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Navigating the Strait of Magellan: mapping a new paradigm for neurosurgical residency training

Presidential Address to the Society of Neurological Surgeons, May 7, 2007

A. John Popp

At the conclusion of his year as 81st president of the Society of Neurological Surgeons, the author delivered the following address at the 2007 annual meeting of the Society of Neurological Surgeons in San Francisco. In his address, Dr. Popp used the voyage of Ferdinand Magellan to illustrate the present climate affecting residency training and why the current training paradigm must be examined and, where necessary, changed. Based on this call to action the leaders of the American Association of Neurological Surgeons, The American Board of Neurological Surgeons, The Congress of Neurological Surgeons, The Council of State Neurosurgical Societies, The Residency Review Committee for Neurosurgery, The Society of Neurological Surgeons, and the Washington Committee for Neurosurgery agreed to hold an unprecedented Education Summit meeting to investigate a comprehensive approach to evaluating and changing the current neurosurgical residency training model.

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A. John Popp

✓ During Eldridge Campbell's tour of duty as the neurosurgical consultant to the Mediterranean theater of World War II operations, he was introduced to a then-revolutionary method of wound treatment. Ironically, Campbell's diligent research efforts later revealed that this method of wound treatment had first been advocated seven centuries earlier—in the same geographical location—by the Italian surgeon Theodoric. Although controversial, this method of wound care was subsequently applied and supported by Theodoric's outspoken pupil, Henri de Mondeville, despite intense opposition from the prevailing medical authorities who supported the doctrine of “laudable pus” for wound management. With Mondeville's death, Theodoric's technique lapsed into obscurity, relegated to a historical footnote until modern biology and the discoveries of Lister and Pasteur would again bring to light the benefits of nonsuppurative wound treatment.

In this article the author discusses the work of Theodoric, Mondeville, and Campbell in light of the medical climate of their times and explores the contemporary parallels noted by Campbell in terms of the neglect of other, more recent medical discoveries. These examples encourage us to accept or reject medical treatments based on a thorough examination of their efficacy and not on the stature of their advocates within the medical community.

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A. John Popp

✓ The concept of musical genius used to frame a discussion of the “art” practiced by neurosurgeons is the focus of the 2004 Presidential Address to the American Association of Neurological Surgeons (AANS). The musical genius, in contrast to the musically talented individual, is profiled and placed in the pantheon of those who have demonstrated extraordinary creativity. Observations and speculations about the specialization and elaboration of brain structures in musicians evolve into a discussion of artificial intelligence as a foil to what constitutes the essence of humanity. Taking an inductive approach, the author juxtaposes the conclusion about “music, musicians, and the brain” with the theme of the 2004 annual meeting of the AANS, “Advancing Patient Care Through Technology and Creativity,” to elaborate on the characteristics of the consummate neurosurgeon. (Note: Musical vignettes used in the address can be found in the accompanying article posted on Neurosurgical Focus http://www.aans.org/education/journal/neurosurgical).

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A. John Popp

✓ The concept of musical genius used to frame a discussion of the “art” practiced by neurosurgeons is the focus of the 2004 Presidential Address to the American Association of Neurological Surgeons (AANS). The musical genius, in contrast to the musically talented individual, is profiled and placed in the pantheon of those who have demonstrated extraordinary creativity. Observations and speculations about the specialization and elaboration of brain structures in musicians evolve into a discussion of artificial intelligence as a foil to what constitutes the essence of humanity. Taking an inductive approach, the author juxtaposes the conclusion about “music, musicians, and the brain” with the theme of the 2004 annual meeting of the AANS, “Advancing Patient Care Through Technology and Creativity,” to elaborate on the characteristics of the consummate neurosurgeon. (Note: Musical vignettes used in the address can be found in the accompanying article posted on Neurosurgical Focus http://www.aans.org/education/journal/neurosurgical).

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Richard A. Lende and A. John Popp

✓ Sensory Jacksonian seizures were analyzed in 42 patients with regard to anatomical and temporal sequences. The origin of sensory Jacksonian seizures, in contrast to motor Jacksonian seizures, often began at peripheral sites with little cortical representation. The progression of seizure activity across the cerebral cortex followed a course that was neither rectilinear, radiate, nor random; it appeared to proceed in an organized manner to involve functionally coherent units. The patterns analyzed conformed more closely to cortical somatosensory maps reported for the chimpanzee than the sensory sequences presently available for the cortex of man. Complete diagnostic studies are indicated in patients presenting with sensory Jacksonian seizures because of the frequency of related focal pathology.

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Matthew A. Adamo, Doniel Drazin and A. John Popp

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone–secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.

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Daniel L. Friedlich, Paul J. Feustel and A. John Popp

Object. The workforce demand for neurosurgeons was quantified by a review and an analysis of journal recruitment advertisements published over the past 13 years.

Methods. A retrospective analysis of recruitment advertisements from July 1985 through June 1998 was performed by examining issues of the Journal of Neurosurgery and Neurosurgery. Advertisement information that appeared in each journal during the last 3 years was collected from alternating months (July to May); information that appeared prior to that time was collected from alternating recruitment years back to 1985. The authors examined the following workforce parameters: practice venue, subspecialization, and practice size.

They found no significant decrease in neurosurgical recruitment advertisements. There was an average of 102.7 ± 22.4 (standard deviation) advertised positions per year during the most recent 3 years compared with 92.6 ± 17.9 advertised positions per year during the preceding decade. Similarly, there has been no decline in advertised positions either in academic (33 ± 6.1/year for the most recent 3 years compared with 32.8 ± 5.9/year for 1985–1995) or private practice (69.7 ± 21.6/year for the most recent 3 years compared with 59.8 ± 13.4/year for 1985–1995). A shift in demand toward subspecialty neurosurgery was observed. During the past 3 years, 31.2 ± 5.9% of advertised positions called for subspecialty expertise, compared with 18.5 ± 2.8% for the preceding decade (p < 0.05). The largest number of subspecialty advertisements designated positions for spine and pediatric neurosurgeons. Private practice advertisements increasingly sought to add neurosurgeons to group practices.

Conclusions. Contrary to previous reports and a prevailing myth, our data show no decrease in workforce demand for neurosurgeons in the United States over the past 3 years compared with the prior decade. A shift toward subspecialist recruitment, particularly for spine neurosurgeons, has been demonstrated in both academic and private practice venues.

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Daniel L. Friedlich, Paul J. Feustel and A. John Popp

Object

The workforce demand for neurosurgeons was quantified by a review and an analysis of journal recruitment advertisements published over the past 13 years.

Methods

A retrospective analysis of recruitment advertisements from July 1985 through June 1998 was performed by examining issues of the Journal of Neurosurgery and Neurosurgery. Advertisement information that appeared in each journal during the last 3 years was collected from alternating months (July to May); information that appeared prior to that time was collected from alternating recruitment years back to 1985. The authors examined the following workforce parameters: practice venue, subspecialization, and practice size.

They found no significant decrease in neurosurgical recruitment advertisements. There was an average of 102.7 ± 22.4 (standard deviation) advertised positions per year during the most recent 3 years compared with 92.6 ± 17.9 advertised positions per year during the preceding decade. Similarly, there has been no decline in advertised positions either in academic (33 ± 6.1/year for the most recent 3 years compared with 32.8 ± 5.9/year for 1985–1995) or private practice (69.7 ± 21.6/year for the most recent 3 years compared with 59.8 ± 13.4/year for 1985–1995). A shift in demand toward subspecialty neurosurgery was observed. During the past 3 years, 31.2 ± 5.9% of advertised positions called for subspecialty expertise, compared with 18.5 ± 2.8% for the preceding decade (p < 0.05). The largest number of subspecialty advertisements designated positions for spine and pediatric neurosurgeons. Private practice advertisements increasingly sought to add neurosurgeons to group practices.

Conclusions

Contrary to previous reports and a prevailing myth, our data show no decrease in workforce demand for neurosurgeons in the United States over the past 3 years compared with the prior decade. A shift toward subspecialist recruitment, particularly for spine neurosurgeons, has been demonstrated in both academic and private practice venues.

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Eric M. Deshaies, Darryl DiRisio and A. John Popp

In recent decades there have been revolutionary technological advances in the management of traumatic spinal column injuries. Despite these advances, the basic principles of reduction and stabilization of vertebral fractures and dislocations remain similar to those proposed by ancient and medieval physicians. Theodoric of Bologna, in his text Chiurgica de Theodoric (ca. AD 1267), described an extracorporeal approach to the management of traumatic spinal column misalignments. Surprisingly, his techniques are still used in many instances by contemporary spine surgeons, despite the availability of a more advanced technological armamentarium than that existent in medieval times.

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Ossama Al-Mefty, Edward R. Laws and A. John Popp

As it does periodically, the United States healthcare system is, yet again, undergoing a period of change on multiple fronts, including internal initiatives in education, quality, and the workforce, as well as external pressure responding to changes in reimbursement and oversight. In such times, looking back at the foundations of our specialty is helpful, allowing often-beleaguered neurosurgeons to reflect upon what it means to be a neurosurgeon, and how they can be assured that our specialty will continue to flourish in the future. Harvey Cushing envisioned, espoused, and developed neurological surgery as a “special field”—a comprehensive, encompassing, and distinct discipline that studies the nervous system and manages neurological disorders. It provides surgical intervention for the treatment of neurological disorders; it by no means was meant to be developed as a mere technical or procedural skill; it is neither a subspecialty of surgery nor a branch of neurology; it is a “special field” that has flourished to become a crown jewel in the realm of medicine. Herein is a perspective that brings the inception and future of this concept to light. A specialty that is to live and flourish should stand on and recognize its roots.