Commentary
2
there is no research quoted to support this new category. Still, it is important to emphasize that knowledge-based practice and mastery of the field are both categories well beyond what is accomplished by our current educational system, including our current postgraduate processes. One of the points not discussed by the authors is the extensive data on what parameters of experience and study are required to progress along the various phases of the educational scheme. One of the fundamental problems in our current system is that no one knows how long it actually takes to go from novice to beginner to advanced beginner to competency. Current residency training program length was empirically derived, and content is not well controlled. One of the reasons it is so difficult to devise any new educational program at these levels is that no one has ever examined this progression. Until we have more data, I will mistrust any scheme that professes to lead to training to competency. We must prove that competency is reached in any new scheme before it is accepted. The most serious fallacy behind the current arbitrary work hour limitation is that it will still be possible to become competent within those newly required time parameters. No one knows whether this is true. We may be setting the stage for a group of incompetent physicians to be discharged upon the public. By contrast, progression from competency to the mastery of a field or expert performance has been extensively studied among great athletes, pilots, and great concert musicians. I suggest there are strong parallels between neurosurgery and these disciplines. For all of them, there is a 10 000-hour and/ or 10-year commitment to mastery. Whether the innovator expert group postulated in this article exists will have to be determined by serial observation. Certainly, no one knows what the educational requirements are, or the experience needed to enter that group. The authors' emphasis upon developing surgical skills and practice talents is a very important element also. Their emphasis upon the humanist and professional aspects of medical practice is timely now when bureaucracy is seriously eroding both. However, I do have strong objections to the authors' desire to immediately test prospective residents on manual skills and ability. I have this objection, not because I think it is a poor idea, but because there are no empirical data, which allows us to determine which of these skills are important or what levels will eventually lead to competent practice. I suspect that judgment is far more important than manual dexterity in differentiating the great surgeons. There are very little fundamental data that indicate any of the current measures of skills have validity in predicting expert practice. This is a valid point to study. This article is very important because it adds much information, which is not frequently considered by neurosurgical educators. The authors emphasize that simply continuing outmoded forms of education requiring hours of time inefficiently spent is wasteful and costly. Development of improved postgraduate medical education, based first upon training to competency and then expanded through postgraduate process to mastery of the field should be a goal for neurosurgical educators in this new century. There is much helpful information available in cognitive research. Of all people, neurosurgeons should be most interested in emphasizing how the brain works in learning, acquisition of skills, and efficient application of those skills. If we do not take up the challenge of changing our educational programs to conform to the duty hours mandated by society, we run the risk of reducing competency within the profession. Neurosurgery is an unforgiving specialty, and lack of competency will be to the detriment of our patients. We cannot let this happen. Blind adherence to educational forms, which were empirically derived without adequate supporting data, will not supply answers to society's criticism of our educational processes. The authors are to be congratulated for this thoughtful look into a very complex process. Improvement in educational techniques for residents deserves more attention, and should be part of an expanded commitment to improve in education throughout all levels of our specialty for the duration of practice for all neurosurgeons. Don M. Long, MD, PhD Department of Neurosurgery Johns Hopkins University Baltimore, MD 21287, USA In this editorial, Haase et al detail their way of thinking about neurosurgical training. The following comments have been written after I have confronted them to one of my young assistant's opinion. The starting point of this essay is the European time directive and the thinking of some people that reducing working time may negatively affect neurosurgical training results as it diminishes the “learning” time of the residents. The authors say that this view is too simplistic. For them, learning is not only a matter of time but also of quality. In the article, they extensively describe basic principles of the “learning theory” and transfer them to the learning process of a future neurosurgeon. Some of these principles are already well known, others less, and therefore, this review is interesting. It may inspire both surgical trainees and instructors in what can be improved in the current way of training. What is questionable to us, if not absurd, is that the authors suggest personality tests at the beginning of the neurosurgical curriculum in the way airplane pilots are tested. For us, it is obvious that there is no objective and valid method (psychometric tests, interviews, and others) to predict the success of a surgical trainee at a point in time. It is only after a period, which may be individually different, and after working under real conditions, and not the study of a successful curriculum that it crystallizes if a candidate will pursue more. To “sort out bad candidates” 96 Editorial / Surgical Neurology 72 (2009) 89–97
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Transcript of Commentary
there is no research quoted to support this new category. Still,it is important to emphasize that knowledge-based practiceand mastery of the field are both categories well beyond whatis accomplished by our current educational system, includingour current postgraduate processes.
One of the points not discussed by the authors is theextensive data on what parameters of experience and studyare required to progress along the various phases of theeducational scheme. One of the fundamental problems in ourcurrent system is that no one knows how long it actuallytakes to go from novice to beginner to advanced beginner tocompetency. Current residency training program length wasempirically derived, and content is not well controlled. Oneof the reasons it is so difficult to devise any new educationalprogram at these levels is that no one has ever examined thisprogression. Until we have more data, I will mistrust anyscheme that professes to lead to training to competency. Wemust prove that competency is reached in any new schemebefore it is accepted. The most serious fallacy behind thecurrent arbitrary work hour limitation is that it will still bepossible to become competent within those newly requiredtime parameters. No one knows whether this is true. We maybe setting the stage for a group of incompetent physicians tobe discharged upon the public.
By contrast, progression from competency to the masteryof a field or expert performance has been extensively studiedamong great athletes, pilots, and great concert musicians. Isuggest there are strong parallels between neurosurgery andthese disciplines. For all of them, there is a 10 000-hour and/or 10-year commitment to mastery. Whether the innovatorexpert group postulated in this article exists will have to bedetermined by serial observation. Certainly, no one knowswhat the educational requirements are, or the experienceneeded to enter that group.
The authors' emphasis upon developing surgical skillsand practice talents is a very important element also. Theiremphasis upon the humanist and professional aspects ofmedical practice is timely now when bureaucracy isseriously eroding both. However, I do have strongobjections to the authors' desire to immediately testprospective residents on manual skills and ability. I havethis objection, not because I think it is a poor idea, butbecause there are no empirical data, which allows us todetermine which of these skills are important or what levelswill eventually lead to competent practice. I suspect thatjudgment is far more important than manual dexterity indifferentiating the great surgeons. There are very littlefundamental data that indicate any of the current measuresof skills have validity in predicting expert practice. This isa valid point to study.
This article is very important because it adds muchinformation, which is not frequently considered byneurosurgical educators. The authors emphasize that simplycontinuing outmoded forms of education requiring hours oftime inefficiently spent is wasteful and costly. Developmentof improved postgraduate medical education, based first
upon training to competency and then expanded throughpostgraduate process to mastery of the field should be agoal for neurosurgical educators in this new century. Thereis much helpful information available in cognitive research.Of all people, neurosurgeons should be most interested inemphasizing how the brain works in learning, acquisitionof skills, and efficient application of those skills. If we donot take up the challenge of changing our educationalprograms to conform to the duty hours mandated bysociety, we run the risk of reducing competency within theprofession. Neurosurgery is an unforgiving specialty, andlack of competency will be to the detriment of our patients.We cannot let this happen. Blind adherence to educationalforms, which were empirically derived without adequatesupporting data, will not supply answers to society'scriticism of our educational processes. The authors are tobe congratulated for this thoughtful look into a verycomplex process. Improvement in educational techniquesfor residents deserves more attention, and should be part ofan expanded commitment to improve in educationthroughout all levels of our specialty for the duration ofpractice for all neurosurgeons.
Don M. Long, MD, PhDDepartment of Neurosurgery
Johns Hopkins UniversityBaltimore, MD 21287, USA
In this editorial, Haase et al detail their way of thinkingabout neurosurgical training. The following comments havebeen written after I have confronted them to one of my youngassistant's opinion.
The starting point of this essay is the European timedirective and the thinking of some people that reducingworking time may negatively affect neurosurgical trainingresults as it diminishes the “learning” time of the residents.The authors say that this view is too simplistic. For them,learning is not only a matter of time but also of quality. In thearticle, they extensively describe basic principles of the“learning theory” and transfer them to the learning process ofa future neurosurgeon. Some of these principles are alreadywell known, others less, and therefore, this review isinteresting. It may inspire both surgical trainees andinstructors in what can be improved in the current wayof training.
What is questionable to us, if not absurd, is that theauthors suggest personality tests at the beginning of theneurosurgical curriculum in the way airplane pilots aretested. For us, it is obvious that there is no objective andvalid method (psychometric tests, interviews, and others)to predict the success of a surgical trainee at a point intime. It is only after a period, which may be individuallydifferent, and after working under real conditions, and notthe study of a successful curriculum that it crystallizes if acandidate will pursue more. To “sort out bad candidates”
96 Editorial / Surgical Neurology 72 (2009) 89–97
by the accompaniment of each trainee by a mentor on anindividual basis should be reinforced. Short-term goalsmust be defined, and their achievement must be checkedand discussed on a regular basis. If those intermediatesteps are not successfully mastered or reached within areasonable time, then a candidate may be reorientated toother disciplines.
Bernard George, MDService de Neurochirurgie
Hopital Lariboisiere75745 Paris, France
I would like to express my special thanks to Drs Haaseand Boisen for readdressing this very important topic. Wediscussed these same problems in Surgical Neurology lastyear (Kanpolat, Y. 2007 Commentary [Sure U, Miller D,Bozinov, O.] Neurosurgical training in Europe, problems,and possible solutions. Surg Neur. 67, 631). I would like toput forward some questions on an issue, which I personallyconsider to be of the utmost importance as follows:
1. Is the limitation of working hours based on a particularexperience in a special group of trainees in certainEuropean countries, or is it a de facto decision ofEuropean politicians? Is it based on a specialexperience or laboratory studies? If not, then I questionwhy the European Union insists on diminishingworking hours in neurosurgical training when, as anexpert of training in neurosurgery, we have recom-mended 6 years not only in European countries butalso worldwide? Is this new learning culture for usbased on a European Union experiment, and should weaccept this new situation without questioning?
2. Is this culture recommended for application worldwide?3. This is a very significant revision of our training
system. Is it recommended for a small group ofcountries in Europe? Should we not wait for a period
and reevaluate any problems that may arise in applyingthis new method or culture?
Personally, I prefer to wait and see. Immediately afterobserving the benefits of this new learning culture andlifestyle, I will recommend it tomy colleagues andmy country.
Yucel Kanpolat, MDDepartment of Neurosurgery
Ankara UniversitySchool of Medicine
06650 Ankara, TurkeyE-mail address: [email protected]
Our article has certainly provoked a response, or“action,” and that is what we wanted. We may disagreeon details, but still, we have started a discussion onlearning, and that was the purpose. Whether we can“prove” where our memory is situated can be discussed, butthe understanding of why different “memories” exist andmust be stimulated differently is still a valid topic. Ofcourse we have no randomized, controlled, prospectivestudies on our topic; we simply tried to introduce some“thinking,” and that is good for future education. Whetherwe should test surgical candidates before they enter aneurosurgical curriculum can be discussed. For us it isimportant to discuss this, as we do not want to “waste”residents who cannot obtain the minimum dexterity that isneeded to become a master neurosurgeon. It is simplymeant as a support for the trainee. I am very happy for thepublication comments. I disagree with the comment that weshall just “wait and see” however, as we should be active asteachers now, and not in 5 years.
Jens Haase, MDDepartment of Neurosurgery
Aalborg University9220 Aalborg, Denmark
E-mail address: [email protected]
97Editorial / Surgical Neurology 72 (2009) 89–97
