Keywords
neurosurgical residency - residency training program - fellowship - subspecialty training
Introduction
Neurosurgical residency programs worldwide have a unique burden of training future neurosurgeons who must adopt training methods to ever-evolving and advancing practices in the field while simultaneously delivering quality care to their patients. Dr. Jacob Chandy started the first neurosurgical department in India at Christian Medical College in 1949, and a formal residency training program was started there in 1958.[1] Dr. Raja Martanda Varma began the Department of Neurosurgery at the All India Institute of Mental Health (AIIMH), Bangalore, in 1958. Later, the National Institute of Mental Health and Neurosciences (NIMHANS) was formed following the amalgamation of the Mysore Government Mental Hospital and the AIIMH and was inaugurated on February 14, 1975.[2] Under the guidance of Dr. R.M. Varma and Dr. G.N. Narayana Reddy, the Magister Chirurgiae (MCh) course for neurosurgery residency was started in 1971. To date, over 200 students have graduated from the institute in neurosurgery. The institute offers both 5-year post-MBBS course and 3-year post-MS course in neurosurgery. The residency training program has been the same over the years with minor changes incorporated over the years.
With the emergence of new subspecialties and newer advances in treatment, neurosurgery as a specialty is rapidly evolving. The residency program must incorporate these changes and train the residents to shape them into confident neurosurgeons to start their careers. Hence, it is necessary to evaluate the residency program periodically to uphold the quality and adequacy of training in line with the current trends. Young neurosurgeons are prejudiced to pursue additional fellowships, often in many subspecialties. The rationale for the same could be many, including advancement in knowledge, better job prospects, academic prestige, and inadequate training during residency.[3] Spine, pediatrics, and cerebrovascular are the popular subspecialty programs among academic neurosurgeons in the United States.[4]
After finishing their training, a neurosurgeon with a few years of experience can assess the demands of current practice and effectively identify the importance of different aspects of residency training. In this study, we evaluate the perception of graduated neurosurgeons from NIMHANS regarding their residency program they went through, subspecialty exposure, and any feedback to improve the program at NIMHANS. We conducted an online questionnaire-based survey of the institute's alumni to evaluate the residency program's present needs.
Methods
An online questionnaire was designed using the application Google Forms ([Supplementary Material], available in the online version). The questionnaire covered basic details of their practice setting, satisfaction levels of training, the relevance of various aspects of residency program in their practice, and exposure to multiple subspecialties. Respondents' perceptions were graded on a 10-point Likert scale, wherever applicable. The respondents were asked to grade various aspects of training on clinical evaluation, radiology interpretation, surgical anatomy, operative exposure, hands-on experience, follow-up assessments, and multidisciplinary interactions. A score of ≥7 was considered satisfactory and a score of ≤6 was considered subpar. The respondents were also asked if they pursued fellowships after residency and the rationale behind it. They were asked to provide feedback/suggestions to improve the current residency program. The link was forwarded to the alumni of the institute from 2003 to 2021 batches. The batches of the last two decades were selected as they would know the recent trend of residency programs and clinical practice. Results were analyzed after responses were collected and tabulated. Group comparisons for continuously distributed data were made via the independent sample “t”-test when two groups were compared. The chi-squared test was used for group comparisons of categorical data. Statistical significance was set at a p-value of less than 0.05.
Results
One hundred and two responses were received from the 120 alumni the questionnaire was sent to (85% response rate). The mean age of the respondents was 40.38 ± 5.17 years. A total of 55.9% of the respondents completed post-MS and 44.1% completed post-MBBS residency courses. Among the respondents, 60.8% had continued as chief residents in the department for an entire year after their graduation.
At the time of this survey, most respondents (90.2%) practiced in India, while the rest practiced in different countries. While 43 (42.2%) of the respondents practiced in tier-1 metropolitan cities, a similar proportion (48%) practiced in tier-2/3 cities. Two-thirds (66.6%) of the respondents were doing private practice, 30.4% were working in an academic institute run by the central or state government, and two were pursuing fellowships in the United States and Canada at the time of the survey ([Fig. 1]).
Fig. 1 Chart showing the current practice setting of the respondents. Others, those pursuing fellowships at the time of survey.
Satisfaction Levels to Various Aspects of Training Program
Ninety-four respondents (92.2%) were satisfied with the overall residency training they received at the institute (score of ≥7). The respondents were asked to rate the relevance of various aspects of the training program in day-to-day practice and their satisfaction levels. The median scores are represented in [Fig. 2]. Clinical history taking and neurological examination are essential for residency training and help in appropriate decision-making. Preoperative planning and radiology interpretation are paramount for every case. A total of 90.2% of the respondents agreed that clinical evaluation is relevant, and 100% agreed that training in radiology interpretation is appropriate in daily practice. Notably, 95.1 and 97.1% of respondents were satisfied with the training received in the above aspects, respectively. About 79.4% of the respondents were satisfied with the teaching of surgical anatomy during their course. Most respondents (92.2%) were satisfied with the surgical exposure they received during the training, and 88.2% were happy with the hands-on experience they gained. The residents are rotated between emergency and elective services in different units during the course. This maximizes surgical exposure to various cases and provides ample learning opportunities.
Fig. 2 Chart showing the relevance of various aspects of training in everyday practice and its perceived satisfaction level. The median scores graded on a Likert scale from least to most (0 to 10).
Assessment of patients' postsurgery and follow-ups is essential to clinical practice. Most respondents (95.1%) reported that these aspects were relevant to their practice. However, 13.7% were unsatisfied with the quality of follow-up assessments, and 11.8% were unsatisfied with multidisciplinary interactions during their residency. Part of this could be explained by the department's practice, where the faculty assess all the follow-ups. It may be crucial to involve residents in this aspect.
Exposure to Various Subspecialties
The respondents graded the surgical exposure to various subspecialties during their training period, represented in [Fig. 3]. The majority of respondents (89.2%) agreed that the exposure to trauma and emergency care was most adequate (score of ≥9). Exposure to neuro-oncology, cerebrovascular, and open skull base was deemed sufficient (score of ≥7) by 91.1, 87.2, and 78.4%, respectively. Although a significant proportion of the cases encountered in daily clinical practice are trauma and spine, it was alarming to note that 57.8% of the respondents rated spine exposure to be subpar (score of ≤6). Despite having many cases undergoing functional surgery and radiosurgery, only 34.3 and 50.9% of the respondents found the training in these subspecialties, respectively, to be adequate. Exposure to endovascular surgery was described as uniformly poor by all respondents, as neuroradiologists solely carry out endovascular interventions.
Fig. 3 Chart showing the relative exposure of various subspecialties during residency.
On analyzing the responses based on their graduating years, 2003 to 2012 versus 2013 to 2021, there was no significant difference between the groups in terms of satisfaction levels on various aspects of training. However, the mean scores for exposure to subspecialties like neuro-oncology, cerebrovascular, open and endoscopic skull base, and functional neurosurgery were higher in the 2013 to 2021 group. This indicates that the training program has evolved in these aspects with time. The rest of the parameters are outlined in [Table 1].
Table 1
Breakup of responses based on graduating year 2003 to 2012 versus 2013 to 2021 to assess the trend
|
Parameter
|
2003–2012 graduating year
|
2013–2021 graduating year
|
p-value
|
|
No. of respondents, n (%)
|
48 (47.1)
|
54 (52.9)
|
|
|
Satisfaction levels of training on various aspects
|
|
Clinical evaluation
|
9.00 ± 1.29
|
9.33 ± 1.03
|
0.155
|
|
Radiology interpretation
|
9.13 ± 1.12
|
9.02 ± 1.37
|
0.667
|
|
Surgical anatomy
|
7.58 ± 1.56
|
8.11 ± 1.98
|
0.135
|
|
Surgical exposure
|
8.29 ± 1.46
|
8.81 ± 1.44
|
0.072
|
|
Hands-on experience
|
8.02 ± 1.59
|
8.46 ± 1.60
|
0.165
|
|
Follow-up assessment
|
7.00 ± 2.29
|
6.54 ± 2.39
|
0.320
|
|
Multidisciplinary interaction
|
7.56 ± 2.37
|
6.80 ± 2.36
|
0.105
|
|
Exposure to various subspeciality
|
|
Trauma and emergency
|
9.29 ± 1.13
|
9.33 ± 1.71
|
0.883
|
|
Neuro-oncology
|
7.88 ± 1.50
|
8.93 ± 0.97
|
<0.0001
|
|
Cerebrovascular
|
7.40 ± 1.74
|
8.43 ± 1.36
|
0.001
|
|
Open skull base
|
7.06 ± 1.90
|
8.26 ± 1.78
|
0.001
|
|
Radiosurgery
|
5.77 ± 2.74
|
6.54 ± 2.42
|
0.140
|
|
Endoscopic skull base
|
4.08 ± 2.57
|
6.96 ± 2.15
|
<0.0001
|
|
Spine
|
6.21 ± 2.16
|
6.04 ± 2.03
|
0.682
|
|
Functional
|
4.90 ± 2.41
|
6.06 ± 2.36
|
0.016
|
|
Endovascular
|
2.46 ± 2.20
|
1.65 ± 1.72
|
0.043
|
|
Fellowship pursued after residency, n (%)
|
23 (48.9)
|
24 (51.1)
|
0.725
|
There was no significant difference in the above parameters when analyzed between respondents who had completed 1 year of chief residency versus those who did not, and between respondents who did a post-MBBS course versus those who did a post-MS course.
Additional Fellowship Training
Forty-eight of the 102 respondents (47.1%) had pursued additional fellowship degrees in one or more subspecialties. Of these, 52% completed training in more than one subspecialty. Most of them had completed fellowships in open and endoscopic skull base surgery, spine surgery including minimally invasive and endoscopic spine surgery, and functional neurosurgery, as shown in [Fig. 4]. Of these, 16.6% had completed short-duration programs of less than 3 months, and 52.1% had completed long-term programs of more than 12 months. Most (85.4%) responded that pursuing a fellowship in the subspecialty significantly contributed to their practice. About 59.6% answered that they received inadequate training in that subspecialty during residency. The rationale behind doing additional fellowships were various, including exposure to multiple cases, hands-on experience, advanced equipment, research opportunities, learning different viewpoints, new techniques, and skilled mentors. In all, 57.8% of post-MBBS course respondents and 36.8% of post-MS course respondents pursued additional fellowships (p = 0.035).
Fig. 4 Chart showing additional fellowship programs pursued by the respondents.
Feedback on the Current Training Program
At the end of the survey, each respondent was asked to share feedback or to recommend any changes in the current training pattern of the residency program. Many (78.4%) thought that the formal training in neurosurgery was adequate for their everyday clinical practice. Few deemed this the best residency training program in the country, with ample learning opportunities. Most respondents uniformly suggested starting structured postdoctoral fellowship courses in various subspecialties and offering such courses to chief residents who continue for a year after graduation. Few said that chief residents should be offered to focus on one or two subspecialties of their interest, and a certification at the end of training in the desired subspecialty would enhance job prospects for the new graduates.
Another consistent feedback we received was regarding the need for more exposure in endovascular interventions and spine surgery. Many wished for better hands-on experience and exposure to minimally invasive spine surgery, endoscopic spine surgery, and deformity corrections. Regarding academic training, suggestions were made to have combined neuroradiology sessions and neurology case presentations, faculty lectures, dedicated postings to skills/cadaver laboratory for training in microvascular suturing, brain dissections, and cranial and spinal approaches. Some of the suggestions included that residents would also benefit from training in introductory biostatistics and research methodology, which would also improve the number of publications from the department. Incorporation of a case logbook for residents to ensure uniformity of exposure and hands-on training for a variety of cases was also suggested.
Discussion
A residency training program is as good as the students graduating. Upon graduation, the students step into the real world and start their practice as confident neurosurgeons, and the training program significantly impacts their careers. The surveys that have been done previously to assess residency programs predominantly took considerations of residents in training regarding their aspirations, experiences, and expectations of the training program.[5]
[6] This present survey aims to evaluate the perception of graduates regarding the training they had in the institute and identify the aspects of the training program that can be improvised.
The neurosurgery residency program at NIMHANS is more than 50 years old. It is essential to periodically upgrade the course curriculum to incorporate current developments in neurosurgery. It should also cater to the requirements and demands of present clinical practice to produce quality neurosurgeons who can successfully and confidently start individual practice. Hence, reevaluating the training program at regular intervals is necessary.
Satisfaction Levels to Various Aspects of Training Program
Most respondents agreed that training in clinical evaluation and radiology interpretation forms the program's backbone. A survey to evaluate residency programs in India also reported that the residents corresponded with the significance of these aspects of training.[5] In the same study, they said that 13.5% of the respondents were unsatisfied with the quality of operative teaching, and 24% of residents wished for better hands-on experience during their residency. Both of these aspects were deemed satisfactory by our respondents. A study assessing different surgical residency training programs reported that operative case volume and hands-on training were the most significant predictors of resident satisfaction.[7] While evaluating neurosurgery residency in Europe, Stienen et al reported a substantial decline in surgical exposure during training between 1976 and 2019.[8] This could be due to stricter work-hour regulations[9] and an increase in the number of trainees in recent years. The number of procedures performed independently, supervised, and assisted during residency were comparable across programs in Europe, but cranial procedures were more often performed than spinal surgeries. The number of surgeries residents performed was considerably related to their academic satisfaction.[10] In our department, after completing a full year of chief residency, each graduate will have performed approximately 1,200 to 1,400 cases, of which 450 to 500 cases would be performed independently or under the supervision of a senior or consultant.
Although not reported in other studies, the training on follow-up/outcome assessments and multidisciplinary interactions are crucial to wholesome training. This was agreed upon by most of the respondents in our survey. Multidisciplinary meetings happen as part of presurgical evaluation for epilepsy and movement disorders programs. Joint neuroradiology conferences, combined clinical case discussions with the neurology department, and tumor board meets with the oncologists would be helpful if they are a part of the academic schedule.
Exposure to Various Subspecialties
Subspecialty exposure is another aspect of training that has gained more importance recently. Although most respondents felt content with their neurosurgery training, the differences in exposure to various subspecialties were evident. A recent study reported that exposure to neuro-oncology, spine, and neurotrauma was considered most adequate, and exposure to stereotactic and functional neurosurgery, peripheral nerve surgery, and endovascular surgery was considered least adequate.[11] When Yaeger et al studied the recent trends in neurosurgery education of the last decade in the United States, they noticed an increase in endovascular, functional, trauma, and spine case logs.[12] A survey was done by Gadjradj et al in which members of the Congress of Neurological Surgeons responded that they were least proficient in endovascular surgery, endoscopic lumbar discectomy, and deep brain stimulation, and wished they had learned spinal fusion, endovascular, functional, and skull base surgery during their residency.[13] In the United States, around 20% of the programs had mandatory away rotations, primarily for pediatric, functional, peripheral nerve, and trauma, to meet minimum case log requirements.[14] As outlined in [Table 1], there is a trend toward better exposure to vascular, skull base, and functional neurosurgery in recent years at the institute. Also, exposure to endovascular neurosurgery is practically nil, and in recent years, residents in their final year have been allowed to observe the same in a different program as part of the curriculum. This is the right step in the desired direction.
A year of chief residency is essential for the transition to independent practice. This year allows for subspecialty focus and career planning.[15] In 2004, the University of Florida Department of Neurosurgery started a Transition to Practice program with a set of curricular objectives for a safer transition to the role of independent practitioner.[16] With this program, the chief resident was given additional responsibilities of a junior faculty and at the end of the program, the residents reported the development of self-confidence and a real sense of responsibility for patients. A Canadian survey of program directors and neurosurgery graduates cited that the graduates needed to be proficient in specific vascular, functional, peripheral nerve, and endoscopic procedures due to limited exposure during training, and most felt these techniques required additional structured subspecialty training.[17] Similarly, consistent feedback from the respondents was to provide the opportunity for chief residents to focus on a desired subspecialty for additional focused training.
Additional Fellowship Training
As neurosurgeons advance their careers, they sometimes narrow their practice and increase volumes.[18] A study reported that 30% of their respondents (practicing neurosurgeons in the United States) felt that they would seek a recognized focused practice certification if offered in their area of subspecialty focus. Among the surveyed residents in training in the United States, 84.6% considered pursuing further fellowship training.[3] A recent analysis showed that 79.13% of academic neurosurgeons had completed fellowship training.[4] Among North American neurosurgical residency graduates of two decades, 40.7% had completed fellowship, the most common being spine (27.2%), endovascular (14.6%), and pediatric (14%).[19] The proportion of residents pursuing fellowships increased from 1997 to 2006 to 2007 to 2016 (29.1 vs. 49.6%). In our study, the proportion of graduates seeking a fellowship in the two consecutive decades was similar (48.8 vs. 45.8%). Skull base open or endoscopic, spine, and functional neurosurgery were the popular choices in our survey.
Few neurosurgery residency programs in the country provide training in endovascular procedures.[20] And very few neurointerventional fellowship programs are open to neurosurgeons.[21] However, the duration of these programs is variable, and the training is nonstandardized. The majority of trainings in radiosurgery for neurosurgical residents are through nonfocused rotations.[22] In our study, a few respondents also said that the exposure to functional neurosurgery and radiosurgery was not uniform, even though these services were routinely provided in the department. Uniformity in resident rotation between teams and maintaining a case log and periodic evaluation might help improve perception levels. Integrating formal and structured radiosurgery, elective rotations or an extended radiosurgery fellowship postresidency fills the gaps in knowledge and improves procedural competency.[23]
Scholarly productivity is a critical component of academic advancement. Many of our respondents pursued further fellowships for the broadened research opportunities. A trend has been observed showing a greater mean h-index score for those who completed fellowships.[24] Among fellowship-trained spinal neurosurgeons in the United States, 37.2% held academic positions.[25] They also reported that completing more than one clinical fellowship in any of the top five programs that graduated most fellows, higher h-index during residency, and protected research time during residency were independently associated with an academic career trajectory.
Limitations
There could be a recall bias in such a survey, especially with respondents who finished their residency more than a decade ago. This being a study to evaluate the residency program of one institute, its scope is limited to this particular institute. However, it emphasizes the need to periodically reevaluate the training program at every institute to meet current needs.
Conclusion
Overall, the alumni of the institute report a high level of satisfaction with the training program. The surgical exposure and the hands-on experience during training are some of the bests in the country and at par with the programs around the world. With changing trends in neurosurgery and increasing subspecialization, the transition to independent practice is becoming challenging. The present study highlights the need for periodic reevaluation and upgradation of residency training programs in prominent institutes. Sincere efforts should be made to improve the perception levels of graduates in terms of exposure to upcoming subspecialties. Our survey has revealed the expectations of graduates and the scope for improvement of the training program. This can be a model to improve and regulate the training programs across the country. Attention to these critical components of resident education will likely affect training outcomes.
