NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS
|Year : 2015 | Volume
| Issue : 4 | Page : 464--467
Neurosurgical Education: Some thoughts
President, National Brain Research Centre, Nainwal More, Manesar, Gurgaon - 122 050 Haryana. Founder Head of the Department of Neurosurgery, AIIMS, New Delhi, India
P N Tandon
President, National Brain Research Centre, Nainwal More, Manesar, Gurgaon - 122 050 Haryana. Founder Head of the Department of Neurosurgery, AIIMS, New Delhi
|How to cite this article:|
Tandon P N. Neurosurgical Education: Some thoughts.Neurol India 2015;63:464-467
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Tandon P N. Neurosurgical Education: Some thoughts. Neurol India [serial online] 2015 [cited 2020 Oct 27 ];63:464-467
Available from: https://www.neurologyindia.com/text.asp?2015/63/4/464/161959
Thinking about the request from Professor Sanjay Behari to contribute to the newly introduced section on "Timeless Reverberations" in our journal, I, having devoted more than half a century as a teacher, decided to put some of my thoughts on Neurosurgical Education. Let me hasten to add that this is more to generate a debate on the subject than to present some preconceived notions. After this decision was made, Prof. A.K. Banerji brought to my notice that the Neurological Society of India (NSI) had recently appointed a committee on issues related to, "Making Uniform Guidelines for Neurosurgery Residency Curriculum." I have gone through the draft report, but would desist from commenting on it at this stage except to state that the thoughts expressed here transcend the limited issue of uniform guidelines for neurosurgical curriculum. No doubt, I have certain preferences, may even be strong leanings, for some presumptions regarding the subject. For one, I am convinced that the current trends in neurosurgical education, and for that matter medical education in general, are in need of a critical evaluation and a radical change. 
At the outset, let it be stated that the emphasis of this presentation is on "Education" and not simply on "Training," which no doubt constitutes an important component of the former since it is concerned with a profession deeply dependent on skills. On the occasion of the Golden Jubilee of the Department of Neurosurgery, NIMHANS, Bangalore, I presented my thoughts on "Training of a Neurosurgeon."
We are living in a constantly changing world of knowledge and of needs as mentioned by Allen Gregg in 1953 at the time of the Second Foundation Day of the Montreal Neurological Institute.  This is even more so today. The rapid advances in knowledge, techniques and technologies in recent years demand a system of education responsive to these changes. As Prof. D.S. Kothari, an educationist par excellence, advised, "In the rapidly changing world of today one thing is certain, yesterday's educational system will not meet today's, and even less so, the needs of tomorrow."  In our educational system in general and medical education in particular, there is an over emphasis on information transmission and gathering.  In the current environment of information explosion, no one - not even a genius - can hope to keep abreast with all relevant information. Mercifully, the simultaneous developments in information technology make information collection by an individual greatly redundant. As Horrobin (1977), stated in Medical Hubris, "-------it is habits of mind and standards of performance that we should aspire to teach, not the illusion of enduring facts.?
In case of educating neurosurgeons, it is obvious that it is not only training of surgical skills but also enough theoretical knowledge of the subject that constitutes the two legs to stand on. This has been poetically expressed in ----- it is habits of mind and standards of performance that we should aspire to teach, not the illusion of enduring facts."
In case of educating neurosurgeons, it is obvious that it is not only training of surgical skills but also enough theoretical knowledge of the subject that constitutes the two legs to stand on. This has been poetically expressed in Yoga-Vasistha:
"It takes both its wings for a bird
To fly about in the sky-
So it takes both knowing and doing
For man to perfect himself"
Centuries ago Susruta advised, "He who knows theory only, but is not so good in practical work, gets bewildered on being confronted with a patient, ----------. On the other hand, he, who is good in practical work because of his boldness, but lacks theoretical knowledge is not respected in the cultured society, actually he deserves punishment by the government. Only that intelligent person who knows theory and practical work is capable of obtaining success in the same way as only a two-wheeled vehicle is useful in the battle field" (Susruta SS 1.3.48,79,53).
In his lecture on "Neurosurgery - Yesterday, Today and Tomorrow," Wilder Penfield proposed, "Neurosurgery is a body of accepted basic principles, yes, and a group of technical and operative procedures which conform to these principles. But something more …… the alluring promise of new discovery…… this is what makes her such an irresistible mistress." And furthermore he warned, "Elaboration of surgical technique is an important mechanical achievement. But beware of vain glory, for it may be that our intellectual maturity is yet far off, and to be acquired only after years of further pioneering," and, "…… that for each of the arts there is a purpose beyond the skill and in that purpose there are eternal values for society."  One of my other teachers, Kristian Kristiansen in his address on, "The Present and Future of Neurosurgery" pointed out that, "In the neurosurgical profession, the practical skill is important, but far more important is the knowledge of the principles on which this skill is based." and, "It is necessary to develop real insight into the anatomical, physiological and pathological conditions underlying the surgical diseases of the nervous system, an insight which can only be acquired by personal research work."  At present, we should add molecular biology, neurochemistry and genomics to the list of the basic sciences mentioned by him. In his lecture, "Neurosurgery Today and Tomorrow," Jefferson (1953) pointed out, "No doubt some will be attracted by the technical side of neurosurgery, yet there will be others who crave to look beyond that. Education should recognize these needs and provide for fulfillment of desire of either or better still inculcate this spirit in all." 
A doyen of Indian Neurosurgery, B. Ramamurthi discussing the "Future of Neurosciences in India," questioned, "Will the future neurosurgeon be only a competent technician or will he continue to contribute to the advancement of knowledge of the nervous system?" He cautioned, "Increasingly sophisticated technology and greater emphasis on technological competence of the neurosurgeon is also likely to affect his intellectual creativity unless conscious precautions are taken." He advocated, "This desirable objective should continue to motivate future neurosurgeons, thus preserving their role as neuroscientists and contribute to knowledge." 
It would appear that there is a general consensus that education should promote knowledge acquisition, adaptation, generation and utilization as a seamless continuous process. Thus, neurosurgical education should aim at producing a knowledgeable, well-informed, technically competent person ready to learn and at the same time, motivated to advance knowledge through research. Laudable goals no doubt, which patterned on the programs initiated by Profs. Jacob Chandy and B. Ramamurthy, I and my erstwhile colleagues in the Department of Neurosurgery at AIIMS had tried to promote. The educational program followed by us, fulfilled the needs of the time and was generally appreciated both by our peers and students.  Being aware of the recent advances in Neurosurgery, I dare say, it would not meet the current demands. The real question is whether in the current environment of phenomenal advances in knowledge, the necessity to adopt as well as adapt to rapidly changing techniques and technologies, proliferation of subspecialties, and allied disciplines, it is possible to formulate an educational and training program to achieve the above goals, within a stipulated time frame.
Starting in the 1950s, when most training centres in India did not have a full complement of qualified specialists in allied disciplines - neuroradiology, neuropathology, or neurophysiology and basic neurosciences - the education of a neurosurgeon was planned to be "comprehensive and self sufficient." The attempt was to train every trainee to be a competent surgeon fully conversant with allied neuroscience disciplines and be exposed to research methodology. The scenario has rapidly changed. Towards the later part of 20 th century, there has been an explosion of knowledge in basic neurosciences on the one hand, and rapid continuous introduction of new technologies both for diagnosis (CT, SPECT, MRI, evoked potentials) and treatment (operating microscope, lasers, high spinal instrumentation, powered drills, ultrasonic suction) on the other. Neurosurgery itself has become a conglomerate of new sub-disciplines - stereotactic surgery, pediatric surgery, vascular surgery, spinal surgery, skull base surgery, endoscopic neurosurgery, etc., Classical neuroanatomy has to be reoriented to serve the needs of microneurosurgery; neuropathology has got supplemented with molecular biology and genomics; the standard neurosurgical techniques had to be replaced by sophisticated new technologies and procedures (image guided surgery, per-operative MRI, stereotactic radio surgery, interventional radiology and robotic neurosurgery).
These new developments have no doubt made neurosurgery safer and even applicable to lesions till recently considered inapproachable. In turn, it imposes extraordinary demands for education of the trainees. At the same time, at least some major training centres now have specialists in neuroradiology, neuropathology, neurology, and even interventionists. So a neurosurgeon working in such centres may have support available unlike those in earlier years. Yet there are still many places where neurosurgeons have to work without such support and hence have to take the responsibility of allied disciplines to a varying extent.
It would be obvious that the earlier training programs cannot be suitable for the current educational/professional needs. As early as 1989, Dr. Ramamurthi questioned the then prevalent educational programs in the country thus, "Is it necessary to train every neurosurgeon to treat, teach and do research?" An attempt was made to establish two streams of training through the establishment of the National Board of Examination. The original intention of the two streams has already been subsumed by demands for equivalence between the two.
While planning to revise the educational/training programs to meet the new challenges, the following elements would need to be considered, even before attempts are made to achieve uniformity of the curriculum.
Aim of Training
The end product should have acquired knowledge, skill, aptitude and attitudes to be able to function as an independent clinician/consultant and a teacher acquainted with research methodology. In addition he/she should have acquired a habit of mind for continuously acquiring new knowledge and skills befitting a learned member of the society.
Should be well acquainted with the current literature on relevant aspects of the basic, investigative, clinical and operative neurosciencesShould have learned indications and performance skills of common neurological operationsShould have acquired performances, skills and ability to interpret relevant clinical investigationsShould be able to diagnose, plan investigations and treat common conditions in the specialty by relevant current therapeutic methodsShould be acquainted with allied and general clinical disciplines to ensure appropriate and timely referralShould be able to identify, frame and carry out research proposals in the relevant specialty.
For this purpose, those formulating the curriculum should take into consideration the following:
Theoretical knowledge including allied neurosciences. How much basic neurosciences, neurology, neuro-radiology, neuro-pathology to be taught?Degree of professional competence - Conventional neurosurgery only and/or extent of various subspecialtiesExtent of exposure to newer techniques and technologies - microsurgery, endoscopic surgery, stereotactic surgery, subarachnoid radiosurgery, roboticsHow much of neurosurgical skill training can be carried out using virtual training platforms and specialized cadaveric laboratory developed for this purpose (as at AIIMS) or with the help of web-based technology utilizing smart phones? Training in research methodology and participation in research programs.
For various elements of theoretical education, clinical work, technical training and research:
Is current period of education (3 years after MS or 6 years after internship) adequate? (I am convinced that the latter has proved to be better)Should the educational program be tailored for those planning for an academic career versus those expected to discharge professional responsibilities only?Should a specified period devoted to research be compulsory for those opting for an academic career? I for one have been convinced of the need for such a training. I believe, "……… while preoccupied with looking after the immediate needs of patients, a caring clinician, with an enquiring mind, is confronted with many doubts and unanswered questions which call for systematic investigations. These critical questions in the ward provide an invaluable opportunity for clinical research, with or without the help of field, laboratory or experimental studies."  In addition, we all know that there are innumerable unanswered questions like the ideal treatment of severe head injury, traumatic paraplegia, vasospasm secondary to subarachnoid hemorrhage, malignant gliomas of the brain, etc. The comments that I had made on this issue regarding some of my papers are as relevant today as when they were made. To quote just as few:
Reviewing progress in management of severe head injury between 1960-1995, I came to the conclusion that, "Inspite of the innumerable clinical, pathological and experimental studies, the ideal management of traumatic brain injury remains an elusive goal" Notwithstanding some marginal gain, the mortality and morbidity of severe head injuries remain unacceptably high…… I am convinced that while improved methods of diagnosis, and technically high standards of surgery made possible by recent additions of a lasers, ultrasonic suction aspirator, operating microscope, etc., have continuously improved our ability in providing greater relief to the unfortunate victims of supratentorial gliomas, the ultimate solution is unlikely to come from a "sharper knife" or a more powerful source of radiation, but from a better understanding of the biology of these tumours. Is there a need for specialized courses for sub-specialties after the formal course? With machines making diagnosis and robots performing surgery, what will be the role of a neurosurgeon? "Before I give an impression that all these new techniques will replace an astute clinician, let me say that an astute clinician will always be the most essential person to decide when to utilize these techniques, how to interpret these, correlate their findings, and apply these to the patient as a whole and modify them to enhance their utility." 
In my opinion, it is the responsibility of the Neurological Society of India to deliberate on this subject and obtain a consensus, if necessary, in consultation with experts in allied neurosciences, as was done in 1986 on the initiative of Prof. A.K. Banerji. The matter can then be taken up with the Medical Council of India, which is the ultimate authority for laying down essential requirements for a degree course.
I, on my part, sincerely feel that there is an urgent need for critical evaluation and radical change of our post graduate teaching and training programs for M.Ch. in Neurosurgery, keeping in mind the recent developments both with respect to theoretical and technological advances. 
Let me conclude by recalling for the teachers a very old saying, "Every piece of marble has a statue in it waiting to be released. As the sculptor to the stone so the teacher to the child (student)".
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