon as one who practiced in a public teaching institution is too restrictive. To my mind, any neurosurgeon who is in a position to impart training to neurosurgical residents should be eligible to be considered as an academic neurosurgeon.
Does one become an academic neurosurgeon by virtue of working in a centre that trains neurosurgeons? And conversely, do those not working in such a centre not qualify as academic neurosurgeons? I believe that the type of practice rather than the milieu in which one works determines whether one acquires the moniker of an academic neurosurgeon. Training of the next generation of neurosurgeons is definitely one of the requirements necessary to be considered an academic neurosurgeon. But this activity in itself does not make an academic neurosurgeon. I will argue this later in my article.
I will dwell a bit on neurosurgical training. Neurosurgical training was fashioned after the surgical residency program that was initiated by William Halsted in the Johns Hopkins Hospital in Baltimore in the late 1800s. The Halstedian “pyramidal” surgical residency gave way to the more efficient and predictable “rectangular” program proposed by Edward Churchill, a thoracic surgeon at the Massachusetts General Hospital in Boston. Harvey Cushing following in the footsteps of his mentor and teacher William Halsted, started training neurosurgeons initially at Baltimore and then at Boston. Neurosurgical training has always been a long and arduous endeavor, taking several years of a physically and mentally punishing schedule. But essentially, the training program has undergone little, if any, change since the time of Harvey Cushing. The residency follows an apprenticeship model wherein the trainee works with one or more academic neurosurgeons and imbibes their approach to the management of neurosurgical disorders. Usually there is a formal exit examination conducted by academic neurosurgeons from other centres where the candidate is evaluated for his/her ability to manage patients with common neurosurgical conditions. But this format of training neurosurgeons is sure to undergo some changes in the future.
Some of the changes I anticipate in the neurosurgical training regime are outlined here. Instead of a fixed period of training, the duration might be flexible (beyond a basic minimum), based on the trainee's proficiency and interests. Cadaver and simulation based training will become an integral part of the program. But I suspect that instead of focusing almost exclusively on the technical and knowledge aspects of neurosurgery, more attention will be paid to the development of so-called “soft skills”.
The technical and knowledge sides of neurosurgery will, in the not so distant future, become mostly the function of robots and artificial intelligence. Recently, a semi-autonomous robot (Smart Tissue Autonomous Robot or STAR) bested a trained human surgeon in anastomosing pig intestine. So it is not inconceivable that such robots will take over most of the technical tasks of a neurosurgeon in the operating room. However, soft skills such as professionalism, communication, cooperation, empathy, judgment and other intangible skills will remain the domain of humans. These soft skills do matter as much if not more than technical skills in determining patient outcomes.
There is already evidence that these soft skills play a role in determining surgical patient outcomes. A study published recently compared the outcomes in large, matched cohorts of patients who were operated upon by female and male surgeons in a Canadian province. Patients operated upon by women surgeons had significantly better outcomes than those operated upon by men surgeons.
Although the authors could not pinpoint the exact reasons for this difference, they speculated that the possible reasons could include better selection of patients. Women surgeons exhibit less risk taking behavior and thus the outcomes were better for elective surgery but not for emergency surgery where patient selection is often not left to the surgeon's discretion. It has been established that women have better knowledge and are more likely to stick to protocols. The fact that women have more empathy in general than men, might result in a better rapport with patients. Patients are probably more likely to follow instructions given by empathetic surgeons.
Finally, women are more likely to ask for help when needed as compared to men. Don't we all know that when lost on the road, women drivers are more likely to stop and ask for directions than men drivers!
Well, the good news is that soft skills such as empathy, which were earlier considered to be innate traits, can be learnt and taught. Thus, the focus of neurosurgical training, indeed training of medical professionals in general, will veer towards the acquisition of these soft skills displacing technical skills and knowledge that presently form the core of a neurosurgical training program.
There are four essential components to teaching surgery. These are: technical proficiency, surgical knowledge, communication skills and judgment. The easiest of these to teach (going against conventional wisdom) is technical proficiency, and the most difficult to teach is judgment.
The best person to impart these four essentials to trainees is a mentor. All surgical trainees should have mentors. Mentors have qualities and skills that distinguish them from trainers or teachers. A surgical mentor is expected to perform several functions besides training and these include providing opportunities to mentees for a host of activities such as training outside the department, making presentations at scientific meetings, to perform research and assist them in their careers. There can be no debate that an effective mentor leads by example. More important than recognizing the strengths of a trainee, a mentor should recognize the trainee's weaknesses, as it is for the latter that the trainee needs the inputs of a mentor.
It is my belief that one of the most important requirements in teaching a surgical procedure is for the mentor to be able to do that procedure cleanly and efficiently. A trainee watching a master do a procedure several times and successfully navigating through different anatomical and pathological variations in doing so, will discover a level of confidence that cannot be acquired otherwise. This transfer of confidence from the mentor to the trainee occurs imperceptibly and is not given much importance by most mentors and mentees. Ultimately, good surgery is all about confidence. Confidence is what helps the experienced, older surgeons to continue to deliver good surgical results in the face of declining physical faculties.
Teaching and learning surgery is a two way street. You need a receptive and responsive mentee as much as a good mentor to have a good product. A trainee neurosurgeon, however, faces several attitudinal barriers to learning surgery. These arise from myths and commonly held beliefs among trainees and neurosurgeons.
I am sure most neurosurgeons and trainees would have heard epithets such as “born surgeon” and “gifted hands” applied to competent surgeons and conversely “all thumbs” used to describe incompetent surgeons. The use of these terms to describe surgeons, competent or otherwise, does disservice to the budding neurosurgeon on at least two counts.
First, these terms imply that surgical talent is innate and will discourage most young neurosurgeons who will undoubtedly have a difficult time doing their initial surgeries. It will make them believe that there is no hope for them since they do not have the innate “traits” necessary to become a good surgeon. Second, surgical competence is reduced to manual dexterity and nothing can be further from the truth. To negate the over-emphasis on manual dexterity being the determinant of the competence of a neurosurgeon, Harvey Cushing remarked that he looked forward to a day when a “handless” surgeon would be appointed in a hospital as he rightly believed that operations were the least part of a neurosurgeon's work.
Manual dexterity, so often touted as the most essential skill required of a surgeon, is like any other human skill. It follows a normal “bell curve” distribution in the population. Nearly 70% of the surgeons will fall in the “average” central part of the curve, with a few being at the two extremes of the bell curve. This means that there are no “born surgeons”. All surgeons have to be made.
If surgical skills do not reside in the hands of a surgeon, where do they exist? Acquiring surgical skills, like most manual skills, are essentially cerebral exercises and consist of forming “mental representations” of the surgical procedures in our brains. While even mundane human physical activity depends on mental representations, what it takes to become an expert in surgery is to develop “highly complex and sophisticated representations” of the surgical situations.
One of the important and oft ignored paths to developing mental representations of a surgical procedure is the mindful observation of mentors and other surgeons performing surgery. This plays a very important role in learning not only how to do surgery but also in learning what to avoid during surgery. This aspect of learning surgery is under-recognized by most trainees and not given the importance due to it. I would attribute 70%-80% of the surgical learning to observation. There are other preparations that help in forming the “mental representations” of a surgical procedure. Knowledge of the surgical anatomy and steps of a procedure is essential before entering the operating room. Every surgery should be performed twice; once in the mind of the surgeon before the surgery and the second time in the operating room. It is also important to remember that a number of determinants of surgical outcomes are delivered outside of the operating room. A trainee surgeon should endeavor to focus as much energy on learning the post- operative management of a patient, as is spent on learning operative surgery.
One of the consequences of having well developed mental representations is the ability to recognize patterns when confronted with a set of confusing facts or images or surgical anatomy on the operating table. This “pattern recognition” helps an expert surgeon in finding a solution for difficult clinical problems both in the operating room and in the post-operative management of a patient.
It is a commonly held belief that “practice makes perfect” and, therefore, surgeons and their trainees would like to operate on a large number of patients to perfect their technique. But repeated practice, in my estimate, contributes only 20% to 30% to the trainees' skill acquisition process. The other 70% - 80% is contributed by diligent reading of the surgical anatomy and the surgical steps, and most importantly, focused and purposeful observation of the surgery performed by mentors and experts.
It is vital for a trainee surgeon to recognize that he/she cannot improve skills with “mindless” or repetitive practice of surgery without any evaluation of the results and consequent course correction. The right kind of practice is “deliberate” practice. This is a term introduced by the Swedish-American psychologist, Anders Ericsson, in the early 1990s. His recent book Peak elaborates on the concept of deliberate practice by explaining the processes involved in the transformation of average novices into exceptional performers. The concept of deliberate practice has also received endorsements from other authors such as Malcolm Gladwell and Geoff Colvin, who have documented, with examples of high achievers, as to how several hours (10,000 hours) of deliberate practice are necessary to excel in any field of human endeavour.,
The first requirement of deliberate practice is an assessment of existing skills by a mentor or coach who will determine the deficiencies and provide a road map on how to correct them. It also requires constant feedback from the coach or mentor. Finally, deliberate practice is mentally and physically exhausting and requires dedication and focus. There is now evidence, even a randomized controlled trial, that deliberate practice improves the technical performance of trainee and inexperienced surgeons in the performance of surgery, both in the laboratory on animal models and in the operating room on patients.,
Just as feedback is an essential component of deliberate practice, so is it an essential ingredient of a good training program. Residents should be evaluated periodically by all the teachers in the department and not just the head of the department. The evaluation process should be fair, transparent and objective as far as possible. The other kind of feedback is meant not only for the residents but also for the entire faculty. I am referring to surgical audits which should be conducted in a dispassionate manner in a forum which includes peers from the department. These audits should be looked upon as learning and teaching exercises and not a finger-pointing or fault-finding session.
A surgical teacher or mentor expands the circle of service by “performing” surgery through his/her colleagues, residents and fellows, alumni of the department and trainees of these alumni. However, the spread of the service is relatively modest and may push the number of patients benefited by the academic neurosurgeon from 10,000 to probably 100,000 – a substantial jump but nevertheless, way short of the million mark that was targeted.
If a neurosurgeon were to provide “service” to a million patients or more, then he/she has to go beyond just training the next generation of neurosurgeons and conform to all the attributes of an academic neurosurgeon and fulfill the responsibilities of one.
The identity of an academic neurosurgeon goes beyond performing high quality surgery and training the next generation of neurosurgeons. Rosengart et al., identified seven attributes of an academic surgeon which I believe also apply to an academic neurosurgeon. Analyzing patient outcomes, dissemination of knowledge and technical expertise, asking questions to advance patient care and thus, finding innovative solutions to difficult surgical problems are some of the additional traits that characterize an academic neurosurgeon. As you will recognize, these attributes define a clinical researcher.
It is obvious that only through the fruits of clinical research can an academic neurosurgeon reach out to a million if not more patients [Figure 1]. I will briefly touch upon one research contribution from my department which I believe has enabled us to positively influence the lives of several thousands of patients not only in India but worldwide.
Our research contributions in the field of neurocysticercosis (NCC) began with the identification and labeling of the entity of Solitary Cysticercus Granuloma (SCG) in 1989 and continued with the proposal and validation of the diagnostic criteria for SCG.,,, SCG was mis-diagnosed initially as “micro-tuberculoma” and our work provided the scientific basis for its recognition as a benign form of NCC which resolves spontaneously with a good seizure outcome after withdrawal of antiepileptic drugs (AEDs). We also proposed a management algorithm for patients with SCG based on their natural history and long term seizure outcome.,, SCG is the commonest form of NCC seen in over 60% of Indian patients and NCC is the commonest identifiable cause of late onset epilepsy in several countries which are endemic for NCC. Using data obtained from a community-based study of NCC, we estimated that at least a million patients have active epilepsy due to NCC in India. Several more have seizures (but not active epilepsy) due to NCC and SCG in particular.
Since we demonstrated that patients with SCG can be managed effectively with just AEDs and albendazole in some, and have a good outcome after withdrawal of AEDs following granuloma resolution, I can justifiably claim that we have probably saved several thousand if not millions of patients from being prescribed potentially harmful and toxic anti-tuberculous therapy.
We as neurosurgeons are fortunate to have Harvey Cushing as the father of our specialty. Being the epitome of a surgeon-scientist, his life and work should inspire almost every neurosurgical trainee or neurosurgeon to pursue research. In spite of this legacy, there are several neurosurgeons in academic practice who are not indulging in clinical research for a number of reasons including absence of a research-enabling environment. While there could be several mechanisms to incentivize research among neurosurgical residents and faculty, the role of an appropriate mentor cannot be over-emphasized. In the absence of a mentor, motivation could be provided by exposing neurosurgical residents to the lives of neurosurgeons who have contributed to clinical research in the field and the impact of their research on patient care and outcomes., Academic neurosurgeons owe it to the specialty to not only indulge in clinical research but also to ensure that their trainees are enthused about research. We as clinicians are best placed to make research contributions that can directly and expeditiously impact on the care and outcome of our patients. Otherwise we risk becoming mere technicians who do the bidding of other scientists as they will determine the best management strategies for our patients.
The ability to contribute to the well being of several thousands of patients both seen and unseen, not only in our own lifetime but even after, is truly the gift of academic neurosurgery. All of us who are fortunate to have been given this opportunity should be grateful for the same and deliver on the responsibilities that accompany this gift.
This article is based on the thoughts and ideas articulated during the Dr. John S Carman Oration conferred on the author by the Division of General Surgery, Christian Medical College, Vellore, and delivered on 30th November 2017 at Christian Medical College, Vellore. The author has modified the title and some of the content of the Oration to suit a neurosurgical readership.
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