Neurosurgical Education: Educating the Next...

Neurosurgical Education:

Educating the Next Generation

Stacey Quintero Wolfe, MD FAANS

Associate Professor and Residency Program Director

Director of Neurointerventional Surgery

Wake Forest Baptist Medical Center

Disclosures

• No conflicts of interest

Thanks to Larry Chin, MD FAANS, for his contribution and collaboration

http://www.sports-logos-screensavers.com/user/Wake_Forest_Demon_Deacons.jpg


Developing Excellence in

Neurosurgery

• Workforce

• Training

• Opportunities for improvement?


US Neurosurgical Residency:

Limited training positions

• Medicine: 6,465

• Neurosurgery: 210


Exceedingly high standards


Attrition

• 86% Rate of Graduation

• 79.4% ABNS board certification


1990s Overall Attrition: 14%

• Difference by gender

• Male attrition: 13%

• Female attrition: 24%

• Male ABNS pass: 81%

• Female ABNS: 63%

1171

111

1059

190

35

156

-100

100

300

500

700

900

1100

1300

1500

Total Women Men

Completed Attritioned


2000s Overall Attrition: 6.7%

Renfrow et al, JNS 2016

• PGY 1-4


Ongoing Gender Variability

• Gender inequity

• Male attrition: 5.3%

• Female attrition: 17%

• Significance???

1857

200

1657

135

40

93

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Total Women Men

Completed Attritioned


Wake Forest Baptist Medical Center www.aamc.org

Workforce:

Medical School Graduates 2016: 50%

Wake Forest Baptist Medical Center AANS Data 2016.

Neurosurgery Resident Match 2017: 17%

Wake Forest Baptist Medical Center ABNS Data 2016.

Board Certified Neurosurgeons 2016: 6%


Women in Neurosurgical Match

• 1990s: 10.7%

• 2000s: 12%

• 2013: 15.5%

• 2016: 16%

• 2017: 17%

• 30% gen surg



Neurosurgery

Overall

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017

Female

Male

Not reported

0%

10%

20%

30%

40%

50%

60%

2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017

Female

Male

Not Reported

Match: Gender differential

Courtesy of Jay Wellons


Opportunities with the goal of

Excellence

• Improve recruitment

• Rooney Rule (2003)

• NFL coaching searches must consider at least 1 minority

• Minority coaches increased to 22% from 6%

• NOT Affirmative action

• Improve retention

• Education

• Mentorship


Good educational practice

• Learner-faculty contact

• Active learning techniques (ie- Participatory)

• Cooperation between learners (ie- Team)

• Instant feedback

• High standards

• Understands and addresses diverse learning styles


Kolb learning styles

• Assimilating (Observe and think)

• Reflective observation, abstract conceptualization

• Diverging (Observe and experience)

• Reflective observation, concrete experience

• Accommodating (Do and Think)

• Active experimentation, abstract conceptualization

• Converging (Do and Experience)

• Active experimentation, concrete experience

NRS

ORTHO

Richard et al., J Surg 71: 110-118, 2014


Fleming VARK learning styles

• Visual

• Pictures, videos, flowcharts, diagrams

• Underlining, highlighting, different colors

• Look at notes to review

• Aural

• Attend classes/lectures

• Discuss topics with others

• Remember interesting examples and stories

• Read/Write (Higher USMLE 1 scores)

• Lists, handouts, textbooks, notes

• Kinesthetic

• Real-life examples

• Engage all senses

• Hands on, trial and error Kim et al, J Surg Ed, 2016


Flipped classroom techniques

• Small groups

• Teacher/facilitator

• Preassigned videos

/technology

• Pre- and post-test

In Theory In Neurosurgery

• Have Residents:

• Teach a technique to faculty (No powerpoint!)

• Write board-style test questions and explanations

• Draw surgical anatomy from memory

• Narrate the case before the surgery (scrub sink) and highlight pearls after

Anders Ericsson

• 10,000 hour rule (popularized by Gladwell)

• Average hours of practice for violin students to become an Expert

• Differs by specialty- piano students required longer

• Two types of Expertise: Routine and Adaptive

• Adaptive Expert = Deliberate Practice

• Expert coaching

• Stretch outside comfort zone

• Full attention and conscious action

• Feedback and modification

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Neurosurgery: 10,000 hours?

• US Operative experience increased from a median

of 995 to 1,273 cases from 2012-2017

• 3,312 hours (about 14.1% of total residency)

• Range 1652 hrs to 4972 hrs (21% total residency)

• Based on ACGME and CMS data

West et al, In submission


Master coaching

• Requires depth and breadth of knowledge

• Master observers (not orators)

• Teaches perfection of basic skills

• Targeted information and instant feedback

• Adaptability to student


Master coaching in Neurosurgery

• Review fundamental surgical skills: bipolar technique, bone

removal technique, suction, etc

• Never let residents get sloppy

• Resident should visualize and describe entire operation

before performing

• Unsupervised practice (independent struggle) plays a small

role

• Feedback should be instant and continuous

• Difficult parts of operations can be broken into components

that can be practiced without affecting patient care


Dunning-Kruger effect

• Poor performers overestimate their ability

• Unable to distinguish good from bad performance in others

• Experts underestimate their abilities

• Improving metacognition requires improving skills

Kruger J, Dunning D: Unskilled and Unaware of it. J Personality Social Psychol 77:1121-1134, 1999


O-Score: Ottawa Surgical Competency Operating

Room Evaluation, Gofton et al, 2012


Objective Structured Assessment of

Technical Skills (OSATS)

• 6 faculty, 8 residents completed evaluations for 299 procedures

• 55 VPS/revisions, 19 ETVs, 18 tumor craniotomies

• No significant difference between faculty and resident self-assessment scores overall

• Faculty members scored senior residents significantly higher than junior residents only for the

"knowledge of instruments" domain (p = 0.05)

• For expert procedures only, faculty scored seniors significantly higher than juniors (p = 0.04)


Zwisch Model

Show and tell

Active Help

Passive Help

Supervision only


Ignition: Motivation and Culture

• Break it into Chunks

• Slow it down

• Repetition

• Embrace the struggle

Deep Practice Ignition

• Embrace the long-term

commitment

• Identify with excellence

• Motivate by praising the

effort not the result


Generationalism

• 5 generations working side by side in 2020

1960-1980 1981-2000


Generational attitudes to work

• Work hard because of loyalty

• Expect long-term job security

• Expect to pay their dues

• Virtuous self-sacrifice

• Respect authority

Baby Boomers Generation X

• Work hard when there is

balance

• Does not anticipate job

security

• Paying dues?

• Self-sacrifice

endured…maybe

• Question authority


Millennial learning styles

• Open communication

• Want to know reason why (clinical relevance) and not

learning for learnings sake (Baby Boomers)

• Want frequent feedback

• Prefer faculty know their names- Mentoring very important to

them

• Prefer a more casual learning environment

• Prefer face to face or combination learning over totally web

based

• Like case based learning, work in teams

• Desire acknowledgement for job well done

Lourenco, J Am Coll Rad 14: 92-95, 2017


Millennial faculty development

• Different models of academic success

• Alternate models of compensation besides money (flexibility,

vacation)

• Work/life integration more important than work/life balance

• Encourage teamwork and team building

• Multiple mentors for different aspects of career

• Collaborative mentoring style and avoid top-down approaches

• Provide frequent feedback (no news is not good news) and

accept it as well

• Foster early leadership opportunities and give back as a mentor


Gender learning styles

• Overlap with Millenial learning styles

• Gender is a more personality than chromosome in regard to education

• Early identification of gender roles

• Dramatic loss of female interest in

science and math in 6th and 9th grade

• Confidence

• Role models

***Editorial

• Teach your girls confidence

• Be a role model in your local schools


The Confidence Gap • Shipman and Kay, The Atlantic 2014

• Confidence is likely the single most different

characteristic between men and women

• Men will apply for a job when they meet 50% of the

qualifications

• May require ego-checking

• Women will not apply until they have exceeded

qualifications (Perfectionism/Underestimate themselves)

• Very coachable, but require positive affirmation

• Both desire explanation (Millenials)


Men

• Require more explanation

(develop trust)

• Deflect criticism or take as

a challenge

• Overestimate abilities,

don’t relay doubts

• Discussion

Women

• Gravitate towards a team

• Personalize criticism as

indication of self-worth

• Lack of confidence leads

to risk avoidance and lack

of experience

• Encouragement

Gender Differences in

Neurosurgical Training


Lead From The Front

• “The most important thing I learned is that soldiers watch what their

leaders do. You can give them classes and lecture them forever, but it is

your personal example they will follow.” – General Colin Powell


Know Your People

• Motivations

• Learning Styles

• Limitations

• Resources

• Ask the question


Foster Character

• Millenials have an innate desire to be involved and to please

• However, the initiative to do that has often not been

fostered

• Need specific goals and instructions

• Need clear and timely feedback

• They have not been allowed to fail

• Shy from such situations


Mentorship

• Understand the differences

• Help your trainees to understand

• Help your patients to understand

• Sponsorship

• Coaching


Summary

• Leadership: Intentional Implementation

• Expect Excellence

• Consider diversity

• Initiate Deliberate practice to train Adaptive Experts

• Develop Master Coaching in faculty

Thank You

[email protected]


Career Paths Women in Neurosurgery

• 379 Graduates

• 1964-2013

• 16 retired

• 8 career change (2%)

• 3 deaths

Private Practice

71% Academics

26%

Affiliated Academics

3% Academic Jobs: 1 in 2 occupied by fellowship trained Private Practice Jobs: 1 in 5 occupied by fellowship trained

Renfrow et al, Neurosurgery 2017

N= 349


Fellowship Training (25%) Women in Neurosurgery

Pediatric, 33%

Oncology, 15%

Spine, 13%

Vascular, 10%

Endovascular, 7%

Functional, 11%

Peripherial Nerve, 9%

General, 7%

Skull Base, 2%

One in four female neurosurgery graduates pursued fellowship training (N=103)



Affiliated Academic (3%)

Private Practice (71%)

Assistant (46%) *Male overall 33%

Associate (36%) *Male overall 19%

Professor (18%) *Male overall 43%

Academic (26%)

Academic Rank Women in Neurosurgery



Academic Rank

• Tomei, et al J Clin Neuroscience 2013

• 10.9% full professorships were female

• Neurosurgery

• 11.8% (vs 88.2%) Assistant Professor

• 12.4% (vs 87.6%) Associate Professor

• 6% (vs 94%) Professors


Similar gender disparity in other

surgical subspecialties

• Of 124 medical deans, only 14 (11%) were women

• Only 9% of all department chairs were women Andrews, NEJM 2007

• Analysis of >90,000 academic physicians shows gender disparity in

associate and professor ranks even after adjusting for age and research

• Orthopedic Surgery Ence et al, Ortho Forum 2016

• 12.9% Assistant Professor

• 11.3% Associate Professor

• 6.4% Professors

• Significantly fewer females in senior rank 29.9% vs 39.6%

• Cardiology Blumenthal et al, Circulation 2017

• 30.6% vs 15.9% Full Professors


Research and Publications

• Male neurosurgeons have overall higher research

productivity (h-Index 13.3 vs 9.5) Tomei, et al J Clin Neuroscience

2013

• Similar in ortho, spine, ENT, cardiology, surgery Singh et al

Spine J 2017, Mueller et al, BMC Surg 2017

• Female research productivity increases throughout

the career, with higher publication rates later in life Mayo Clinic 2007, Eloy et al Otolaryngol 2013

But

• NIH funding equal Valsangkar et al, J Am Coll Surg 2016


Salary Inequities

• Jena et al, Jama Int Med 2016

• N=10,241 academic physicians at 24 public medical

schools

• $51,315 absolute difference ($206,641 vs $257,957)

• $19,878 when adjusted for age, experience, specialty,

rank and clinical/research productivity

• Adjusted salaries of female full professors compare

to those of male associate professors

• BUT… DO WE ASK?


Factors in ongoing gender disparity

• Asymmetric family responsibilities

• Lack of mentors

• Lack of institutional support, especially early career

physician-scientists

• Lower levels of secretarial support

• Meetings before 8a and after 5p

• No on-site childcare

• Attrition of female academics at higher levels

• Overt or perceived gender discrimination

• Unconscious gender bias

Blumenthalet al, Circulation 2017

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