Education of the Spine Surgeon

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Chapter 208 Education of the Spine Surgeon

There are two routes toward becoming a spine surgeon—orthopaedics or neurosurgery—both requiring long and distinct educational pathways. Historically, neurosurgeons performed surgery on the spine with special technical emphasis on alleviation of extrinsic decompression of the neurologic elements or operating intrinsically on the spinal cord and roots. Orthopaedic surgeons have historically focused on the structural spinal components and have pioneered instrumentation and deformity correction. Over the course of many decades, the differences between a competent spine orthopaedist and neurosurgeon have faded significantly. The care of most spinal pathology can be addressed with an equal level of expertise by either subspecialty. The aptitude of a fully trained spine surgeon is independent of which journey is taken. However, the pathway to become a fully trained spine surgeon remains quite different for the orthopaedist and neurosurgeon.

Orthopaedic Resident Education

The orthopaedic spine skill repertoire has expanded far beyond instrumentation and spine stabilization techniques. Several generations of orthopaedic surgeons have acquired advanced decompressive techniques and continue to pass that knowledge down via the residency training process. The training of orthopaedic residents remains a subcomponent of the general training period of 5 years. Most orthopaedic residency programs have dedicated rotations during the clinical training period, but there is no minimal time mandated by the Orthopaedic Residency Review Committee.¹ It is typical that the orthopaedic residency exposure to spine surgery averages between 3 to 6 months during training. Many programs have focused attention on deformity treatment experiences during these months. Emphasis on providing the orthopaedic resident sufficient educational experiences in joint surgery, trauma, or sports medicine often precludes a more extensive spine surgery exposure during residency training. Although not mandatory, the majority of orthopaedic spine surgeons have achieved greater levels of expertise during fellowships.

Neurosurgery Resident Training

Contrary to commonly held beliefs, most practicing neurosurgeons perform more spinal operations than cranial operations. Nationally, 60% of all procedures performed by neurosurgeons are spine related.² Similarly, the training of neurosurgical residents has a greater emphasis on spine surgery than on cranial surgery. Neurosurgery training exposes residents to spine surgery pathology and techniques—typically in the early years. This continues in most programs until completion of the chief experience. The residency experience is a minimum of 6 years. Neurosurgery residents have a significant degree of competency, with the operative management of most spinal pathologic conditions at the end of residency. Most residents go on to practice spine surgery without additional training. Many neurosurgical programs introduce residents to deformity correction principles, but many interested in spine deformity obtain fellowship positions. Increasing numbers are doing such under the direction of experienced orthopaedic surgeons.

Fellowship Training

It is during the fellowship experience that residents with both neurosurgical and orthopaedic backgrounds begin to acquire greater advanced skills and expertise with the care of spine patients. It is also during this year that the differences between the two specialties become progressively more indistinct. There are many different types of spine surgery fellowships, and many programs are nonexclusive to either neurosurgery or orthopaedics candidates. Some programs have a special emphasis on deformity, others on minimally invasive surgery, and many others seek to provide a diverse educational experience. In the spine fellowship program at the Cleveland Clinic, orthopaedic and neurosurgery fellows are treated equally and exposed to a balanced mix of spine surgeons of both specialties.³ Our graduating fellows retain some of the unique strengths of their residency training experience, but the skill levels among trainees are independent of orthopaedic or neurosurgery heritages. The integrative fellowship experience offers an opportunity to combine orthopaedic and neurosurgery specialties in ways that foster healthy collaborative efforts on the fronts of patient care, education, and research.

Evolving Accreditation Council of Graduate Medical Education Changes

The Accreditation Council of Graduate Medical Education (ACGME) oversees all U.S. allopathic orthopaedic and neurosurgical residency programs. Residency programs must be accredited by the ACGME to receive government funding in support of graduate medical education and to enable their graduates to qualify for specialty certification.⁴ Over the past decade, there have been several mandates from the ACGME that have altered how residents are deemed competent and how long they can spend in the hospital.⁵ Each of the specialties has its own residency review committee within the umbrella of the ACGME that is responsible for accreditation of individual programs and monitors compliance with ACGME mandates. Currently, spine surgery fellowship programs “live” outside the domain of ACGME accreditation, but many have adopted the mandated changes in graduate medical education.⁶ Two ACGME directives in the past 10 years have had a major impact on residency training: the Outcome Project and duty hour regulations.

Outcome Project

In 1998, the ACGME mandated a paradigm shift in graduate medical education to a competency-based process of education with a focus on outcome measures.⁷ Concluding that the existing educational evaluative process was inadequate, the ACGME decided to specify six general competencies: patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal skills and communication, and systems-based practice. When the ACGME adopted the general competencies, it was mindful that each specialty must engage in individualizing the task. Each specialty was given the assignment of establishing general outcomes, and defining competency regarding patient care and medical knowledge.

The definition and use of the six core competencies by the ACGME has posed challenges for educators.⁸ This challenge perhaps has been most apparent in the surgical subspecialties. The assessment of medical knowledge has been a difficult but not an insurmountable problem. However, the improvement and assessment of the remaining core competencies has been considerably more challenging. Assessing surgical performance must span across several of the competencies. Developed competency assessment tools have the potential to fall short in comprehensively addressing the specific needs of many program directors and, most noticeably, can provide suboptimal specific feedback to residents. Often, the faculty and residents struggle with well-established competency-based tools in place to “get to know” resident strengths and weaknesses.⁹ As such, residents have to struggle to self-reflect and improve based on measures, in particular, related to surgical experience.¹⁰ Many electronic assessment tools are in position, but systems do not integrate with one another across institutions. This limits the opportunity to unify the process of resident assessment and outcomes at the national level.

Resident Assessment Tools and Measures

Numeric and global rating assessment tools have been used to assess resident performance for quite some time. Rating systems provide a “unit of measure” or “grade,” which most learners (and teachers) have likely grown accustomed to during their own formalized educational process. One argument for numeric scoring summaries is that they may indeed provide some useful data, assisting the program director to “objectively” assess residents and the program as a whole. On the other hand, there is debatably greater value to providing highly meaningful detailed feedback to individual surgeons in training.¹¹ Isolating a competency to a single numeric value provides feedback that often fulfills requirements but fails to provide the resident feedback concerning targeted areas of improvement. When measuring across multiple competencies, it is quite likely that there will be some residents who achieve an overall satisfactory score but who perform poorly in a single competency. Global ratings have been shown to be highly subjective when graders are not well trained.¹² At times, some raters may rate all competencies equally, regardless of performance. Scores may be biased when raters inappropriately make severe or lenient judgments or avoid using the extreme ends of a rating scale. Reproducibility of scores by raters appears easier to achieve for the domain of knowledge and more difficult to achieve for patient care and interpersonal and communication skills. Perhaps the greatest criticism against the use of global rating tools is that a numeric score can provide suboptimal feedback to the individual resident attempting to learn from the evaluation process.

More specific and useful information used to create a summary of an individual resident’s performance can come from the narrative components of assessment tools. In many programs, emphasis on resident assessment numeric scoring is reduced or eliminated, and specific competency-based narrative commentary is heavily relied on. Self, peer, faculty, as well as 360-degree assessments make up a collective formative database. Strengths and weaknesses can be specifically and immediately queried by the resident, mentor, and program director. The resident should be responsible for keeping track of the formative database. The downside of a system that heavily relies up narrative feedback is that greater time is required to compose a summary compared with scoring schemes. There are also varying degrees of “narrative skill sets” that faculty have in regard to providing rich and meaningful feedback, which limits an assessment system that purely depends on the written word.

Portfolio for Assessment of Professional Development

Several residency programs have begun to use educational portfolios to assess graduate medical education performance.¹³ Principal functions are to lay the groundwork for reflective learning, assess to promote learning, provide useful feedback for improving performance, inform rather than just measure, and document the longitudinal progress. Portfolios were initially described as a purposeful collection of student work that exhibits to the student (and/or to others) the student’s efforts, progress, or achievement in one or more given area(s). This collection must include student participation in the selection of portfolio content, the criteria for selection, the criteria for judging merit, and evidence of student reflection.¹⁴ Essential to the core of the revamped assessment plan is that the resident must take responsibility for creating his or her own portfolio.

The ACGME issued an Executive Summary Report in 2007, launching their own pilot portfolio project ¹⁵:

The learning portfolio will support the development of self-directed habits of lifelong learning and reflective practice, which are critical to the process of professional formation. Residents will have the opportunity to reflect on important patient encounters, procedures, conferences, didactic sessions, etc. and to make meaningful inferences about these experiences. Equally important is the opportunity they will have to seek feedback from mentors and peers in guiding their reflection, self-assessment, and plans for practice improvement. Since the portfolio will also function as a repository for all structured evaluations of performance, the learner will have these assessments to inform and validate their own thinking. The educational “story” of the resident, which chronicles progress over time, will be housed in one virtual location, allowing the resident to easily monitor his or her own learning and growth with the availability of robust reporting.

The ACGME is currently in the beta phase of this pilot project, and expected global presentation in the next few years should be anticipated.

Milestone Project

One major criticism of the Outcome Project is that it has not resulted in the practical implementation of effective measurements for specific residents, for specific programs, and more comprehensively for specific specialties. The competencies as created by the Outcome Project remain non–specialty-specific and without timelines for achievement. There remain no standards per competency per year of training for either the orthopaedic or neurosurgery resident. Certainly there are no guidelines using the current competency tools that provide program directors detailed specialty-specific parameters for resident advancement within the program.¹⁶ Making it even more difficult for program directors is that their faculty often do not share a collective conviction of definitive and particular defined expectations for their trainees. This makes it very challenging to devise a meaningful remedial plan for a learning physician struggling in a specific domain.

In recent years, the ACGME leadership has challenged the medical education community to create and develop milestones of the six core competencies for each discipline.¹⁷ The Milestone Project has the goal of providing programs with specialty-specific standards per competency, defined over a specific time period, to assist program directors in assessing if residents are meeting nationally defined benchmarks. Residents will not be allowed to move to the next level without first reaching certain milestones, and failure to reach certain targets would trigger appropriate corrective action. Residents currently receive feedback without a framework of defined expectations per competency per a period of time, and it is hoped that a longed-for structure to assist with meaningful action plans can be created via the Milestone Project. The ACGME expects to monitor each program’s participation in this process, and a breakdown to comply with the documentation of the process may result in accreditation action for the training site. The Milestone Project has engaged several of the nonsurgical specialties.^18,¹⁹ The expected time frame for the rollout for orthopaedic and neurosurgery programs remains uncertain, but they are anticipated in the next few years.

Duty Hours

The ACGME-implemented duty hour mandates have dramatically altered how educators regulate the time residents spend in the hospital training. The 80-hour work week maximum has been implemented since 2003. Given no alternative due to accreditation ramifications, the specialties of neurosurgery and orthopaedics accepted the rules required by the ACGME. This represented a major cultural change for many demanding surgical residency programs, some of which worked residents more than 110 hours a week. Many educators would agree that the mandate has been reasonable given the issues that surround resident fatigue. Much controversy has existed over the impact of the reduction of duty hours on patient safety.²⁰^–²⁶

Results of a national survey of the program directors and residents in neurosurgery training programs included 93 program directors and 617 residents.²⁷ As many as 93% of all respondents thought that work-hour restrictions had a negative effect on continuity of care. Forty-six percent of residents perceived that work-hour restrictions would facilitate research/publication activities, and only 21% of program directors agreed. Forty-one percent of residents and 74% of program directors perceived that chief residents operate on fewer complex cases. Seventy-five percent of residents thought that they are less familiar with their patients. Sixty-one percent of the residents and 79% of program directors noted that the ACGME guidelines have had a negative impact on their program.

In July of 2011, the ACGME mandated modified duty hours rules regulations, which further reduced the time training physicians can work continuously (16 hours for interns and 24 hours for all residents).⁵ The new rules do not further limit the work hours per week but do mandate a greater emphasis on safety and resident oversight. Some increased flexibility for residents in the advanced stages in training as defined by specialty residency review committees was created to allow for continuity of care in select circumstances.

The outcomes of the modified new regulations remain to be seen. There is some indication that the quality of resident life has improved since the 2003 hours went into effect.²⁸ To date, no authorities have definitively shown that the reduction of work hours has led to improved patient safety. Concerns continue to surround the potential for detrimental impact of further reduction of hours on procedural skill acquisition and clinical decision making, discontinuity in care, and patient safety.²⁹

Simulation Training

The use of technology to simulate real-world scenarios for training purposes has a rich history in the airline, aerospace, and military industry. Historically, surgical simulation was limited to cadaveric or animal laboratories. Recently, technologic advances make virtual surgical simulation possible. Surgical simulation provides a zero-risk setting in which skills can be obtained through repetition. Even the crudest simulation of multistep procedures can aid the trainee in planning for a procedure by allowing rehearsal of the steps involved. More advanced, technically accurate simulation systems that provide sensory feedback can further aid the trainee in developing and refining the mechanical skills required for the procedure. Ultimately, the best metric for a simulator is how well skills derived from simulation transfer to actual procedures.

Simulation is now widely accepted for enhancing the resident training experience in a wide range of scenarios, including surgical training of laparoscopic procedures,³⁰^–³³ endoscopy,³⁴ colonoscopy,^35,³⁶ thoracoscopy,³⁷ cataract surgery,³⁸ peripheral vascular endovascular interventions,³⁹ and airway management.⁴⁰^–⁴² These simulation systems replicate procedures that involve two-dimensional visualization. The application of simulation in the realm of spine surgery training and education has lagged somewhat compared with other specialties, likely because of the challenge inherent in replicating a complex three-dimensional reality. However, improvements in computer processing power, volume rending, graphics, and haptics have allowed the creation of sophisticated, albeit limited, simulation systems with neurosurgical applications.⁴³

Simulation of surgical procedures such as laparoscopy has been fully incorporated into the training of general surgery residents. The role of simulation in spinal surgical education is yet to be defined. There are two main components to a procedure that simulation can reinforce.

First, the order of steps required to perform any procedure successfully can be rehearsed under different scenarios. For example, A, then B, then C, is performed, and the outcome of this management algorithm is awaited. Once the outcome is defined by the simulation system (adverse or desired), a new treatment algorithm can be instituted in a reiterated process.^44,⁴⁵ This learning environment could be very beneficial and efficient, particularly for relatively rare yet vital occurrences in real-world patient encounters, such as critical resuscitation.^46,⁴⁷ Not surprisingly, there is evidence that simulation of cardiopulmonary resuscitative efforts, for example, can improve performance and subjective perceptions of self-competence among trainees,^46,⁴⁸ and an intensive, curriculum-based simulation module can be as beneficial as 6 months of clinical ward experience.⁴⁹

Second, simulation of technical procedures can also be of benefit by providing a no-risk environment for rehearsal of mechanical skills required. Simulation has been shown to be effective for relatively simple procedures such as direct or peripherally inserted central venous access catheter placement and transnasal endoscopy.⁴⁹^–⁵¹ These findings reflect a transfer of skills acquired from the simulator to an actual patient encounter. It would be expected that the closer a simulation can mimic an actual procedure the more readily the skills can be transferred. Strategies using simulation into training must also incorporate periodic retraining of skills to avoid deterioration over time.⁵²

Limited simulation systems are currently available for the rehearsal of percutaneous spinal procedures such as kyphoplasty. Surgical planning using strategies that include the manipulation of three-dimensional stereoscopic imaging such as CT and magnetic resonance angiography has been demonstrated to be useful for intracranial surgeries.⁵³^–⁶² Demonstrated benefits include the establishing a good surgical strategy, enhancing intraoperative spatial orientation, and increasing the surgeon’s confidence. Our center (the Cleveland Clinic) is investigating novel methods of incorporating surgical navigation systems into the spine realm whereby stereotactic coordinates can be used for the placement of virtual spinal instrumentation. In this manner, both resident and fellow trainees could rehearse different screw trajectories in the cervical, thoracic, and lumbar spine, all the while gaining a greater appreciation of the three-dimensional anatomy involved.