Question for residents: what do you know how to do for your level?

[?????]

I’ve been seeing a lot of posts about what type of procedures certain level residents can perform so I want a consensus for some.

So from things as simple as an evd to to clipping an aneurysm, at one point should residents be adept at doing these cases?

[Guest]

varies by program for me:
end of PGY1: evaluate consults well, ID surgical emergencies, perform EVD independently, first assist well on traumas, know how to set up traction/halo (not perform solo but watched)
end of pgy2: first assist well in basic tumor/spine, independently can: evacuate SDH, perform shunt (abdominal portion too), open crani for tumor down to dura (set up nav, turn a crani), expose for laminectomy, start some very simple drilling of lami
end of PGY3: more complex exposures (independent now in retrosig), acdf exposure, can put in lumbar screws and lateral mass screws, lamis, lumbar disc/nerve decompression, can take out simple tumor under scope, can take out disc and open ligament in acdf can do a diagnostic agram, traction/halo placement, set up endoscope and do basics of ETV, learning to split fissure
pgy 4/5: research year, variable but should go to or, gain experience with more difficult things like vascular skull base and complex spine
end of pgy6: you should be pretty independent by now, can do traumas, can do spine stabilization, can put in interbody work, can do acdfs independently, independent more complex tumor work (p.fossa, skull base basics like drilling the clinoid, retrosig, unlikely you'll be doing a translab unless you're at that type of program), can clip aneurysms (mca and pcomms are for sure good starters), if you're edovascualar oriented should now be able to take out clot in vessel and some basics of coiling
PGY7: just icing on the cake and choosing cases you will learn from. if you can't operate by now that would be concerning or due to your program's culture.

[Guest]

Highly program dependent based on what sort of cases are predominant as well as you as an individual and your personal relationship w/ your chief or attending, but in general:

Interns: EVDs, bolts, basic floor/ICU procedures and basic assist in OR (if any OR time) such as helping assist/position patient, pinning, suctioning, incision/closure

PGY2: Should know ins/outs of patient positioning, navigation setup, prep have room ready to go, etc. Basic cranial/spine exposures, washouts, basic bread and butter trauma, minor (2-3 level) spine cases (performing laminectomy, throwing rods/screws w/ supervision early on), and VP shunts supervised. Do good portion of peripheral nerve/functional cases as well.

PGY3: Build on pgy2 and resect superficial tumors and perform basic skull base (including endonasal) approaches, more hands on w/ endoscopic cases (i.e. ETV) in general. Play larger role in big spine (think deformity) or complex MIS cases. Some peds exposure including craniosynostosis, chiaris. Should be comfortable doing PGY2 level cases independently for the most part. This year really depends on how much your seniors will let you do. In some cases your stuck watching the chief/attending tackle a complex case, i would say pay close attention to every move each one makes during these kinds of cases. 

PGY4/5: Elective, for those doing endovascular, how hands on depends on your program; open vascular is admittedly not robust here, but complex aneurysm not amenable to embo still come in.  How much protected research time/operating you do these years is highly variable depending on the path you take (research, enfolded fellowship, etc) and if you still are called in for cases/take call.

PGY6: Chief year, move towards more complex tumor including skull base (vestibular schwannomas and other CP angle tumors, pituitary resections) and larger gliomas, meningiomas. Vascular including CEAs, clippings, AVMs, bypass, moyamoya (again seeing less and less clippings). Intramedullary tumors, pediatric tumors. Comfortable with majority of spine including MIS and deformity. 

PGY7: Fellowship or chief year depends on program, basically attending.

I would like to again reiterate every program "graduates" their autonomy differently. Ours is front loaded with protects time for research/fellowship. Also, we don't have large open vascular presence whereas some centers do so at those places those cases trickle down to more junior levels. Other programs are exceptionally strong in spine yet lacking in tumor, so I hope that people reading this can appreciate these variations when deciding on residencies. Programs with big name guys often don't let residents touch their patients and rely on fellows, something else to consider.

[Guest]

These are great responses. Could anyone at a classic “academic, lower volume” place compare to what their experience has been?

[Guest]

There are PGY 4/5s out there doing translabs?

[Guest]

The post above is simply not accurate for the majority of programs. I (highly) doubt it's accurate for the program that person claims to be from. Case in point, there are simply not enough programs in the country doing significant open vascular these days for graduates to all feel comfortable with aneurysm clippings. That is an established, known fact - why else would the RRC be annually dropping the case requirements for open vascular? It's laughable that the above poster thinks that the PGY6s at their program feel good about their skull base procedures. I've seen enough skull base fellows come through my own program with plenty that they need to learn (all from pedigreed programs).

"PGY2s should be able to do a good chunk of peripheral nerve." Obviously haven't seen a brachial plexus case. There are <5 NSGY attendings in the country that can do those well, let alone residents. CTRs and ulnar n. work don't count.

"PGY3s play large role in complex MIS deformity case." Huh? No. Just no. Mummaneni just did a podcast where he talked about having to teach his fellows about posting and planning. His FELLOWS.

"PGY6 bypass, moyamoya." Unless you're at Stanford or BNI, most places do <30 per year. And if you're at Stanford, please don't talk about your amazing autonomy.

Whatever your programs progression (front or back loaded), there are a list of cases that you should be able to perform autonomously by the end of PGY4. This is the concept of the "core" training that is progressively becoming the norm among programs. That would include cranial trauma (including shunts and abscesses), basic spine (ACDFs, cervical and lumbar lami fusions), basic tumor (simple cortical met). The honest truth is that many programs will still struggle to get you there.

Here's what my and my friends programs expect to be autonomous by each level. Important: if the attending needs to be in the room at all, it's not autonomous.
PGY1: consults and bedside procedures
PGY2: positioning, opening/closing
PGY3: independent for most cranial trauma and VPS, significant progress on simple spine - getting through majority of bone work (ACDF, lami), tumor openings
PGY4: tasting more complex spine (maybe MIS, maybe deformity), understand opening for open vascular cases, taking out some tumor (need to get that frozen path cooking)
Chief: independent with typical PP spine, taking out the tumor, fissure splitting
Elective: comfortable with diagnostic angios if endo, SPOs/osteotomies and pelvic screws if spine, everything but the ATL if functional, multi-level TLIFs and lateral approaches if MIS

[Guest]

(10-11-2020, 11:58 AM)Guest Wrote: The post above is simply not accurate for the majority of programs. I (highly) doubt it's accurate for the program that person claims to be from. Case in point, there are simply not enough programs in the country doing significant open vascular these days for graduates to all feel comfortable with aneurysm clippings. That is an established, known fact - why else would the RRC be annually dropping the case requirements for open vascular? It's laughable that the above poster thinks that the PGY6s at their program feel good about their skull base procedures. I've seen enough skull base fellows come through my own program with plenty that they need to learn (all from pedigreed programs).

"PGY2s should be able to do a good chunk of peripheral nerve." Obviously haven't seen a brachial plexus case. There are <5 NSGY attendings in the country that can do those well, let alone residents. CTRs and ulnar n. work don't count.

"PGY3s play large role in complex MIS deformity case." Huh? No. Just no. Mummaneni just did a podcast where he talked about having to teach his fellows about posting and planning. His FELLOWS.

"PGY6 bypass, moyamoya." Unless you're at Stanford or BNI, most places do <30 per year. And if you're at Stanford, please don't talk about your amazing autonomy.

Whatever your programs progression (front or back loaded), there are a list of cases that you should be able to perform autonomously by the end of PGY4. This is the concept of the "core" training that is progressively becoming the norm among programs. That would include cranial trauma (including shunts and abscesses), basic spine (ACDFs, cervical and lumbar lami fusions), basic tumor (simple cortical met). The honest truth is that many programs will still struggle to get you there.

Here's what my and my friends programs expect to be autonomous by each level. Important: if the attending needs to be in the room at all, it's not autonomous.
PGY1: consults and bedside procedures
PGY2: positioning, opening/closing
PGY3: independent for most cranial trauma and VPS, significant progress on simple spine - getting through majority of bone work (ACDF, lami), tumor openings
PGY4: tasting more complex spine (maybe MIS, maybe deformity), understand opening for open vascular cases, taking out some tumor (need to get that frozen path cooking)
Chief: independent with typical PP spine, taking out the tumor, fissure splitting
Elective: comfortable with diagnostic angios if endo, SPOs/osteotomies and pelvic screws if spine, everything but the ATL if functional, multi-level TLIFs and lateral approaches if MIS

I'm a resident at an operatively heavy program out west and I agree that the above is only possible at a small handful of programs. That person is obviously from Mayo Rochester, where they have top notch peripheral nerve and skull base with good resident autonomy, but this isn't really feasible at the majority of places. Some other programs where you MAY be able to get to that level (- the peripheral nerve/SB) are BNI, Carolinas, Pitt, and USC. The vast majority of academic places won't even come close to those benchmarks.