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Jacob K. Greenberg, Eric Milner, Chester K. Yarbrough, Kim Lipsey, Jay F. Piccirillo, Matthew D. Smyth, Tae Sung Park, and David D. Limbrick Jr.

OBJECT

Chiari malformation Type I (CM-I) is a common and often debilitating neurological disease. Efforts to improve treatment of CM-I are impeded by inconsistent and limited methods of evaluating clinical outcomes. To understand current approaches and lay a foundation for future research, the authors conducted a systematic review of the methods used in original published research articles to evaluate clinical outcomes in patients treated for CM-I.

METHODS

The authors searched PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and Cochrane databases to identify publications between January 2003 and August 2013 that met the following criteria: 1) reported clinical outcomes in patients treated for CM-I; 2) were original research articles; 3) included at least 10 patients or, if a comparative study, at least 5 patients per group; and 4) were restricted to patients with CM-I.

RESULTS

Among the 74 papers meeting inclusion criteria, there was wide variation in the outcome methods used. However, all approaches were broadly grouped into 3 categories: 1) “gestalt” impression of overall symptomatic improvement (n = 45 papers); 2) postoperative change in specific signs or symptoms (n = 20); or 3) results of various standardized assessment scales (n = 22). Among standardized scales, 11 general function measures were used, compared with 6 disease-specific tools. Only 3 papers used scales validated in patients with CM-I. To facilitate a uniform comparison of these heterogeneous approaches, the authors appraised articles in multiple domains defined a priori as integral to reporting clinical outcomes in CM-I. Notably, only 7 articles incorporated patient-response instruments when reporting outcome, and only 22 articles explicitly assessed quality of life.

CONCLUSIONS

The methods used to evaluate clinical outcomes in CM-I are inconsistent and frequently not comparable, complicating efforts to analyze results across studies. Development, validation, and incorporation of a small number of disease-specific patient-based instruments will improve the quality of research and care of CM-I patients.

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Hari S. Raman, David D. Limbrick Jr., Wilson Z. Ray, Dean W. Coble, Sophie Church, Ralph G. Dacey Jr., and Gregory J. Zipfel

OBJECTIVE

The challenging nature of neurosurgical residency necessitates that appropriate measures are taken by training programs to ensure that residents are properly progressing through their education. Residents who display a pattern of performance deficiencies must be identified and promptly addressed by faculty and program directors to ensure that resident training and patient care are not affected. While studies have been conducted to characterize these so-called “problem residents” in other specialties, no current data regarding the prevalence and management of such residents in neurosurgery exist. The purpose of this study was to determine the rate and the outcome of problem residents in US neurosurgical residency programs and identify predictive risk factors that portend a resident’s departure from the program.

METHODS

An anonymous nationwide survey was sent to all 108 neurosurgical training programs in the US to assess a 20-year history of overall attrition as well as the management course of problem residents, including the specific deficiencies of the resident, management strategies used by faculty, and the eventual outcome of each resident’s training.

RESULTS

Responses were received from 36 centers covering a total of 1573 residents, with the programs providing a mean 17.4 years’ worth of data (95% CI 15.3–19.4 years). The mean prevalence of problem residents among training programs was 18.1% (95% CI 14.7%–21.6%). The most common deficiencies recognized by program directors were poor communication skills (59.9%), inefficiency in tasks (40.1%), and poor fund of medical knowledge (39.1%). The most common forms of program intervention were additional meetings to provide detailed feedback (93.9%), verbal warnings (78.7%), and formal written remediation plans (61.4%). Of the identified problem residents whose training status is known, 50% graduated or are on track to graduate, while the remaining 50% ultimately left their residency program for other endeavors. Of the 97 residents who departed their programs, 65% left voluntarily (most commonly for another specialty), and 35% were terminated (often ultimately training in another neurosurgery program). On multivariable logistic regression analysis, the following 3 factors were independently associated with departure of a problem resident from their residency program: dishonesty (OR 3.23, 95% CI 1.67–6.253), poor fund of medical knowledge (OR 2.54, 95% CI 1.47–4.40), and poor technical skill (OR 2.37, 95% CI 1.37–4.12).

CONCLUSIONS

The authors’ findings represent the first study to characterize the nature of problem residents within neurosurgery. Identification of predictive risk factors, such as dishonesty, poor medical knowledge, and/or technical skill, may enable program directors to preemptively act and address such deficiencies in residents before departure from the program occurs. As half of the problem residents departed their programs, there remains an unmet need for further research regarding effective remediation strategies.