• Neurosurgery Resident Education: A Twist on the Traditional

    Authors: Fady Girgis, MD
    Jonathan Miller

    The education of neurosurgical residents is of paramount importance in academic neurosurgery programs. Well-trained residents not only manage the clinical service, but also serve as mentors to more junior residents and medical students, promote the specialty and the department, and form the future of our profession. No less important is the immense sense of satisfaction felt by an attending as we watch our residents grow and develop their skills, knowing we played a role in their success.

    Educating our future workforce, however, is no easy feat. There are several major challenges that must be overcome. The volume of information that needs to be mastered is daunting, and clinical obligations frequently limit the amount of time that can be devoted to education. Fatigue and frequent clinical distractions often make it difficult to maintain a high degree of engagement during formalized learning sessions. Furthermore, unlike most other educational environments in which knowledge and experience are relatively uniform across students, residents range from interns just out of medical school to chief residents about to enter practice. It can be difficult to design activities that are appropriate for all levels without being too advanced for junior residents or too simplified for the seniors. As a result, formal didactic resident curricula in neurosurgery are rare, and learning is often comprised of lectures and case presentations, with the vast majority of information being self-taught.

    Thankfully, there are alternatives to traditional methods. Recent advances in adult learning theory have revolutionized preclinical and clinical training across a number of specialties, and novel pedagogical methods have emerged. One such example is the 'flipped classroom', where students review materials ahead of time in order to maximize the value of in-classroom discussion.1 In contrast to traditional classroom instruction in which ideas are introduced in a lecture and subsequently applied during homework assignments, the flipped classroom involves an introduction to relevant concepts during a self-directed independent study period followed by application of ideas in a facilitator-guided, interactive setting.2 This provides a novel approach to neurosurgical education.

    Does the flipped classroom concept work in neurosurgery?

    We put this idea to the test by designing a flipped classroom curriculum for all twelve residents in an academic neurosurgery training program based on 40 mentored discussions.2 Each discussion was focused on a particular topic, such as aneurysms, gliomas, brachial plexus injury, etc. Weekly, each resident was randomly assigned to research a specific aspect of the assigned topic appropriate to his or her level of experience: junior residents about what characterizes each clinical entity, mid-level residents about when to intervene, and chief residents about how to administer the medical or surgical treatment. During the sessions, a neurosurgical faculty member was present and available to answer questions, but the discussion was resident-led allowing the residents to educate each other. Six months after implementation, residents completed an anonymous survey about the program, and performance on the written board examination was assessed before and after implementation of the curriculum.

    Not only did resident performance on the written examination improve (from a mean of 316 to 468, p<0.05), but we also found that feedback was overwhelmingly positive. Residents stated that distribution of the workload made it possible to "cover more than could be accomplished working independently" and this led to a "sense of teamwork and camaraderie" as they learned to rely on each other. The division of labor across different degrees of complexity made the activity appropriate for both junior and senior residents, allowing everyone to contribute based on their own level of knowledge and experience.


    Advantages of Flipping the Neurosurgery Classroom

    The principles of flipped learning have many advantages for resident education compared with traditional instruction techniques involving didactic lectures and case discussions. The main advantage is that residents become more engaged in the learning process because they are responsible for teaching their colleagues.3,4 Also, the collaborative discussion mimics a real-world problem-solving environment and allows each resident to bring their level of expertise to the discussion. Junior residents who recently completed medical school share their understanding of basic pathophysiology and pharmacology, while more senior residents impart their proficiency in clinical management and surgical techniques.  Furthermore, each resident is able to personalize their learning when preparing for the sessions, allowing them to study at their own pace using their preferred methods and resources. Finally, faculty preparation time is reduced, and a more efficient learning environment is created, as in-class time is no longer absorbed by didactic instruction.5

    In summary, the flipped classroom is a viable approach to resident education that is positively viewed, engaging, and associated with improvements in test performance. Although larger studies are needed to quantify the impact of this technique, our data suggests that the approach offers a promising and pragmatic alternative to didactic resident education that may be associated with improved knowledge and board performance.



    1. Mazur E: Peer Instruction: A User’s Manual Series in Educational Innovation. Upper Saddle River, NJ: Prentice Hall, 1997.
    2. Girgis F, Miller J. Implementation of a “Flipped Classroom” for Neurosurgery Resident Education. Can J Neurol Sci. 2017; 00: 1-7
    3. Cornelius-White JH, A.: Learner-centered instruction: Building relationships for student success. Los Angeles, CA: Sage, 2010.
    4. Jacobsen M: Teaching in a Participatory Digital World. Education Canada 50, 2010.
    5. Mazur AD, Brown B, Jacobsen M: Learning Designs Using Flipped Classroom Instruction. Canadian Journal of Learning and Technology 41, 2015.

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