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“Magister neurochirurgiae”: A 3-year 'crash course' or a 5-year 'punctilious pedagogy'?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_1175_16
Sir, ”In the arts, athletics, games, and other realms of human activity, I have found nothing that matches the difficulty of surgery.” Richard H. Bell (Presidential Address, American Board of Surgery, 2009)[1] Ever since we can remember, animated discussions on 3 versus 5-year neurosurgery training programs have been doing the rounds in elite neurosurgical circles [Table 1]. We were enthralled by Professor A K Banerji's soul-stirring analysis [2] on the evolution of neurosurgical training in India gathered from a legacy of experience. This wonderful discourse inspired us further to critically evaluate a few fundamental questions,
Contemporary neurosurgical trainees are expected to be brilliant diagnosticians, master surgical craftsmen, tough call decision makers, sharp researchers, and above all, empathetic human beings.[2],[3] Living up to the superhuman expectations of the faculty and academic administration at times, compromise the joys of 'neurosurgical living,' in the training period.
An ideal ratio of neurosurgeons relative to the general population for a developing country like India is difficult to define. Attempts to define this ratio in the United States (as 1:1,00,000, SOSSUS Report, 1977)[4] have drawn a lot of flak [Table 2].
As each academic year passes by, India's pool of trained neurosurgeons grows bigger and the optimum utilization of their services seems a challenge.[2] As long as human neural tissue has structural flaws, dysfunctional elements and injured or worn out components, neurological surgeons will continue to be relevant and have a crucial position in the society. With India's population crossing 1.27 billion, it is estimated that at least about 3 million Indians would need a neurologist/neurosurgeon in their lifetime. At current epidemiological estimates, the number of neurosurgical patients is steadily rising and the output of freshly graduating neurosurgeons (110-130 per year) may be woefully inadequate to meet the need. The current ratio in India of 1 neurosurgeon for around 0.6-0.8 million people does not sound appealing in a developing economy such as ours and creates the need for the establishment of more neurosurgical training opportunities. This pressure to produce more neurosurgeons could tempt us to cut corners and make compromises in quality neurosurgical training.[2] ”See one, do one, teach one” has been a traditional paradigm in surgical training.[5] However, in centers with scarce resources, “seeing one” may itself be a luxury, let alone “doing one” or “teaching one.” Surgical operations are no longer the traditional “cut-and-cure” therapies but are rather multi-disciplinary holistic treatments where cure extends beyond the scalpel. Thus, a future neurosurgeon is expected to be proficient in technical surgical skill and sound decision making that is further bolstered by adjunct skills in endoscopy, endovascular therapy, radiosurgery, robotics and research. Surgical disease no longer remains just purely surgical; and, surgical science has moved beyond the operating room.[6] Traditional Halsteadian learning or supervised experiential training in surgical specialties is often not ideally possible. Constraints include lack of sufficient surgical mentors and “hands-on” training opportunities. No amount of theoretical knowledge on meningioma classification or theories of colloid cyst formation can make up for the actual experience of having operated on a patient harbouring either of these tumors. This deficiency in the hands-on exposure may be somewhat compensated by simulation training, didactic cadaver workshops and skills laboratory training programs.[5],[6]
Typical teaching in Neurosurgery rarely happens in didactic lectures and classrooms.[3],[6] Bedside clinics, operating room discussions, surgical apprenticeship, conferences, workshops and technical course are all part of a learning process that is often informal. Contemporary neurosurgical training is, therefore, a fine balance of the technical skills, adjunct skills and that 'something extra.' Technical skills Master craftsmen and sports professionals train over 10,000 hours to achieve a superlative level of mastery of the craft.[6] However, in residency training, only about 5-10% of the work time is actually spent in the operating room for the honing skills in Neurosurgery. Sound technical skills and reducing avoidable adverse events form the cornerstones of surgical training. Technical finesse includes a sound anatomical know-how and an awareness of the pathological distortions. Technical skill acquisition in a structured and hierarchical manner has been objectively described by the Zwisch model for surgical education [Figure 1].[7] Undoubtedly, the place of technical skills in surgical training is unparalleled.
Adjunct skills Surgical training needs to develop specialists of the disease rather than technicians of the knife. The actual surgical operation is often a joyous experience for a surgeon while the real challenge lies in sound judgment, presence of mind, and decision making.[3] These and other adjunct skills are essential for the success of surgical operations that go way beyond their technical aspects. Something extra! A contemporary neurosurgeon also needs administrative, leadership and research skills to survive and pitch for the neurosurgical causes. Soft skills, computing skills, manuscript writing, conference presentation skills, working knowledge of medical law and ethics add to the 'nice to know' list in neurosurgical training. Thus, the emphasis now lies on a holistic training which is more need-based and relevant to the current times.[7],[8] An ideal training program still remains a utopian dream. Exit exams and future employment Exit exams are not particularly standardized and most universities have their own systems and protocols. The focus still remains on the essay-type questions, traditional clinical neurology skills of case presentations with varying emphasis on radiology, pathology and operative skill assessment.[3],[6] Too much weightage remains on a single exit exam at course completion rather than a continuum of assessments along the course. The thought of a suitable neurosurgical employment prospect looms large over the examinees facing exit exams and adds a touch of worry. The concept of campus recruitment for neurosurgical trainees, as is the practice in the elite engineering/management schools, is rarely seen even in reputed neurosurgical departments in the country. “Fitting in” the fresh graduates to neurosurgical jobs does not, at present, seem to be the responsibility of training institutes or professional societies, and the skilled, fresh neurosurgical professionals are often sadly left to fend for themselves.
It is estimated that about 11-15% of human ailments require surgical therapy. The earliest surgeons were specialists in all surgical ailments across several organ systems. However, in the contemporary era of sub- and super-specializations within Neurosurgery itself, generalists may not stand a fair chance.[2] Neurosurgery has certain surgical skills that are innate to the speciality [2](the suction holding grip, fine dissection techniques, microneurosurgical manoeuvres, etc.). At the same time, general surgical skills for procedures like neck exposures, retroperitoneal dissections, laparotomy, or thoracotomy, and laparoscopy may have a space in neurosurgical operations as well. However, not all general surgical skills can be extrapolated or “transferred” to Neurosurgery, quid pro quo. At times, general surgical gross dissection skills with the the Metzenbaum scissors and Yankauer's suction may have to be “unlearnt” to develop the finesse of microneurosurgical suction-dissection-hemostasis techniques. “Pack and control” hemostasis mechanisms, as in general surgical operations, do not stand in good stead in neurosurgical operations like repair and reconstruction of venous sinus injuries. Triage and decision-making, that have been learnt as an integral part of general surgical skills, are nevertheless invaluable even in Neurosurgery. Undoubtedly, the pros and cons of a background general surgical training prior to a training in neurosurgery are evenly poised ([Table 1])
Not having enough hands-on exposure is a common grouse of neurosurgical trainees in every part of the world.[1],[5] High volume training centers are often assumed to impart sufficient surgical skills to residents. However, training could be skewed disproportionately despite the numbers. Clipping too many aneurysms may not make one adept at intrinsic brain resections or spine fusions. Thus, a variety and an adequate balance of surgical exposure is essential, and skills acquired in one procedure may not often be transferable to another. The need of the hour in training centres is to inculcate the western concept of “surgical minimums” or a compulsory operative log for each level of resident training.[1] This would ensure that each trainee has performed a basic requisite of essential procedures both under supervision and with reasonable independence.
Immense variability exists in the technical skill acquisition aptitude and surgical judgment of neurosurgical trainees. Thus, the minimum number of cases needed to reach the basic/expert level on the learning curve for a particular procedure is variable too.[1],[3] Hence, lending an element of objectivity to the surgical learning curve by citing a minimum number of cases to attain proficiency in a procedure is practically difficult. A hierarchy of cases based on increasing difficulty should be made part of every neurosurgical training curriculum. Every trainee, based on his/her technical skill and aptitude, should have an equal opportunity for surgical career progression. Thus, the more skilled would have a fair chance to do more and train faster without affecting the opportunity of another trainee.
Every residency program should strive hard to have a clear sense of purpose and camaraderie. Residents should not merely be work horses for mundane surgical chores; rather, they should be equal stakeholders in the exciting process of delivering neurosurgical care. Even well beyond formal training, neurosurgeons are being constantly challenged to reshape their surgical skills. Times are ever changing and the traditional 5 cm incisions of the time-tested “open” technique are being resized to 5 mm “hot and happening” minimally invasive/percutaneous options. Thus, staying abreast with the evolving standards of neurosurgical care, extends far beyond formal training.
The whole point of a neurosurgical education is not just to get a job but to inculcate a practical skill set, impart a body of readily applicable knowledge and develop the ability to challenge the intellect and skills further. The sheer vastness of neurosurgical science and evolving technology may deem even 5 years of training as inadequate.[9],[10],[11],[12] Maybe, in the long run, the little creases in the 3-year and the 5-year neurosurgical training programs iron out evenly. Surgical expertise and the little extra skills needed, shape up further, far beyond the duration of neurosurgical training, often guided by life's many experiences on the job and the forces of nature. The debate on 3 or 5 years is perhaps evenly poised, though coloured by moments of temporary triumph for either side. There is no clear winner as yet, however hard we cry ourselves hoarse. Nevertheless, let this 3- or 5- year debate never dampen spirits or create groups, as at the day's end, all that matters to a neurosurgeon, is the satisfaction of a job well done and a life saved. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1]
[Table 1], [Table 2]
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