(08-23-2020, 12:58 AM)Guest Wrote: Seriously what are the expected skills/cases by the end of PGY4? In my program, we do the drilling/instrumentation of simple PCDF, laminectomies or lumbar laminectomies with attending heavily involved. For closing the attending leaves but I am concerned of this poor autonomy or this is how it's in most of other programs
Junior attending here. I would expect that as you become more senior, the experience across programs is going to vary. Some programs are training community neurosurgeons and some are shooting for academic subspecialists, so the training philosophy for senior residents is going to be geared toward that.
The obsession with autonomy is misplaced (but not surprising) among residents. If you're actually doing the operating, it shouldn't really matter whether an attending is there or not for you to learn the technique. IMO autonomy matters for the "oh shit" moments, where you have to make a call based on an intra-op error, aberrant anatomy, change in instruments, etc. If they aren't leaving you alone, good attending should ask or teach you about these things. If not, it's up to you to ask.
I wouldn't expect most attendings to be comfortable with a PGY4 doing a spine case independently, no matter the simplicity or the practice environment. They are not very familiar with your skill and you probably haven't seen enough to know what to do if something goes wrong. Spend more time learning about your cases, watching (and I mean watching with intent) your attending operate, and perfecting your technique. The autonomy will come. No matter how much of it you get, you'll be scared as hell on your first day as an attending anyway.
(08-23-2020, 12:03 PM)Guest Wrote: (08-23-2020, 12:58 AM)Guest Wrote: Seriously what are the expected skills/cases by the end of PGY4? In my program, we do the drilling/instrumentation of simple PCDF, laminectomies or lumbar laminectomies with attending heavily involved. For closing the attending leaves but I am concerned of this poor autonomy or this is how it's in most of other programs
Junior attending here. I would expect that as you become more senior, the experience across programs is going to vary. Some programs are training community neurosurgeons and some are shooting for academic subspecialists, so the training philosophy for senior residents is going to be geared toward that.
The obsession with autonomy is misplaced (but not surprising) among residents. If you're actually doing the operating, it shouldn't really matter whether an attending is there or not for you to learn the technique. IMO autonomy matters for the "oh shit" moments, where you have to make a call based on an intra-op error, aberrant anatomy, change in instruments, etc. If they aren't leaving you alone, good attending should ask or teach you about these things. If not, it's up to you to ask.
I wouldn't expect most attendings to be comfortable with a PGY4 doing a spine case independently, no matter the simplicity or the practice environment. They are not very familiar with your skill and you probably haven't seen enough to know what to do if something goes wrong. Spend more time learning about your cases, watching (and I mean watching with intent) your attending operate, and perfecting your technique. The autonomy will come. No matter how much of it you get, you'll be scared as hell on your first day as an attending anyway.
Excellent advice, thank you
(08-23-2020, 06:28 PM)Guest Wrote: (08-23-2020, 12:03 PM)Guest Wrote: (08-23-2020, 12:58 AM)Guest Wrote: Seriously what are the expected skills/cases by the end of PGY4? In my program, we do the drilling/instrumentation of simple PCDF, laminectomies or lumbar laminectomies with attending heavily involved. For closing the attending leaves but I am concerned of this poor autonomy or this is how it's in most of other programs
Junior attending here. I would expect that as you become more senior, the experience across programs is going to vary. Some programs are training community neurosurgeons and some are shooting for academic subspecialists, so the training philosophy for senior residents is going to be geared toward that.
The obsession with autonomy is misplaced (but not surprising) among residents. If you're actually doing the operating, it shouldn't really matter whether an attending is there or not for you to learn the technique. IMO autonomy matters for the "oh shit" moments, where you have to make a call based on an intra-op error, aberrant anatomy, change in instruments, etc. If they aren't leaving you alone, good attending should ask or teach you about these things. If not, it's up to you to ask.
I wouldn't expect most attendings to be comfortable with a PGY4 doing a spine case independently, no matter the simplicity or the practice environment. They are not very familiar with your skill and you probably haven't seen enough to know what to do if something goes wrong. Spend more time learning about your cases, watching (and I mean watching with intent) your attending operate, and perfecting your technique. The autonomy will come. No matter how much of it you get, you'll be scared as hell on your first day as an attending anyway.
Excellent advice, thank you
As a senior resident I would disagree with this to an extent.
Graduated autonomy has been a core aspect of neurosurgical training for many years and I think it remains critical for appropriate progression throughout residency with the ultimate goal of graduating a competent neurosurgeon. We spend more time as residents than other disciplines and are more focused on specific pathology. Naturally, we should be pretty comfortable by the time we graduate with basic operations (MLDs, ACDFs, simple fusion, shunts, simple brain tumors). You should also be comfortable with dealing with potential difficulties or complications that may arise during/after these procedures. There is sub-specialization that occurs for vascular, skull base, deformity, etc. but most community neurosurgeons won't need these skills to be successful and take care of patients. At most programs, residents aren't clipping aneurysms and performing deformity operations solo, but if you are, good for you, you probably deserve a pay bump.
Not having someone watch every move you make matters because silence from someone observing you is really an indication that the move you are about to make is acceptable. Learning when a decompression is complete, judging when a screw that looks good on nav/xray is gonna be out or staying on the tumor margin without leaving a rim behind are skills that have to be learned through doing. Someone needs to show you and walk you through it many times, but eventually you have to just do it. The reality is that gaining confidence to do a procedure solo can either happen in residency with an attending backing you up to deal with complications/fallout or it can happen early in your career.
As stated previously, autonomy and the gradation of when it occurs is heavily program specific and dependent on how early and often you get to operate. Unfortunately, the places with appropriate graduated autonomy are decreasing. Programs with VAs and county hospitals tend to provide more than those with solely private hospitals.
To answer the original question: if you look at the ACGME neurosurgical milestones ( https://www.acgme.org/Portals/0/PDFs/Mil...stones.pdf) you should be at a "level 4" by the end of chief year, level 5 at the end of fellowship. Assuming chief year is PGY-6 then i think it's fair to say you should be at level 2 by the end of PGY-3 (though the authors submit that's not the intent of the system, let's assume it's the best guideline we have for your question). This means by the end of PGY-3 you should be "assisting" with simple procedures in spine, tumor, vascular, trauma, functional, which they define as simple lami's, convexity meningiomas, simple mets, hemicrani's, burr holes, DBS, spinal cord stims, shunts, etc.
I interpret that more specifically as:
1. Doing a simple craniotomy by yourself, incision, exposure, craniotomy itself, open dura safely
2. Opening, exposing, and closing spine adequately
3. Simple spine instrumentation (PCDFs, thoracic/lumbar pedicle screws in straight forward anatomy)
4. Do simple procedures completely by yourself (Burr holes, battery changes, shunts)
At my program that's pretty consistent with a PGY-2 late in the year, but I don't think that's at all standard. Some programs are geared more to do floor work and call early on with rapid progression from PGY 3-7, and all that matters is where you end at graduation.
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