Author: Ganesh Rao
Neurosurgical Education in the modern era: The evolution of medical education
Medical education in the U.S. at the turn of the 20th century was in disarray with wide variability in the quality of instruction, standardization of curriculum, and requirements for admission and graduation. At the time there were 155 medical schools for a U.S. population of approximately 75 million people. Contrast that with 141 MD and 30 DO schools today when the U.S. population approaches 330 million. Medical schools in the year 1900 had virtually no oversight, and training in all but a handful was poor. Over 100 years ago, Abraham Flexner was commissioned by the Carnegie Foundation to assess the state of medical education in the United States1. The report was issued in 1910 and has had profound effects on medical education that reverberate to this day.
Today, medical education is again in a state of significant upheaval. Medical schools are shifting away from a four-year curriculum that traditionally involved basic science coursework in the first two years, to more practical, clinically-relevant education and early exposure to the outpatient and inpatient settings. Technology has played a prominent role in this transition. High-quality courses are available online and there is almost no need to sit in a classroom. These changes allow students to learn at their own pace. Simulation and virtual reality are now supplanting traditional cadaveric dissections for learning anatomy. Laparoscopy simulators have allowed general surgery residents to become technically proficient before they touch a patient. Simulation has also taken hold in neurosurgery,
permitting the practice of procedures on a virtual patient. It is now possible to coil an aneurysm or deploy a stent on a simulator that mimics real human anatomy. Three-dimensional modeling and augmented reality are enabling surgeons to perform a practice run of a procedure before they do so on a patient. Robots are now guiding pedicle screw placement and the implantation of electrodes for seizure mapping. These technologies are certain to improve training for our students and residents and will no doubt improve outcomes for our patients.
An explosion of medical literature
The amount of instructional information available to individuals at all levels of medical training is staggering. By some estimates, more than 2.5 million scientific publications are generated every year. Thomson Reuters indexes over 18,000 scholarly and technical journals with 108 million citations. Treatments and the indications for their use can change quickly in the present environment. Sometimes this can have deleterious effects; keeping current requires almost impossible attention to the literature. Aaron Carroll, a professor of pediatrics at Indiana University, has noted that it is hard for physicians to adapt to new evidence. As an example, he cites well-performed research showing that tight glycemic control in critically ill patients results in a significantly higher rate of death compared to traditional, less stringent, glucose control2. However, these results were in contrast to previously published studies that had been accepted as dogma and, as a result, many ICUs still adhere to tight glucose control in critically ill patients. Unlearning a practice that has been ingrained is hard to do. The reasons are multifactorial but include difficulty keeping up with the vast amount of medical literature as well as being able to critically analyze how well a study was performed.
We rely on medical journals to publish well-conducted studies after peer review. Still, it is incumbent upon the reader to critically analyze the methodology, results, and conclusions of a study. As physicians, we are probably better equipped than most to determine the quality of a study, but it remains a challenge. Sure, we all know that p<0.05 is statistically significant, but how many of us know if the appropriate statistical test was performed, or if a sample size was powered appropriately, or if the appropriate controls were employed? The difficulty in determining the validity of a study is compounded by the vast number of studies being produced. We have ways to determine the importance of a published study, including the reputation of the authors and the journal publishing the work (often measured by the much-maligned impact factor) but this hardly insulates us from poorly conducted research. Perhaps the most infamous example of this is the work published in The Lancet by Andrew Wakefield in 2004. Wakefield's study of just 12 children linked the measles, mumps and rubella vaccine to a "pervasive developmental disorder" and was a catalyst for the anti-vaccination movement. The article has since been disavowed by The Lancet who indicated in the notice of retraction that there were "several elements of the paper" that were "incorrect and contrary to the findings of an earlier investigation". Nevertheless, Wakefield continues to defend the study and remains an anti-vaccination activist. Measles outbreaks are now more common, particularly in areas of decreased vaccination rates. This is the price of poorly conducted peer-review. The rise of predatory journals has also become a significant problem in recent years. These journals, which often charge a significant sum for publication, have taken advantage of the current publish or perish era when one's h-index3 is used as a metric for career advancement. Because many are "open access" they are available to the public who may not have the understanding that some of these journals do not always employ rigorous peer review.
The democratization of information undermines expertise
The internet has given our patients nearly unlimited access to medical studies. At face value, the democratization of information may appear to be a good thing. However, our patients' ability to parse good studies from bad is limited. We have all had patients show up in our office, web page in hand, asking about the latest herb, vitamin or cannabinoid oil to treat their condition. For the less informed, the internet can be hazardous to your health, full of unsubstantiated claims and spurious data. With the internet, anyone can appear to be an expert and every false expert undermines the trust in and effectiveness of actual medical expertise. This devaluation of expertise threatens public health. Our years of experience with effective treatments are doubted because a sleek website with questionable content can be built and published overnight. The negative effect of ignoring well-established medical care is exemplified by the treatment Steve Jobs sought after being diagnosed with pancreatic islet cell neuroendocrine tumor. It is well known that Jobs initially used alternative medical treatments for his condition, though his tumor was potentially curable with surgery, Jobs delayed definitive surgical treatment, which may have led to an early demise.
NEXUS, CNS' online case repository, was designed to allow residents and surgeons to quickly review a case like their own before going into the OR.
The future of medical education
We neurosurgeons and our patients have benefitted greatly from advances in technology. The internet has given our neurosurgical residents the ability to prepare for procedures by referring to online content that includes vivid intraoperative photographs and interactive videos4. Our residents have virtually all medical knowledge in the palm of their hands. There is arguably no reason not to know an answer to a medical question within seconds. And yet the internet can also be the source of significant confusion for our patients and trainees. Our own specialty is susceptible to the misinformation that is widely available to the public. Unproven technologies for the treatment of back pain and useless (and sometimes dangerous) treatments for cancer are becoming more commonplace. For our residents, equipping them with the ability to critically evaluate the medical literature in an ongoing fashion will help to insulate them and their patients from potentially harmful treatments. Fortunately for neurosurgery, lifelong learning is in our DNA. Over 100 years ago, the Flexner report resulted in a seismic shift in medical education by creating education standards for medical schools. We must again adjust medical training and our own practices to the significant changes that modern technology has wrought.
- Flexner is a controversial figure. He advocated for closing all but two African American Medical Schools. This legacy has negatively impacted health care for African Americans ever since.
- The h-index is defined as: h published papers each of which has been cited in other papers at least h times
- The CNS’ NEXUS is an excellent example. Available for free at www.cns.org/nexus.