I'm going to speak just for about 15 minutes on certification. So you're all in the middle of a seven-year residency program, and what I'm going to do is just give you an overview of the certification process. You're all familiar with the written exam that you do, which must be passed for credit by the time that you finish your residency program, or else you don't graduate, as you know. And so what I'm going to show you is I used to run the oral exam, I ran it for six years at the American Board, and you'll be sitting for your oral exam within about four years of completion of your residency. And that's the final process and the final milestone towards certification. And so what I'm going to do is I'm going to give you a set of slides as to how we run the oral exam and how we tell guest examiners to behave during the exam. So this is sort of an insider's view of how we execute the exam and what we expect out of the candidates, okay? And so all of you will have completed a seven-year residency program. You've passed the written exam to complete your residency. You submit your application, and you're scheduled within five years. This is going to go to four years, I think. And then 150 cases of operative data are reviewed. And you're going to give basically 150 cases. We used to do it a year of cases, but we found such variability in the experience of some candidates that we felt 150 cases we needed to be able to review the quality of the data. And then you may get people asking questions to clarify some of the outcomes on those patients. We also audit now the data review with your hospital on a percentage of cases just to make sure that people are including all of their cases in there and not excluding any particular cases. And then you submit letters of recommendation, evidence of licensure, and then current hospital appointments. So the examination is three hours long. And we changed the exam during the time that I ran. It used to be divided into cranial cases, spinal cases, and then other. But what we do now is we treat the exam just like anybody going to an emergency room, is that you don't know where the pathology is located a priori before you see the patient. So we mix them all up. But then we extract the subspecialty areas out in the evaluation process at the end by looking at the grading of the different cases within each of the hours. So these are the topics that are covered, all of neurosurgery that you're all familiar with, that you're all training in right now. And in each of the hours, there's two examiners. There's a board member, and then there's a guest examiner. And the guest examiners are usually people that are senior people that are well-established in the community or they're program directors, but not board members. So they're all fairly experienced people. So we ask the candidates to introduce themselves. And then we don't try to trick anybody with the exam. It's a straightforward exam. We want to make sure. We want to really evaluate what you know. And it's amazing with experienced examiners how we can determine exactly what you know. So we don't ask where the candidate works or trains. We don't give any verbal feedback as to how the candidate is doing. We don't lead them in any way. And we don't let them flounder. If they're having trouble, we move on, because it's to the candidate's benefit if we get through more questions and more vignettes during the hour. And we don't ask trick questions, or we don't ask for didactic material. What we're trying to determine is if you're safe, and we want to know how you're going to manage the patient. We also understand there's lots of different ways to treat a patient. And we understand we're open-minded as to different avenues of treatment or different ways of doing this operation. But we really just want to know what you would do. So what we do is we simulate actual clinical encounters in the ER, in the office, et cetera. And then the candidates can actively participate so that you can ask, well, did you do a CBC? What do the white counts show, et cetera? It's a dialogue back and forth. And the candidates are expected to provide rationale for their decision-making process. So what we do is this is a typical vignette. And we'll do six or seven of these, usually, during the hour. So each one lasts about 9 or 10 minutes. We try to get through as many as possible, because if somebody bombs on one of them, it's to their advantage that we get through more, statistically. So we'll give you the presentation of the patient. I'll give you an example of a case. We look at test results and image. We ask you to create a differential diagnosis that's reasonable. And then we want you to go ahead and manage the patient. If the patient requires surgery, we'll ask you details about the surgical procedure, the planning. And then we'll give you a complication, usually, that you'll have to manage. It could be intraoperative. It could be perioperative complication. It could be a postoperative complication in the ICU, for instance. And then also, we'll ask you to do the post-op management. If the patient doesn't need a surgery, then we'll ask you the natural history of that disease. Say it's an MS plaque, and you've decided you don't want to operate on it, but you want to treat the patient, then we're going to ask you, how would you treat the patient, and what's the natural history of the disease? And that's important, because the grade's given based on that as well. So again, we ask a minimum of six questions per hour. We move on if they're floundering. And we focus on judgment, and we're open to alternative solutions. And it's a comprehensive exam. So even if you're a pediatric neurosurgeon, we expect you, for this exam, to understand the concepts and basics around peripheral nerve, et cetera. So this is how the exam is graded. We give you three separate grades for each of these tasks. Diagnosis, creating a good differential and coming to the correct diagnosis. Management of the patient, we give double weighting for this grade. And then complications, so we give you a complication to manage. Now if we don't operate on the patient, then we expect we give a grade based on the natural history of the disorder and the outcome of the disorder. It's a five-point grading scale, quite intuitive, something we've all grown up with. A, B, C, D, F. And these are all the verbal descriptions of the, but basically we want people to achieve a three or better, a C or better, across the exam. So each hour is graded, and we develop a composite grade. So each vignette is graded specifically. And then at the end of the hour, we derive a composite grade, which is what are basically, it's a overall assessment of the candidate based on each of those three tasks. And then are there safety issues? This is probably the biggest one that we deal with, because we have some people that have had a terrible vignette and have a terrible outcome, and then we have a lot of discussion about whether that's a fatal flaw or not. So it depends on, the exam is actually graded by the psychometricians ultimately in the past point is determined by a psychometric analysis. And it's important to understand that they have a long history of the people who are continuous test givers like me. They know exactly how severe I am with my grading. So what happens is, is that all of the examiners are evaluated as to the severity of the grading. So ultimately, the past point is determined based on the severity of the question, the severity of the examiner, and it's normalized. And then the past point is given to us a couple weeks after the exam, and then we determine where the passing grade is, and who passes and who fails. So these are the three subject areas that are gleaned from all the three hours. And we develop a grade for cranial, a grade for spine, and a grade for this critical care and other, which includes neurology, functional pediatrics, and peripheral nerve, if it wasn't included in the spine. And we now made a requirement that we expect this is a comprehensive test, and we expect all of the candidates to pass all three of these different areas. So what we do is we have a discussion period after the exam is given. And there's people that are clearly pass, people that are going to pass well, and there's people that are clearly going to fail. And the people on the bubble are the ones that we discuss. And we then go through the questions and answers and understand why a candidate did poorly. And then there's an opportunity for the board director to be able to change the grade of the guest examiner if we thought it was an unfair grade. So we'd go ahead and discuss it, and then we basically throw it to the psychometricians at this point, and then they determine where the pass point is. There's no vote on pass, fail, and then the computer analysis determines the pass, fail standard subject to board review about two weeks after the exam process. And again, this is adjusted for the severity of the examiner, the question severity, and the task severity. There's one other thing that I want to mention. And we put this form on the grading form, this question on the grading. Are there safety concerns? Because if we feel that a candidate is unsafe, we can actually bring this up, and this will weigh into the grading. And this may decrease if somebody's on the bubble. We may use that as a determination of whether we think that they should pass or fail. So I want you to know that this is the overarching principle for this entire exam is, is this candidate safe? Are they making a reasonable judgment and proceeding with reasonable treatment? So I'll just give you a two-minute example of a case that could be presented. This is not a standard case. About half the examination now is standard cases, but this is not one of them. So this is one of my old cases that I gave many years ago. But here's a woman with who's been insulin-dependent diabetic for 30 years, hypertension, and she has hearing loss and anxiety. And she presents, and she's on glucophage, and you can see all the meds that she's on. And on examination, this is what she looks like. And obviously, there's coarse features here. And a good candidate would clearly recognize that this is an acromegaly patient. So we don't expect a medical student differential diagnosis for this. We expect people to be practical and say, this patient has acromegaly. She's got diabetes, and she's got heart problems as well. And so they expect them to go ahead and order an MRI. And you can see her hands compared to one of our residents here. And here's her MRI, which demonstrates a pituitary tumor, a little bit of enlargement here. And you can see the tumor right here. And then we'd expect them to do an endocrine evaluation, know what tests to order, and the results show here that the growth hormone is elevated, IGF-1 is elevated. And then they go ahead with appropriate treatment, which would be surgical treatment as the initial treatment. And then we may give them a complication intraoperatively to manage, and then expect a post-operative. And we may give them that they didn't cure the patient with surgery alone, so what would be other adjuvant treatments that you would consider for this patient? So that's an example of the types of cases that would be presented. So I just wanted to mention the Goodman Oral Board Prep course, which is put on by Alan Levy. He's done a fantastic job over the years at putting this course together. But what they do is they do a very similar case-based simulation of the examination across a broad range of topics in all those areas that I mentioned. And I think it works out that every candidate going through the examination actually goes to at least one of those courses. And so it's routine now for everybody to do that, and it's been terrific. And we can really tell people when they've been prepared properly. And the course is given twice a year, usually the week before the oral exam in Houston, Texas. These are the dates for the next ones. And so my last topic I would like to talk about is just MOC. And this is maintenance of certification. So you get your primary certification, and then you, all of you in the audience, are going to have to maintain that on an annual basis. Now this is a moving target. When I was certified back in the early 90s, and when Rich and Jim, we're all grandfathered in. We have lifetime certificates. I'm actually in MOC. I do it voluntarily. But all of you are going to have time-limited certificates. And it's a moving target. And I'm going to show you where we're at as a snapshot today, and where it's likely going to go over the next few years. And I was, I asked Vince Tranellis for these, because he's the chair of the MOC committee at the AB&S, the board. And he gave me the slides that he presented at their most recent retreat about it. And so these are the number of diplomats that are participating in MOC, just over 2,000. And you can see a few of us are doing voluntary recertification. And everybody who is certified since 1999 is required to be enrolled in MOC. And we expect MOC will equate to MOL, maintenance of licensure, in states within the ensuing few years as well. So this is tracked on the AB&S website, MOC login here. And it's getting a lot of airplay. AB&S is now really promoting it in all specialties. And some specialties are much more rigorous than ours right now. My wife's actually a pediatrician, and she has to do it every year now. So the primary aims for AB&S MOC is to reduce medical errors and improve practice performance with patient outcomes through a process of continuous professional improvement. So that's their mission. The new MOC standards are ensuing. And these are the four standards that we've been currently working under. There's four categories of MOC. One is professionalism, two, lifelong learning, three, knowledge assessment by way of a test, and four, improvement in medical practice. And the big changes are in part four. In addition, there's an overlay now of two general standards. GS1, and you in the room are all familiar with these, because this is your six core competencies that are part of the milestones that you're living with right now. So these are now being overlaid on MOC. And GS2, general standard two, increased value with MOC program monitoring. So the part one is fairly straightforward and rudimentary. It's basically evidence of professionalism, professional standing, so that you're a good citizen, that you've still got credentialing in your hospital, et cetera. Part two is lifelong learning and self-assessment. And these are, the goal is to establish requirements and document that diplomates are meeting learning and self-assessment requirements, and integrate patient safety principles into MOC programs. So this is where it's going. There's four mechanisms for complying with part two right now. That's like using the SANS, and you'll see when you log onto the website, when you're in practice, you can go ahead and take the SANS with no charge for MOC. And then there's MOC review course given both by the Congress and also by the NNS. And then we're just actually starting, Bob Harbaugh and I and Mitch Berger, a NNS review, a yearly review book that will be an ongoing iterative update every year that you can participate with MOC. Part three is basically the assessment of knowledge, which is classically the test. And it's an ongoing examination. It's given once every 10 years, but probably will become more frequently. It may become every three years. In some specialties, it's ongoing every year. Basically the problem that we have right now, the test is done yearly, and it's usually given in academic centers. We give it to the neurosurgeons in Utah, for instance, in our office every March, the same day that you take your written exam when you're a resident. And the proposal is to start taking the test from home and making it more relevant to the education materials that are designed to prepare the candidate for this. So for instance, with the Goodman Oral Board course, it simulates beautifully the real test. But there's a disconnect between the SANS and the review course and the test, and we're going to try and coordinate that a little bit better so that it'll make it more practical and more relevant. And then we'll propose taking the test from home, no proctor, increase in time allowed. And so that's in progress and will change definitely by the time that you get involved with this process. And then part four is the big one where it's in evolution right now. This is one that's a little hard to grasp, but basically the idea is to incorporate an ongoing practice assessment and improvement into the MOC program. And so the way it's been currently done is every person involved in MOC puts 10 key cases in. So say you're an epilepsy surgeon, you can use temporal lobectomy and use that as a key case. And then what you can do is you take 10 consecutive key cases and compare them to the rest of the individuals using that key case nationally, and you can see how your results compare nationally with your peers. We're going to make it be made a little more rigorous because we felt it was really a nominal effort initially, the key cases. We understood that. But it's going to have more teeth, and the idea is that it's going to be an expanded part four. It'll be much more ongoing daily use for you by the time you're in practice. So the idea is that we want to use some of the existing reporting mechanisms that we're doing. So we're looking for ways of people involving, for instance, with N2QO2 that you heard about is whether they could use part of that data for their ongoing MOC part four. The standards emphasize relevance to neurosurgical practice, specific quality improvement aims, and cooperative learning, and analysis of data from practice by using registry data. So we're thinking about having an essentials module, for instance, where it would be a boiled down limited database registry project that you put in almost half of your cases over time, and we'd monitor the outcomes for that at the board level. So these are these multi-institutional registry programs, quality improvement projects. And so we're thinking about a portfolio of different options to qualify for part four that people could participate in. Manuscript development, practice improvement modules, et cetera. So this is all in flux and will be definitely changed over the next few years. The idea that NPA, which is NeuroPoint Alliance, will serve as a primary portfolio sponsor and data management partner, and you'd collect all your registry data and all your quality improvement projects on the database, and then it would be monitored by the ABNS on an ongoing basis.

neurosurgeon certification

oral exam

residency program

MOC program

patient management

practice assessment