Chapter 208 Education of the Spine Surgeon
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.
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 project15:
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.
