Is there any serious talk about changing neurosurgery residency training to eliminate nursing and hospitalist responsibilities that take up the intern year and up to half of the second and third year in many places, to eliminate or make optional the two research years, and to make fellowships optional final year, after the chief year? With the work hour restriction and growing popularity of using PAs and APRNs to do floor care and clinics, could there be redesign of the neurosurgical residency to focus more on the work on the OR, minimize double scrubbing, and make fellowship part of residency to eliminate the creep in length of training and eliminate problems that introducing fellowships poses in terms of exploiting neurosurgeons for suboptimal pay and taking cases away from residents? Perhaps part of accreditation should include having sufficient mid-level, nursing, ICU and hospitalist support; as well as guaranteeing there is no double scrubbing for residents, and providing residents with OR training on daily bases?
For example:
PGY1: junior operative year
PGY2: senior operative year
PGY3: elective year that can be some combo of research and specialty training (eg endo/MIS/functional)
PGY4: chief year
PGY5: fellowship or research year (can be done at other institution, be accredited fellowship, and serve as transition to attending year)
News flash. The people who care don’t matter and the people who matter don’t want to give up the free labor.
Yes, this actually has been discussed at the national leadership level, although the proposal was slightly different. Essentially 5 straight clinical years (with elective years eliminated) would result in a board eligible, "general neurosurgeon" and some type of fellowship would then be required for subspecialty training. This is essentially how ortho functions, where after 5 clinical years essentially everyone does a fellowship.
Unfortunately, as you can tell, the folks at the top did not bite. Who's going to work in the lab?
Break off spine surgery to a separate training program. The “general neurosurgery” jobs at the end are 90% degen spine anyway. It seems a poor use of training hours to have these trainees spend long says in skull base and vascular cases that they will never do again in their career. Conversely, those entering training hoping for largely academic cranial jobs should spend time in the lab versus doing XLIFs. I image the vast majority of current training slots could be allocated to spine with a small minority pursuing cranial.
This isn't a bad idea and there's been a lot of talk about it among big names in both neurosurgery and ortho, but there's one huge problem. Over 50% of the departmental revenue at most programs comes from spine. If you spin off spine surgery, the cranial chairs would lose control over a huge percentage of the money, which makes it hard to appropriately pay good people to be physician-scientists, invest in tech (the exoscopes and robots for functional don't come cheap), and negotiate for protected OR block time in the hospital. Endovascular makes a lot too, but there are way fewer of them, so the raw numbers are much smaller.
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Don't forget it was only ten years ago when the eliminated six year programs.
A lot of neurosurgery residency is wasted/unnecessary time, I agree, but the above poster is correct, it will not be shortened or made more efficient. Too much of the current status quo depends upon cheap labor, which cannot be found anywhere else. Similarly, as someone above pointed out, cranial surgeons have a vested interest in spine not spinning off, as spine pays all the bills, keeps the lights on, and subsidizes the existence of the cranial guys. Neurosurgery departments at most hospitals are important and influential due to the income they bring in. If spine were to leave, and neurosurgery were cranial only, neurosurgery would become almost irrelevant, as surgical volumes would plummet, department RVUs would plunge, and even outcomes would worsen (cranial patients generally don’t do as well due to obvious nature of their pathologies). No neurosurgery department head wants to lose spine.
And yet the skull base guys shit on spine continuously…like having an ungrateful child
While most jobs are PP and >70% degen spine, someone still needs to be around to take cranial call. If you break spine off to its own speciality, then you will train fewer "pure" neurosurgeons. There will not be enough to go around after a couple of decades.
I would also question whether most programs can hit minimums for cases and experience if the time is shortened. A shocking number of places skirt by and many do not give adequate autonomy anyways.
The skull-base and clipping guys should take seats. GK and endo are eating them alive.
Most skull base and vascular surgeons have incorporated GK and endo into their practice. I am vascular and am on pace for >20,000 RVUs this year. Nevertheless, I agree that spine is a financial powerhouse due to the capacity to support numerous spine surgeons at one institution. Apart from the financial aspect, I think if you separated spine and cranial the quality of training would suffer. As an early resident I gained most of my procedural confidence doing spine cases, and without that I don’t think I would have been trusted to eventually do more in cranial cases. Without that extra volume of cases, you’d have poorly trained “cranial” surgeons that never did a case on their own in training. On the flip side, even for the hardcore spine jockeys, is knowing how to do brain surgery really not worth a couple extra years of training? I’d bet that the brain tumors PP guys take out are some of their most enjoyable cases.
