Postgraduate Training in Neurosurgery—A UK Perspective
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.293473
Source of Support: None, Conflict of Interest: None
We read with great interest Garg et al.'s article on neurosurgery training in India. We congratulate them on their attempt to gather trainee feedback on a national level. Clinical governance and standardization require centers to undertake such training audits and questionnaires on a regular basis in Western countries. Garg's article is possibly the first of its kind in providing feedback on neurosurgical training in India. Modern neurosurgery education in India is relatively new compared to the Western world. It has progressed rapidly and is well-established with a structured pattern.
The authors have analyzed teaching pattern, subspecialty exposure, examination pattern, surgical training, and medium of learning in their well-written article. They have highlighted several positive points in neurosurgical training. Preoperative discussions were the most relevant form of teaching (89%), while journal presentations were the least preferred among residents. The current pattern of Exit exams (62–88%) and teaching (53–89%) have good relevance and acceptance among training graduates. The operative exam, although quite popular, is practiced in very few centers across the country., As apt for the 21st-century trainees prefer electronic media (e-books and e-journals) as their source of reference and learning (60–81%).
Few of the less accepted aspects of training are the fields of image interpretation, operative teaching, hands-on opportunity of residents, and speciality exposure. Only 37% of trainees felt that training on image interpretation was good/excellent. Subspecialty exposure was considered inadequate by most respondents, but for exposure to radiosurgery. Considering the length of training in India, it would be challenging to get vast exposure to several specialities in a short period of training. The volume of exposure would also depend upon the training institute, whether government or private.
As a surgical resident, one of the most important aspects of training is the surgical skills they develop through the period. The authors from their study quote that 55% of the respondents felt that operative training was Good or Excellent, while only 42% felt that were provided with adequate hands-on exposure to neurosurgical cases. If this is the scenario in few of the country's best government medical schools, the residency programs by the National Board of Examinations in the private sector have already acknowledged limitations in resident opportunities for actual “cutting and stitching” although there is plenty of clinical material and modern equipment. This is a serious concern with regard to the competence of graduating residents safely performing independent procedures.
The corresponding author completed his neurosurgical training in one of the premier institutes of India and relocated to the UK for further training and certification as a consultant neurosurgeon. Having seen the best of both systems, we recommend some simple, non-bureaucratic measures that can be implemented in India. These can have significant impacts on the quality of surgical training.
The United Kingdom has a very comprehensive system of assessing surgical competency over their training period. Their accreditation board proposes the candidate should have completed 1200 cases (including 70 pediatric) over an 8-year duration, with 2/3rd performed independently or under the supervision of a trainer. It also defines 50 index cases across specialties that have to be performed as a primary surgeon.
Candidates who do not fulfill this cannot appear for the examination. Following successful completion of the examination, one has to register onto the specialist register which satisfies criteria in clinical experience, operative experience and competence, research, quality improvement, medical education and training, management, leadership, and participation in conferences. This sets high standards in surgical competency and expertise, improving patient safety and outcome.
In India, the governing body for neurosurgical education does have a very comprehensive curriculum for postgraduate training. It recommends a minimum of 400 cases during the training program spanning either three years or six years, with at least 10% (40 cases) performed independently. It recommends a minimum of 10 craniotomies to complete neurosurgical training. Further, there is no reference to the concept of index cases during training. It is probably time to look into these numbers with more detail, in a country with a population of a billion people. A finishing surgical resident should be “competent” at a minimum and preferably “proficient” in essential procedures.
A surgical logbook that is maintained and validated by trainers will enable us to ensure a higher quality of training in surgical specialities, especially neurosurgery. Monitoring the type of case is considered one way to ensure a general level of experience and growing competence before beginning post-residency practice. It provides an objective performance of residents and medical schools with evidence that the level of operative participation is significant in technical skills development. The e-logbook (www.elogbook.org) is an initiative by the Royal Colleges in the United Kingdom with support and guidance from national surgical societies like the Society of British Neurological Surgeons to record and monitor the training of its residents and build a surgical portfolio helping them through appraisals, revalidations, and recertifications. It is a free resource that can be used by practicing surgeons across the globe. Each procedure is tagged with the level of involvement of the trainee and also breaks down each step of the surgery to record participation in operative stages [Figure 1]. A comprehensive report at the end of residency can help evaluate one's strengths and weaknesses and guide further improvement [Figure 2].
Implementation of such systems will strengthen our already sound curriculum in neurosurgery education. The Neurological Society of India (NSI) can lead this initiative in India by encouraging its fellow members and trainees to use these systems and also perhaps develop a national portal in lines with the e-logbook initiative to monitor and accredit neurosurgical trainees. The need of the hour in training centers is to inculcate the western concept of “surgical minimums” or a compulsory operative log for each level of the resident training. This would ensure that each trainee has performed a basic requisite of essential procedures both under the supervision and with reasonable independence. This would also help us validate our surgical training programmers with the west.
Simulator-based training, cadaveric labs, and surgical workshops are other feedback-based systems that can advance surgical skill development. Simulation permits trainees to acquire key skills in a controlled environment, essential in a specialty such as neurosurgery where technical error can result in devastating consequences. Rapid progress in technologies such as virtual reality and artificial intelligence have made these systems as realistic as possible. The most significant barrier to implement simulator-based training in India would be the high cost of installation and maintenance. An excellent alternative to this would be to setup cadaveric labs and organize regular workshops as a part of the training curriculum. The Neurosurgery Skills Training Facility and Experimental Laboratory set up at AIIMS have succeeded in this endeavor by offering short- and long-term microneurosurgical fellowships for training young neurosurgeons.
To conclude, postgraduate surgical training in India although being advanced and competitive, needs quantitative and qualitative enhancement with consideration of certification. It will help us provide the society with competent neurosurgeons trained to perform basic minimums with reasonable confidence, expertise, and minimal complications in an independent setting.
A good surgeon doesn't just concentrate on technical ability but also on the appropriateness of what you're doing.
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[Figure 1], [Figure 2]