Thanks for the invitation to speak, and thanks to Isabel for organizing this meeting. I'm Rich Byrne. I'll be talking about neurosurgery training in the United States with current structure limitations and future trends. This should fit into the bigger picture of neurosurgery training in the world. I have no industry disclosures. I'm going to be using a lot of terms today, and I've got 15 minutes to go through all this, so I'm going to give you some links to some material if you want to do any further study. The first would be the ACGME webpage. That's the Accreditation Council for Graduate Medical Education. You can find the common program requirements for neurosurgery training and fellowships. Also the Society of Neurological Surgeons, and that's societyns.org, where you can find some of the materials related to the SNS. A few milestones you can find, again, at the ACGME website, and then finally the ABNS, the American Board of Neurological Surgery, that puts out some of the timeline for training. Further terms to understand, the SNS is the Residency Program Directors and Chairmen and Senior Members in American Neurosurgery. The ABMS is the American Board of Medical Specialties, of which the ABNS is a member group since 1940. ACGME, we just reviewed. The RC is the Review Committee that reviews programs. The competencies are the six clinical competencies, patient care, clinical knowledge, professionalism, communication, systems-based practice, and practice-based learning. We'll be referring to those as well. NAS is the Next Accreditation System, starting in 2013. CLER, the Clinical Learning Environment Review Program, CCC, Clinical Competency Committee, and the milestones, which are developmental steps expected to be reached during residency by clinical, technical, and professional subcategory. The ACGME, which sets up the parameters for training in the United States, outlines a few important points. You can read this at your leisure, but a couple of things I wanted to highlight were that they consider it to be developing the skills, knowledge, and attitudes leading to proficiency in all of the domains of clinical competency. And then finally, the concept of graded and progressive responsibility, which is one of the core tenets of American graduate medical education. I'm sure it is everywhere, but the whole idea of getting residents to learn when they're ready to learn. As far as ABNS requirements for neurosurgery training in the United States, the requirement is 84 months of neurosurgical residency training in an ACGME-accredited program under the direction of a neurosurgical program director, which requires some protected time to take care of the residency program. It has to consist of 54 months of core clinical neurosurgery training, including 12 months as chief resident during the last two years, three months of basic neuroscience, and you can choose your pick, in the first 18 months of training, three months of critical care relevant to neurosurgery in the first 18 months of training, a minimum of six months of structured education in general patient care. Again, you can choose what area based on what you think is most important for your residents. Twenty-one months has to be spent in one program, and 30 months of electives, which can come in a variety of different venues. Six to 12 months can be taken in an outside rotation in an ACGME-accredited program, and that can be counted towards the core. Some credit in the elective time, up to 30 months, can be requested by the program director for a prior educational experience, such as a PhD or other clinical rotations, if the resident has completed these. When we think about the core competencies, this is something that Kim Birchall laid out. The synthesis would be the SNS, organized under the Committee on Resident Education. The core committee helps to organize content of resident education. The ACGME, which is the national body, outlines the format. The ABNS delineates what medical knowledge there is, and then sets up written tests, oral tests, maintenance of certification, and other venues to keep track of what medical knowledge a person needs to be board certified. And then the RC, the residency committee, evaluates technical skills and talks about case minimums, et cetera. The ABNS and the RC both deal with medical knowledge and technical skills. Technical skills are in a progression from unsatisfactory, and we're all unsatisfactory when we start, through early learner, competent, proficient, and then finally expert by the time that residents are graduating, hopefully. The case log definitions are listed here. These numbers are constantly changing based on the changing nature of our training and what procedures we think are necessary. Examples that have changed are things like number of open versus coiled aneurysms, carotid artery, endarterectomy versus stenting, angiography. A lot of different things have changed over time as our field has changed. The case log guidelines help residents determine their level of involvement in the case. Now the next accreditation system is something that started a few years ago. This implies that there was a former accreditation system, and there was. The former accreditation system was, I think, fairly burdensome and required a program information form that would be almost 100 pages worth of paperwork to fill out. The next accreditation system replaces that, and it's really looking at a lot of the key parameters that residency programs keep an eye on. We have to provide annual program data regarding the residents, the faculty, major changes, any citations, citation responses, scholarly activity, looking at the curriculum. And then they take a look at the aggregate board pass rate, residents' clinical experience, and the resident survey and faculty survey. There's a semi-annual resident milestone evaluation by the clinical committee in the department, and then a 10-year self-study and self-study site visit. The clear site visits also are a part of this. This is pretty well laid out in an article here by Tom Naska from a few years back for your reference. As far as the clear and self-study, the clear is really more of an institutional evaluation, the self-study more for the residency program. There's a lot of information that has to be filled out. It's essentially just a checkup every year, just making sure that the residency programs have the resources and the curriculum and the staff and the case volumes, the caseloads, that everything is in place for resident education at a checkup annually. The clear study is really more of a detailed study of the institution and the institution's ability to support residency training. When we're talking about milestones, the milestones are really sort of a biopsy at a point in time to find out what can the resident do at that moment, what is the resident's knowledge base. So it's assessing their technical skills, but also assessing their knowledge base and their progression in knowledge in the field. But there's also evaluation for the clinical competencies, and there's a lot of milestones around those clinical competencies and professionalism, communication, et cetera. And the milestones are designed to keep track of learning all the way from pre-medical education all the way through graduate training and into continued medical education once a person has finished their residency. These are all based on the Dreyfus model. I'll give you a reference for that in a few minutes here. And it's organized under the six domains of clinical competency that we've already reviewed. And then finally, there is a holistic evaluation that the clinical competency committee of the department goes through on a twice-a-year basis, incorporating all of this input about an individual resident, looking through the operating room, through the clinic, through professionalism, self-evaluations. Everything comes together and is evaluated by the clinical competency committee. And then there's an assessment of the milestones every six months to see how residents are progressing or, in some instances, even regressing. This is the Dreyfus article that I was referring to. You can take a look at that. But it's essentially just describing the path from novice all the way through expert or master, understanding that it's not always a linear path and that it's helped along by an organized curriculum and oversight, not just by the residency program but by the ACGME. Regarding milestones, again, there is a milestones team, a milestones organization that comes up through the core committee in the Society of Neurological Surgeons. It's been chaired by Nate Seldin for the better part of the last decade. And this is the work group. I've been privileged to be on that work group to see the inner workings of it. We were one of the first subspecialties to put together milestones, both for the first version and the updated version. And we've learned a lot about putting together milestones in the process. And you can take a look here. There's a knowledge-based and then a technical proficiency milestone. As far as the patient care, you can see it progresses from level one through level five, with level four being residency graduate level and level five being fellowship level. And then we talk about how the progression of taking care of cases that are routine through complex to advanced. And there are specific examples of such that are in the addendum at the end of the milestones. And this is a look at some of the general milestones, some of the competency-based milestones that the ACGME gives to all of the various subspecialties to fill out. There's too much to look at here today, but suffice it to say, the ACGME takes the competency-based milestones very seriously. We did revise our milestones in 2007, and then published them in 2017, and then published them in 2018. And this is done in conjunction with the ACGME. But I have to say, they were fairly liberal in letting us create our own milestones that were specific to our own field. And then you'll see there's a nice progression from level one through level five. And we simplified the milestones to make it a little easier to track for residency programs and for the residents themselves to understand their own progression. Backing up the milestones in the national curriculum is the SNS Resident Courses. The SNS Resident Courses started about 12 years ago. They started as regional courses and then came together under the SNS. I have to credit Nate Seldin and Tom Ricciutano for bringing those together. Bob Dempsey was the president of the SNS when that was signed. So it was really a visionary idea to bring residents together at courses throughout the United States, supported with industry partners, but the curriculum entirely put together by the SNS. To help residency programs do some of the simulations that are becoming necessary in our field and that the ACGME encourages. So some of the simulations are technical-based and some are professionalism, competency, communication-based. They're really, I think, a strong effort to bring our society together and our field together to standardize some of the curriculum and support the residency program and program directors. A longer-standing SNS course is the RUN course. The RUN course is all about, it's a research update for neurosurgeons, and it's really about basic science and those who are planning on tracking on a research career, an academic path. About half the residents in the United States per year come to this course when they're, say, mid-level residents. The course runs about five days in Massachusetts. It's an outstanding course supported by a lot of the research leaders in our field. So that's a wrap-up for the way we structure residency training in the United States. I understand it's a little confusing because there are national bodies and then there's societies and then there's our board, and they all come together along with the residency review committee to put together the curriculum, the timeline, the expectations of training, and then keep it organized all under one umbrella. So if you have any questions, I'll be happy to answer them. You can reach me via the AANS after the course. Thank you.

neurosurgery training

ACGME

residency training

milestones

SNS Resident Courses