How is neurosurgical residency in India? Results of an anonymized national survey of residents
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.263264
Source of Support: None, Conflict of Interest: None
Keywords: Neurosurgery, neurosurgical teaching, residency
The history of neurosurgery in India, when compared globally, is relatively short. Dr. Jacob Chandy started the first neurosurgical department at Christian Medical College (CMC) Vellore in 1949 after completing his training in Canada and the United States. At that time, he only had 12 dedicated beds for neurosurgical admissions spread in the various medical and surgical wards. The first residency-training programme of India was started here in 1954, and the first recognized University course for M.S and later for M. Ch. in neurosurgery was begun in the year 1958. Dr. K. V. Mathai was the first truly indigenously trained neurosurgeon. The 3-year neurosurgical residency (M. Ch) was started at the All India Institute of Medical Sciences (AIIMS), New Delhi under the leadership of Prof P.N. Tandon and Prof A K Banerji in 1967. Hence, the neurosurgical residency system in India, though now well established, is not very old. We are currently following the system as established when it was started, with very few changes incorporated over the years. The exacting nature of neurosurgical specialty places extreme demands for precision, swiftness, and attentiveness from the trainee. The explosion of new subspecialties and the rapidly changing nature of the field make it imperative that the neurosurgery training is well structured and assessed periodically so that the quality and adequacy of training is maintained.
The trainee is as much a stakeholder in a residency program as are the instructors. Unfortunately, no serious effort has been made in India to assess the perception of the neurosurgical residents towards the training programs they are currently enrolled in. Therefore, we decided to conduct an online questionnaire survey of the residents to evaluate their residency experience in the respective training programs.
Two authors (SM and KG) designed an online questionnaire using the application 'Google Forms'. The link to the questionnaire was widely circulated among the social media groups of residents belonging to various training programs. The respondents were completely anonymized to ensure a free and frank elicitation of responses. No identification data were sought for from either the resident or the training program which they had joined. The questionnaire covered the basic aspects of training, learning opportunities, academic exposure, and examination system. The perceptions of residents regarding these activities were graded on a 5- point Likert scale, wherever applicable. We asked for responses from candidates currently in training or recently qualified, so as to understand the recent trends and deviations. Authors not involved in the questionnaire design analyzed the responses (HD) of the survey so as to avoid any bias. Results were analyzed after 100 responses were collected.
We received a total of 104 responses from all the major post-graduate training institutes of the country. A majority of the respondents were post-MS (74%) candidates, as apart from All India Institute of Medical Sciences (AIIMS), New Delhi and National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, none of the other institutions are practically admitting trainees directly after graduation. Most (91.3%) of the institutes included in the survey were government funded tertiary care referral hospitals. Among the respondents, the period of joining residency ranged from July 2010 to as late as August 2018 [Figure 1], thus reflecting the current state of residency programs in our country. The most divided opinion was on the pattern of residency. While 44% of the respondents preferred the 3-year post-MS pattern, a similar proportion (40%) preferred the post-MBBS 5 or 6-year pattern [Figure 2]. However, the majority (64.5%) believed that post-MBBS trainees need general surgery exposure and training in order to allow for the versatility of the neurosurgeons' operative spectrum to develop.
An alarming aspect of neurosurgery training in our country was the absence of official work hour regulations at the workplace with only 19% of the respondents having an official work-hour regulation. Couple this with the fact that 89.4% the respondents (>2 response Grade) felt that work hour regulations would improve the overall training experience, and we now have a strong case of some real regulations in this matter. Residents were of the opinion that, apart from more time for personal life (50%), work hour regulations would allow for more time for research and academics (62.7%) and improved efficiency at the workplace (68.6%). This is especially important as only 28.5% of the residents have a less than 80-hour week, with many (35.3%) even working for more than 100 hours per week.
Majority of the residents (91.4%) agreed that clinical history taking and examination forms an important aspect of their training and helps shape them as future neurosurgeons. It was heartening to note that most of the training programs (87.5%) emphasize history taking and clinical examination skills during their training [Figure 3]. Even more, importance was placed on the pre-operative surgical planning and imaging interpretation (computed tomography [CT], magnetic resonance imaging, etc) with all of the respondents (100%) attaching a high importance to training in this aspect. Most of the programs do not have joint neuro-radiology meetings (67.3%), and in about half of the institutes (51%), the neurosurgery consultants interpret the imaging findings for them. Among the places where neuro-radiology meetings are held (31.8%), only 1% of the respondents found these very useful, raising serious questions regarding the educational value of these meetings for the residents. This means that such meetings need to be restructured taking into consideration the resident training. About 83.6% of the residents were satisfied (> Grade 3 response) with the quality of teaching with regards to imaging interpretation during their training.
An alarming number of residents (13.5%) were unsatisfied with the quality of operative teaching at their institution (<Grade 2 response) and 24% of the residents wished for more hands-on intra-operative training during their residency. Operative training in institutes has always been a hand-me-down affair and it was no surprise that the majority (56.7%) of these residents were supervised by a more senior resident during their training. This may also reflect the need for trauma and emergency exposure among residents, as most of these residents will get hands-on exposure for the first time during this essential phase of training [Figure 4].
The status of sub-specialty training was especially insightful. Since 3 (AIIMS, NIMHANS, Postgraduate Institute of Medical Education and Research [PGIMER]) out of the 5 (other Sree Chitra Tirunal Institute for Medical Sciences and Technology
[SCIMST], Sanjay Gandhi Postgraduate Institute of Medical Sciences [SGPGIMS]) major centers mapped with this survey have gamma-knife facilities, 56% of the residents found gamma knife and stereotactic radiosurgery exposure adequate [Figure 5]. Despite 3 (AIIMS, NIMHANS, SCIMST) major institutes having well-established epilepsy programs, only 34% of the respondents had a good epilepsy management exposure, with 62% of them finding it inadequate. A similar distribution was seen in movement disorders with 66% of residents having inadequate exposure despite the same 3 institutes having well-established deep brain stimulation (DBS) facilities. Exposure to endovascular surgery (63%), minimally invasive spine (70%) and spinal deformity surgery (70%) was described as uniformly poor. The rise of postdoctoral fellowship programs may have led to the decreased exposure among course residents for these sub-specialties.
Academic teaching programs continue to follow the same established protocols. Clinical case presentation forms the bedrock of neurosurgical training (91%) at most centers (>Grade 2 response). Regular seminars (91%) and journal clubs (79%) are a feature of most residency centers (>Grade 2 response), with the approval rating being better on seminars and clinical case sessions than journal clubs. However, by far the best approval rating of any part of the training program went to the pre-operative discussion with more than 95% of the residents having a greater than Grade 2 response. Even mortality/morbidity meets have a good teaching value (86.5%) among the residents.
Most (89.4%) of the current residents approve of the present pattern of exit examination with Clinical case presentation (92%) and Operative examination (86%) forming the most relevant portions of the exam. Theory (65%) and Grand viva (83%) too had important roles to play, albeit with lesser relevance [Figure 6]. Majority of the centers do not have periodic assessments (49%) and even if they do, it is not counted towards the final assessment (30.8%). Understandably, the majority of the residents were in favor of having periodic assessments (67.3%), with only 6.7% disagreeing to such a pattern. Majority of the residents still rely on textbooks as their major learning resource though the pattern has shifted from print versions (54%) to electronic versions (85%), probably owing to the costs and ready availability of new editions. Similarly, online journal articles outshine (63% vs 5%) their printed counterparts in popularity. Sadly, non-authenticated sources like Wikipedia are still a part of the resource and research network of many (39%) residents. While the popularity of Neurosurgery educations and training school (NETS-AIIMS, New-Delhi) continues to rise (24%), the convention of visiting libraries and poring over reference books is nearing extinction (6%) among residents [Figure 7].
The experiences and expectations of the trainees in a residency program are immensely important for the assessment of its efficacy. Accordingly, the surgical residency programs in the developed countries are rigorously monitored and feedback is sourced independently from both the instructors and trainees by a central authority. The Accreditation Council of Graduate Medical Education is a non-profit private organization, which oversees residency programs in the United States. It scrupulously maintains statistics of training activities undertaken by residents enrolled in various programs and periodically evaluates the performance of these programs with respect to the fulfillment of the training objectives. An analogous system has not evolved so far in India possibly due to logistical difficulties in coordinating data acquisition from different residency programs in the absence of a centralized registry.
An attempt to evaluate the perceptions of the residents regarding their training programs was long overdue as the oldest neurosurgical training programs in the country were established almost half a century ago. Curiously, programs following two different structures of training are currently being allowed in the country. The 6-year long training program is initiated immediately after graduation (MBBS), while the 3-year long program mandatorily requires a general surgical residency for eligibility. It is unreasonable to expect a similar training experience in these different patterns of training. The structure of individual programs varies between institutions and is frequently nebulous.
Incidentally, the United Kingdom also offers opportunities for a two-stage entry into the neurosurgical residency, a practice similar to what is being followed in India., However, the training pattern and goals are rigorously defined to cover up for any lacunae in the respective neurosurgical residency training periods. With the explosion of different subspecialties, subsequent narrowing of an individual neurosurgeon's repertoire and a trend towards work hour regulation, an extended period of training is naturally expected. This is reflected in the responses we received in our questionnaire, where even the candidates enrolled in the 3-year courses showed a preference for 6-year training pattern. However, an abbreviated rotation in general surgery was deemed essential by the majority of the trainees understandably for the acquisition of basic technical skills.
Regulation of residency work hours is another issue, which is brought to our attention through the survey responses where both ends of the spectrum seem to be requiring attention. Almost 1/4th (28.5%) of the residents reported working for less than 80 hours, which we believe, is insufficient for proper training in an intense and demanding specialty such as neurosurgery. Almost 1/3rd of the residents admitted to working for more than 100 hours/week, which may be physically and mentally draining and leave little time for consolidation and assimilation of the knowledge and experience gained. Though a conclusive advantage of work hour regulations is lacking from experience in the West , the surveyed residents expected diverse benefits from such an arrangement. Strict implementation of work hour regulations may be practically difficult in India where the number of residency spots available in a training program is not relatable to practically useful criteria such as operative case volumes and patient load. Accordingly, it may be prudent to introduce relevant metrics for deciding the appropriate number of residents in a program.
Another aspect to be considered here is the collaboration with other subspecialties and the need for further exposure required in the emerging subspecialties. The significance of proper interpretation of imaging studies in neurosurgical patients cannot be overstated and can critically affect the decision to operate as well as to determine the appropriate surgical strategy. Disconcertingly, most residency programs do not follow the practice of joint meetings with neuroradiological experts for reviewing imaging studies. In programs which have incorporated such meetings, residents found them lacking in utility. Although the majority of the residents were reportedly satisfied with the overall training in radiology interpretation, it may well be a “frog in the well” phenomenon, where residents unexposed to it have not discovered the utility of a well-structured joint neuroradiology conference. The feedback suggests that there is an urgent need to encourage joint radiology meetings and purposely increase resident participation and learning in these meetings.
Subspecialty training is another aspect where residents felt deficiencies. Probably, there is a need for introducing residency rotations in dedicated subspecialties to ensure completeness of residency training, though it will be difficult to implement this proposal in the absence of subspecialized neurosurgical practice at most of the centers. When a particular program is lacking in a sub-specialty area, residents may be allowed to rotate to a different program offering that sub-specialty exposure. Such an arrangement would be most beneficial, understandably, in the final year of training.
Most residents were convinced of the importance of pre-operative discussion and various other academic activities such as seminars and journal clubs. This needs to be interpreted in a positive manner and such sessions must thus be continued and more fervent participation encouraged. However, the pattern of exit examination needs further appraisal. Instead of exams only at the end of residency tenure, which is the norm being followed by most programs, a periodic assessment pattern is preferred by residents. This makes a case for an intermittent evaluation in the form of yearly exams, which would inevitably have a bearing on the final result. The traditional methods of knowledge acquisition have been recently supplemented by newer electronic mediums of education and teaching in the form of electronic copies of journals and books, webinars (an initiative by Neurological Society of India) and surgical education videos. The convenience of access to these mediums makes them a popular choice for residents for reading and referencing in between their hectic training programs. Accordingly, investment in expanding the reach and content of electronic mediums should be the focus area for academic institutions.
We understand certain limitations with this reporting. All institutes were not covered in the survey and this introduces a lot of scope of change in the answers and results. What we hoped to capture was a snapshot of the neurosurgical residency training in India. Also, there could have been many more questions asked but it would have made the survey too lengthy and thus compromised the response rate. Questions such as the usefulness of thesis and research papers were consciously omitted, as these have been asked before. In many institutions, these are compulsory, and hence non-negotiable.
Neurosurgery, with its ever-increasing scope and relentlessly unforgiving goalposts, needs a thorough preparation from clinicians who are going to face its formidable challenges. Our survey has shown that the residents have underlined the expectation for a substantial scope for improvement in our training programs. As a first step, the administrators must recognize the prevalent deficiencies that mandate a remedial action and mentor the required changes associated with the neurosurgical residency programs in India.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]