All right, we're going to move on with the rest of the program. So, as the next speaker, we're going to have Peripheral Nerve Service Education Ratio by Dr. Spinner-Fameo. Well, thanks. It's great to be here. Let's see. Is this? Okay. So, my disclosure, this is a non-data-driven, non-hypothesis-driven talk, so this is really perspective and philosophy on education and related to peripheral nerve. My perspective, I finished Dr. Klein's program, I passed my boards, and there were no approved fellowships. Fortunately, I had a busy practice, so we started one, so what I'm going to talk about is related to a peripheral nerve program and the fellowship that we started and we became cast-accredited over 10 years ago and fortunate to have many of the fellows, clinical fellows in the audience, of whom I'm very proud and probably the biggest accomplishment I'll have in peripheral nerve is them. We became re-accredited a handful of years ago, and that was a pain. It's a lot of work and a lot of time, and I'm not sure really what it's all worth, to be honest, but there's a stamp. There's no certificate, as many people know. Over the years, I've only done post-graduate external fellows. Dr. Puffer's in the audience. I had to go back to CAS to get it then approved again for infolded tendency. Fortunately, at Mayo, we went through a lottery and we won and we had to apply, but it's paid and regulated, so the same work hours and everything are for my external fellow as they are for the residency. We also, so over the years, I think the first one was Ziv Williams, whom I'm very proud of doing great things at MGH. I've had several one-to-six-month visiting clinicians and observers, and they're unpaid and they don't get the Mayo certificate. Theoretically, they could get CAS approval, again, for six months, but it's problematic because then if you have two, you have to get overstaffing, and again, it's lots of hurdles and I'm not sure the CAS stamp gives you much. So my perspective, the world of neurosurgery, you get emails every day about talks across the world talking about neurosurgery and cranial and tumor, skull base, vascular epilepsy, functional spine. I usually delete by then because there is no peripheral nerve, but it's an international neurosurgical conference, and that's what people are promoting is education in neurosurgery. So the world of neurosurgery really is an island, right, and it's a lonely island. No man is an island except for Dr. Klein. So this is our island of neurosurgery, and it's a small island. It's not an archipelago, but that's where many of us have chosen to live, and there's one palm tree. I think the perspective is the joint sections. I think many of us go here and we're the small mouse, not the big elephant, and there's more spine than peripheral nerve. In fact, for the people up here who fight to get us two talks versus their 500, you feel the weight of being a small island in the world of peripheral nerve education, and that's unfortunate. And even their name, it's so divorced of reality that it's unfortunate because it really is a spine conference, but we need to stay with that because spine has the money. So I really think the problem is peripheral nerve, and it's a vicious cycle. There are few people interested. We compete with other fields. There are few centers of excellence, so you have a siphon. So then we have problems with teaching knowledge, gaining knowledge, and then having competency and milestones, and that then feeds into the fact that few people learn it, few people can teach it, few people do it. A few years ago, I want to credit Alan Maneker, who's kind of one of our peers, who wrote a nice paper in 2003 in the White Journal about the problems and perspectives of peripheral nerve, and then Ed Laws wrote this nice editorial in the journal sort of talking about everything we're going to talk about, which is the problems inherent in peripheral nerve surgery despite its rich heritage. So realistically, why do we most commonly teach peripheral nerve? And it's because of board exams. Whether or not it's written exams or oral exams, that's why people learn peripheral nerve. It has nothing to do with patient care. It has nothing to do with innate learning research. It has to do with the fact that the written boards have 20 questions, and you can make or break your P value by learning the peripheral nerve, which are gimme's. So I think it's a very reassuring thing. I'm a little bit disappointed that the oral boards have gone away from having to learn some peripheral nerve because now it's more topic-generated. So the island of peripheral nerve, we need to expose people to it because in addition to the one tropical tree, there are other nice features of this island, and I would welcome you aboard. So I would say we need to have a paradigm shift. We need to educate others about peripheral nerve, that it is an important part of a curriculum. It is an important of training. It is an important part of the practice. It is a basis of everything we do as neurosurgeons. Neurosurgery starts and ends with a peripheral nerve, period. So the physical exam, which we were talking about with Dr. Klein, starts and ends with everything we do. So I would say that the peripheral nerve exam is as important as any part of anything else that make the big plenaries. So in baseball, we all play left field, right, when you're growing up. I feel like we're playing left out, okay? So it's an important part of our heritage, but it's an important part of our future, and that's our role. So what has the RRC done? Well, they instituted minimums. Not maximums, but minimums. So is having a minimum a good thing? And the answer is sure. Our target is 10 cases. Not very much. So in 10 cases, is that competency? Is that milestone base? So where did that number come from? So is 10 achievable? And the answer is yes. So if you look at data from the RRC, you can see these are from all the programs. So the range is 9 to 129. So almost everyone made it recently. The median is 22. And you can see the types and varieties of peripheral nerve cases, et cetera. But that's the make-up. And then you can look in the literature in Canada, and they had 48 cases, similar types of RRC data with peripheral nerve. Okay. I looked at my data. Unlike many other programs that are sort of top-heavy or chair-driven, my residents get the same. But they get less of my specialty than others. So you spend three months with me. It's split because we have a mentored model. So they're working for two different staff. So they get the equivalent of 12 weeks part-time with me. And that's when they accrue 70 cases. I have the fellow we talked about. At the same time, I have a concomitant resident. So I have four residents per year. Three are from Mayo Rochester, and one is from the Mayo Jacksonville program. My priority is to the resident. Resident gets first dib on the case, and then it goes upstream. Okay. So I've had a very talented resident. The fellow moped the whole quarter. Very talented resident. He did the brachial plexus surgery. He read, he studied, he prepared. And that's how we did it. So is 10 cases achievable? Yes. It's prioritized. People go into other rooms at other programs. They count several nerve biopsies. They do all sorts of things. And they're creative. They go spend some time with the hand surgeons to get the carpal tunnels. Is this education? I would say not. So if you look at the interpretation of the data versus reality, there's a broad range. Few programs now fall short because we've lowered the bar. Many programs are creatively reaching or cheating to get the minimums. You don't want to get a red mark. So is 10 the right number? And I would say no. This is a Band-Aid. You have to put it on there. So you create a number. It's a bit artificial. And then you have 10 cases. So what's the right number? Is 10 the right number? I'd say it's too low. And also, it's really not about the numbers. I mean, are we saying that you're competent in peripheral nerve because you did eight serral nerves and you saw three carpal tunnels? I would say that you'd be much better off seeing a post-ganglionic brachial plexus where you did 12 other exposures and harvested serral nerves and used the microscope, et cetera. And then you have augmentation. So whether it's 3D printing or cadaver-based learning, simulation, et cetera, these need to augment, not replace the learning. The patient still needs to be the center of our education. So what's the real target? Well, if you're talking about knowledge and competency, I would say you need a fairly advanced knowledge about what we talked about, what Eric talked about, entrapment, injury, tumor, pain. And then if you get back to the basics of why people are in neurosurgery, it's knowing how to diagnose, knowing how to differentiate this from that. So getting back to the basics for the boards, what's the differential of a foot drop and why is it a perineal versus an L5 and why is it an upper motor neuron lesion? And everyone gets that wrong when they're in the hot seat at Goodman. And that's as basics as ABC. So know what you can treat. Know when to refer. I think that would be a really good reason to learn peripheral nerve. And then as far as competency in the OR, I would say basic operative training. So beyond the seral nerve biopsy. But now if you think about entrapment, I would say you need to know a carpal tunnel, cubital tunnel, perineal nerve. Maybe neuralgia parasthetica, maybe, period. You're not going to be doing suprascapular nerves. You're not going to be doing radial tunnel. And I hope you're not doing lower trunk decompressions or rib resections. For injuries, I think you need to know how to fix a nerve in the ER that comes through the ER and take them upstairs. You need to know when to do a nerve graft first, put it under undue tension. Tumors, I think you need to know what is probably a schwannoma and how to take out a schwannoma if you're in a desert island. And pain, you probably need to know a little bit about neurectomies, period. Everything else, I think you need to know how to call a friend. So I think the solution is very easy. And it's in our hands. We need to own it. So we need to make peripheral nerve sexy, just like the skull base approaches. We need to liven it up. Keynote addresses shouldn't be reports and basic discussions. I mean, they should be what's new. If you're on a plenary talk, it should be exciting towards the masses, not just to review what's already been done. So I think you need to educate frequently and widely. We need to include and involve our learners. So we don't scut them and we don't pimp them on every obscure peripheral nerve thing unless you're really doing it with a smile. We need to excite them. We need to share our passion. And we need to teach them that competing is good. Because otherwise, we're going to lose out on this part of nerve practice, just like we're competing with other people. But there, we're not giving in. We're not giving away the aneurysms. People are getting dual trained. So I would say the island of peripheral nerve is a paradise. So this is Koh Samui in Thailand. And you can see there are a lot of chairs here. So now the chairs are growing and there are more people doing peripheral nerve. And I think that's part of the success. And I think what's exciting? I think everything. I think this is the one field, really, where we can put anatomy, like Kim does so nicely, as an answer for so many things that we do. I think nerve transfers are new. I think everything about nerves transfers is exciting, whether it's the anatomy behind it, what you're finding is expendable, how to be creative, and putting them to new uses, not just nerve injuries, but applying them to, like we were talking yesterday, to more common things, like C5 palsies after spine surgery, or whether or not it's a good thing for an inflammatory neuropathy. New technology. You know, you're investing in people. That's the fellows. And you're investing in technology. We're very happy. We have a 7-Tesla magnet now, the first clinically available one in North America. We're going to be able to see what's invisible. So again, with the tumor stuff, I mean, we're really going to be able to understand things at a new level. Basic research, nerve regeneration, we talked about conduits. I would say, practically speaking, why and what's new and what's exciting. For people who may not want to be academic, this is a niche practice. You go into, you know, a commercial practice, you go into a private practice, and you know peripheral nerve, you're going to be good for the competition. But certainly, if you want to do academics, the field is wide open. Research is wide open. So a few years ago, I said about brachial plexus that this was an orphan drug whose time has come. That's where we are. We're an island. Do we want to stay an island? Do we want to stay an orphan drug? I say no. Thanks.

peripheral nerve education

challenges

centers of excellence

board exams

competency in peripheral nerve