Optimizing the role of learners in quality improvement (QI) and neurosurgical performance requires understanding and closing historical gaps between traditional didactic teaching methods and the needs of today’s contemporary learners. The role in neurosurgical education of technological advancement, simulation, fundamentals courses, cognitive style-based curricula, and practice-based learning (PBL) are presented. In addition, outcomes measurement and continuous QI for residency training are discussed in the context of the Accreditation Council for Graduate Medical Education (ACGME), Next Accreditation System (NAS), which also incorporates explicit educational goals for both PBL and QI.
The Institute for Healthcare Improvement “triple aim”: (1) improved population health, (2) enhanced patient experience (including quality and satisfaction), and (3) reduced per capita cost for American health care now includes a 4th aim, (4) provider wellness and satisfaction. Iterative improvement of both the graduate medical education (GME) and medical practice environments is critical to the overall health care improvement enterprise.
KeywordsResidency education, Simulation, Neurosurgery training, ACGME
A strategy for improving neurosurgical performance by improving education may comprise a broad spectrum of tactics. From a traditional educational standpoint, it can refer simply to improving the knowledge base of medical students, residents, and fellows. With regard to practicing physicians, it can involve refining workflow using quality improvement (QI)-specific education. Additionally, the identification of alarming suicide rates, burnout, and mental wellness gaps among doctors speaks to an obvious need for teaching resilience, self-care, and coping with high-stress situations. By understanding the strengths and weaknesses of our current system and evaluating the present-day demands placed upon surgeons, we may identify and capitalize on opportunities for improving the field of neurosurgery.
Education of Fundamental Medical and Surgical Knowledge
“The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.”—Paul Kalanithi, When Breath Becomes Air.
Medical education, by itself, is a daunting task. Modern US health care demands that all providers train equally to the highest level, while tightly limiting the involvement of trainees in patient care and strictly regulating their independence. Despite error being a fundamental human trait, an expectation of perfect care all the time is emerging. Surgical education, and especially neurosurgical education, carries the additional burden of needing to impart technical excellence on top of a solid foundation of clinical knowledge. As the late Dr. Kalanithi describes so aptly, neurosurgeons are held to standards far higher than the average person, and must constantly strive toward asymptotic perfection.
Historically, surgical training had been accomplished through an unregulated apprenticeship model. Following Halsted’s triad of educational principles, emphasis was placed on an in-depth understanding of surgical pathologies, repetition of techniques, and, most importantly, graded responsibility and eventual independence. Graduation occurred when one was finally deemed adequately trained and occurred at the discretion of the mentor, with no predefined timeline.
The current-day model for neurosurgical education has evolved in limited but important ways from that of the historical apprenticeship approach. First, the residency training environment is highly regulated (principally by the ACGME; www.acgme.org ) including the creation of a fixed duration of training for the vast majority of trainees. There are now multiple highly vetted mentors contributing to the education of each accredited surgeon as part of a more organized training program with specifically designed, rotating clinical, and other foundational experiences. Finally, a widely established curriculum for North American neurosurgery was recently created for trainees. The “matrix” curriculum was created by residency program directors and other educational specialists, including a multidimensional table that specifies content areas, educational resources, evaluation modalities, and level-specific expectations). Now endorsed by the Society for Neurological Surgeons ( www.societyns.org ), representing academic program chairs and residency directors, the matrix curriculum will be housed in an interactive online Portal, which also comprises residency rotation evaluations and reporting tools, by early 2018.
Changes to contemporary medical care, however, have whittled away opportunities for surgical trainees to practice graduated autonomy, weakening the original model implemented by Halsted. Limiting resident work hours, increasing emphasis on attending-driven care, and desire to minimize patient risk have resulted in a gradual decline in opportunities for independent or semiindependent resident practice. While there can be no substitute for the value of actual surgical experience, there are certainly ways to augment a trainee’s understanding and baseline technical skill set prior to engaging in the live clinical environment.
A paradigm shift to simulation training is underway in many residency programs. Although simulation has been used for decades, and in the case of cadaveric simulations for centuries, methods of simulation teaching are evolving significantly. Simulated surgical skills training has traditionally used time-based (e.g., 1 h of practice) or repetition-based (e.g., five attempts) methods. More recent data suggest that a third method: proficiency-based teaching—in which trainees deliberately practice on specific high-value techniques with the goal of reaching prespecified benchmarks—is more effective (e.g., laparoscopic suturing exercise requiring completion within 112 s, < 1 mm of stitch error placement, and no knot security errors). However, proficiency-based training necessitates increased planning effort by teaching faculty in order to ascertain appropriate skill goals and develop mastery criteria for learners to strive toward. Proficiency-based teaching itself also requires additional time, small student-to-teacher ratios, and real-time, direct, actionable feedback in order to truly be effective.
Surgical “boot camps” have been utilized recently in neurosurgery to concentrate a series of high-value simulation experiences in a single setting using a large group of faculty with the capacity for an entire cohort of learners at once. This economy of scale has allowed entire classes of US neurosurgery residents to participate in a centrally designed and nationally vetted curriculum intended to ensure a consistent baseline of fundamental technical and behavioral skills. Other focused, high-density surgical courses also allow residents and fellows to learn focused technical skills at more advanced stages of training.
An equally important skill for beginning residents to learn is awareness and management of nontechnical, human factors. Medical errors most commonly occur not as the result of actual technical missteps, but rather from failures of situational awareness, decision-making, communication, and teamwork. For instance, in the operating room, there is often a gap between surgeon and nursing perception of how well the team is working together. Courses that emphasize awareness and insight into these skills improve performance of beginning surgical trainees.
Time-honored classroom didactic teaching is slowly making way for newer integrative educational methods. While deeply rooted in tradition, the classic lecture setting passes on information in a unidirectional fashion—from active presenter to passive audience—leaving little opportunity for learners to practice application of their new found knowledge and critical thinking skills until possibly years later. Instead, educators are increasingly using practice-based learning (PBL) groups and interactive multimedia presentations, resulting in markedly improved test scores.
PBL may involve small student groups given specially vetted scenarios designed to simulate related aspects of anatomy, pathology, and pathophysiology, focusing students on critical thinking, developing self-teaching ability, and synthesizing pertinent data to create an actionable treatment plan. PBL techniques allow simulation of the data gathering and synthesis needed for more effective practice in the live clinical environment. PBL requires less day-to-day preparation of teaching material than proficiency-based learning, as group facilitators are not generally required to be resources for disciplinary knowledge. Conversely, emphasis lies on the facilitator’s leadership and guidance skills.
Recent technological advances have also led to information globalization. No longer are students and residents limited to information passed on colloquially. Rather, webinars, forums, and instructional videos all lead to a much wider collaboration and sharing of knowledge and mentorship. National neurosurgical societies have created many online course collections such as the Congress of Neurological Surgeons (CNS)’s “University of Neurosurgery” ( learn.cns.org/diweb/start ), and the American Association of Neurological Surgeons (AANS) and Society of Neurological Surgeons (SNS)’s video and podcast collection on iTunes U and YouTube ( www.youtube.com/user/AANSNeurosurgery ).
Additionally, the cognitive style and approach of the modern-day student has fundamentally changed due to the advent of the internet and smartphone. Within less than a generation, students have changed from poring over textbooks to near-instantaneous access to worldwide digital information. Students are no longer willing to pursue systematic review and memorization of material when they can retrieve answers in mere seconds. Ubiquitous media influx has led to shortened attention spans and low yield multitasking with worsened retention of presented material and reduced emphasis on critical thinking and problem-solving skills. In a way, technology has created an artificial attention deficit disorder. While the long-term implications of this phenomenonremain obscure, it is apparent that traditional teaching methods are no longer keeping pace with current students of surgery.
In sum, efforts to improve surgical education should include a focus on the extensive challenges to contemporary surgical education outlined above, including loss of opportunities for repetition and practice, outdated teaching methods, decreased training in critical thinking, and underrepresentation of human factor and nontechnical errors. Ultimately, the colossal amount of information, experience, and operative proficiency needed to become an effective, independent neurosurgeon requires an arduous educational process demanding exacting and meticulous results. To fully optimize student and resident learning, we must understand inherent gaps between traditional neurosurgical didacticism and the needs of contemporary learners.
Education of QI Techniques and Processes
Health care leaders nationwide are engaged in extensive efforts to improve workflow efficiency and the value of patient care. Continuous QI utilizes a methodical approach to the analysis and augmentation of performance. At its core, the basic concepts of QI comprise the identification and prioritization of areas for targeted improvement. The “PDSA (plan, do, study, act) cycle” or the “DMAIC (define, measure, analyze, improve, and control) approach” are common tools used for improving areas of perceived weakness.
Traditionally, medical school curricula have covered very little QI science. Additionally, students are likely to place less priority on these topics, unsurprising given that they have not yet experienced the myriad inefficiencies ubiquitous to hospitals and clinics. Recently the Association of American Medical Colleges (AAMC; www.aamc.org ) and the ACGME have focused effort on closing this gap. Programs such as “Teaching for Quality” have been created to help develop faculty for teaching QI and patient safety curricula to trainees.
The introduction of QI courses has increased knowledge and understanding but also translated into increased QI productivity and leadership. However, there are frequent barriers to student and resident participation in QI initiatives such as clinical rotation schedules, skepticism, and lack of knowledge about QI among faculty members, QI program expense, and the hierarchical culture of medicine (which can suppress resident reporting of safety problems and improvement suggestions). Common to these barriers is lack of a QI culture. Creating a consistent and effective QI culture can be powerful, but is difficult to achieve. Effective change management requires strong leadership commitment and engagement, clear and transparent communication, empowerment of the team, and adequate resources and infrastructure ( qiroadmap.org/change-management ).
Value Improvement in Resident Training in a University Environment
As an example, the authors carried out a QI project specifically designed to train resident learners and assist in building a culture of continuous, iterative improvement. This project involved the adaptation and implementation of the Brain Injury Guidelines (BIG) stratification process for a tertiary care, academic health center. The hospital administration of Oregon Health & Science University (OHSU) prioritized quality and performance improvement initiatives in their recent mission statement, which supported a change in resident culture and resulted in the allocation of resources and administrative engagement to resident-driven and staffed quality initiatives. OHSU neurological surgery faculty members together with GME leaders and hospital quality professionals created the Value Improvement in Resident Training in a University Environment (VIRTUE) committee to support and provide administrative resources for resident-led QI projects. To encourage this process further, the hospital celebrates an annual OHSU Performance Excellence week that highlights and rewards the work of residents who undertake such endeavors. Residents are additionally incentivized with cash awards for the best projects, further motivating positive culture change.
Additionally, the OHSU residency program in neurological surgery initiated a QI project requirement to be completed by the end of the PGY5 year. Resident involvement in choosing project areas improved engagement and the quality of projects completed to meet the requirement over time. Program leadership did require residents to choose from projects that aligned with institutionally chosen quality needs or to design novel projects that fit overall priorities.
In OHSU’s BIG validation and implementation project, the primary objective was to improve management and resource utilization of patients with a frequent neurosurgical problem: mild traumatic brain injury (TBI). At baseline, these were patients who required no neurosurgical intervention, but were subjected to often multiple repeat computed tomography (CT) head imaging and intensive care observation out of concern for possible injury progression. The status quo presented an opportunity to identify or develop a set of criteria that could more accurately categorize injury severity and also define risk for progression, allowing a more consistent and rational deployment of resources. Additional intended outcomes were a reduction in radiation exposure to patients, and reallocation of expensive hospital resources to patients who would benefit.
To support the project, the Department of Neurological Surgery provided protected nonclinical time, mentorship, and other resources to project residents to create, modify, and retrospectively validate the guidelines. The resident project team was also given access to hospital-based EPIC staff to support data collection and analysis. On the basis of these data, new minor TBI management guidelines were created that substantially improved the institutional baseline care algorithm. The safety of the new guidelines was validated in preliminary fashion using retrospective data. Implementation of the revised guidelines included engagement with the leadership and faculty of other stakeholder programs (e.g., trauma, emergency medicine, radiology, nursing, and bedflow) in order to unify an institutional approach to protocol implementation. Concerns voiced by the other services were taken into consideration and modifications to the protocol were made to address them. Time and resources were given to the residents for education of the other involved departments.
Following the adoption of the new protocol, there has been a nearly 15% reduction of admissions to the trauma ICU for relatively minor head injuries and an approximate 35% decrease in repeat CT head scans for injury stability screening. The VIRTUE program and modified minor TBI guidelines project are only a single example of the QI approach, but emphasize the power of engaging learners directly in applied QI work within the active clinical environment. First, learners are a large group of potential additional contributors to the time and energy intensive process of institutional QI. Second, learners are trained to spread both a knowledge of QI and a QI culture to other clinical units within the institution and/or to other institutions after training. Third, learners provide a unique “frontline” perspective about quality gaps in the academic health center. Finally, learners may support academic engagement with QI technique development and the generation of new knowledge about quality, through educational forums, conferences, publications (such as this one, first authored by a VIRTUE project resident), and peer teaching.
Measuring Educational Outcomes
Effective educational assessment, honest feedback to learners, and a culture of continuous personal improvement during training (a component of PBL) are crucial to individual educational success as well as system improvement. In addition to the myriad of other changes affecting contemporary medical education, both educators and regulatory agencies have implemented a nationwide focus on educational outcomes.
Historically, promotion during and graduation from residency were based predominantly on time spent in an approved learning environment. In the modern era, oversight of the learning environment has been reflected by national accreditation, and carried out by the ACGME. During this era, individual residency programs, through their program directors, did globally certify the “competence” of graduating residents, although such judgments were relatively idiosyncratic and very infrequently used any validated measures or instruments.
More recently, the ACGME has pursued a program of explicitly outcomes-based educational system improvement, through the Next Accreditation System (NAS). The cornerstone of NAS is the ACGME milestones, which are hallmarks of developmental progression for key clinical and general competencies necessary for safe, independent practice in each medical, diagnostic, and surgical discipline. Neurosurgery was one of seven early adopter specialties to design, publish, and implement discipline-specific milestones. Preliminary validity has been established for the milestones in general and the neurosurgery milestones in particular. The milestones have been highly valued by residency directors, faculty, and trainees for clarifying educational goals and expectations, promoting transparent and honest feedback about progress, and identifying opportunities for coaching and mitigation early.
The milestones have also required additional administrative and faculty effort. Additionally, they have identified significant gaps in the availability of accurate and objective assessment tools. For example, formal assessment of operative skills, which has traditionally been difficult due to a paucity of user-friendly evaluation systems, is becoming more commonplace with the development of new tools. Finally, the Milestones have incorporated explicit educational outcomes expectations for PBL and QI within residency training.
Education of Physician Well-Being
Medicine depends on a workforce of extraordinarily dedicated clinicians. Unfortunately, physicians are particularly vulnerable to burnout, depression, and suicide. There are nearly 300–400 physician suicides per year, with a far higher suicide completion rate compared with the general public. Physicians tend to be a particularly vulnerable population due to inherent job stresses, irregular sleep patterns, extreme work hours, little time for self-care, forced relocation away from family and friends during training or practice, and feelings of isolation from peers and support.
In residents, suicide is the leading cause of death for males and the second leading cause for females (following malignancy). Most resident suicides happen in the first 2 years, with bimodal peaks in the first and third quarters of the year. The first quarter peak is presumably due to the considerable and abrupt change in life stressors with the transition from the relatively unpressured final year of medical school to internship. The third quarter peak is likely explained by a combination of seasonal affective disorder, holiday season-related stressors, and postholiday depression.
Regardless of specialty, the prevalence of depression or depressive symptoms is between 20% and 43% in medical trainees and, importantly, increases in likelihood over time. In addition, changes to insurance reimbursement and business model-driven health care have reduced physicians’ ability to spend time with each patient, increased clinician stress, and led to massive burnout rates. Burnout, characterized by emotional exhaustion, depersonalization, and a low sense of accomplishment, is prevalent in nearly 40%–80% of trainees. Unfortunately, physician burnout also impacts spouses and other family members, who also exhibit similar rates of psychological distress.
Grit, defined as “perseverance and passion for long-term goals” is a recent psychological construct that has been noted to be an independent predictor of success in high-stress situations, with predictive validity beyond that of IQ and conscientiousness. Some fortunate individuals appear naturally resilient, with abundant grit, while others find that medical training exposes them to emotionally charged and highly stressful situations with little guidance or training in psychological resilience. Use of positive psychological exercises such as “Three Good Things,” in which participants list three things that went well during the day, have been shown to help with mental resilience and to increase happiness. Physical fitness programs can also improve quality of life, and result in nonsignificant improvements in burnout rates.
In 2008, the Institute for Healthcare Improvement (IHI; www.ihi.org ) introduced the “triple aim” for American health care of improved population health, enhanced patient experience (including quality and satisfaction), and reduced per capita cost. More recently, the IHI, along with other stakeholders, broadly adopted a 4th aim, provider wellness and satisfaction. The 4th aim recognizes that only a resilient and motivated clinical workforce will be capable of promoting an effective and efficient health care system.