Author: L. Dade Lunsford
In the United States, neurosurgery residency training takes seven years after medical school. It is longer than any other medical or surgical specialty. To answer the question, "Can neurosurgery residency be shorter than seven years?" we must ask what is the type of product we want to create at the end of residency training.
Neurosurgeons are bright, energetic, creative, focused, and often innovative. They enjoy the complexity of both diagnosis and intervention in a wide variety of brain, spine, and peripheral nerve disorders. In more recent years, neurosurgery resident graduates have become increasingly subspecialized. During, or on occasion immediately after residency, they gain special competence in various high technology fields. Endovascular, neuro-oncology, pediatrics, radiosurgery, and complex spine are examples of such focus. Even the American Board of Neurological Surgery (ABNS) has recognized this shift and begun to examine candidates for oral board certification, in part, related to their areas of subspecialty competence.
Most neurosurgeons either are, or will be, employees of medical centers or academic institutions. They may be part of a large neuroscience center, or a larger, multidisciplinary group practice. They will be recruited based on their general knowledge of neurosurgery so they can take call and cover most urgent or emergent neurosurgical care needs, plus a subspecialty focus that gives them a special niche at that center. Some trainees are destined for academic life, which still requires an investigative mind, a pedagogic ability, and the willingness to do research in some form (clinical or bench) and write about it. To advance up the academic ladder, they will need to demonstrate these aspects of their career and meet the perceived requirements of their employer.
We recently completed a 50-year assessment of our trainees at the University of Pittsburgh/UPMC. One of the goals was to assess whether the current generation of trainees (loosely speaking, the millennials) are, in fact, any different than prior trainees. We compared decade to decade. It was reassuring to note that the incidence of serious performance or professionalism issues has not changed over these past fifty years. The breed remains intact. What was found was that the reporting of resident-related concerns has increased significantly over the past ten years, which we relate to the ease with which complaints can be lodged via the ubiquitous electronic medical record.
To gain a niche, generally two additional years of training beyond core neurosurgery are needed. The answer to the question of shorter versus longer training needs to be couched in the question of whether or not our communities want generalists (basic neurosurgery of spine, trauma, routine intracranial tumors such as meningiomas and gliomas, and simple peripheral nerve disorders), or want neurosurgeons who are both generalists and subspecialists. I believe that competent general neurosurgeons can be trained in five years.
It is clear that the neurosurgery RRC has responded over the last ten years to the increasing need for neurosurgeons. There are now 110 training programs, with the number of starting PGY 1 residents steadily increasing. It is less clear if this increased number of trainees is sufficient to meet a growing demand for neurosurgical services. Couple this trainee increase with the fact that older neurosurgeons are closing practices at younger ages, whether related to burnout or other factors that affect job satisfaction. In general, the survey of our trainees found recent graduates were just as satisfied as older graduates, although many reflected that our families sometimes pay a price.
Neurosurgeons who wish to subspecialize or are filling a job requiring special skills will need to train two additional years after reaching the generalist criteria. To change the current system, organized neurosurgery will need to answer many questions. If basic training is reduced to five years, who will pay for subsequent subspecialty training? Perhaps future employers will need to subsidize training with a stipend in return for a designated commitment. In a compensation system that seems to be based only on easily measured productivity (the RVU system is perhaps the worst perpetrated crime against US medical care), why would a generalist refer to the specialist?