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Robert M. Starke, John A. Jane Jr., Ashok R. Asthagiri and John A. Jane Sr.

is a valued addition to resident education, but direct operating room exposure is still essential. Transition to Practice Following the 2003 duty hour restrictions and the ACGME requirements, a number of centers adopted a transition-to-practice model to ensure that residents were prepared for independent surgical practice. 9 , 17 Residents would fulfill the ACGME requirements, including the chief year, during the first 6 years of residency. The final year would then function as a transition to practice allowing clinical instructors to fine-tune clinical and

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Jay Jagannathan, G. Edward Vates, Nader Pouratian, Jason P. Sheehan, James Patrie, M. Sean Grady and John A. Jane Sr.

Survey responses to questions about the 80-hour workweek were obtained from 110 program directors (78% response rate) and 122 chief residents (76% response rate; Fig. 5 ). These responses were concordant in all areas. F ig . 5. Bar graphs demonstrating the responses of 122 chief residents (right side of each graph) and 110 program directors (left side of each graph) in ACGME-accredited neurosurgical programs to a 6-question survey about the effects of the 80-hour workweek on aspects of resident education, patient care, and surgical training. The

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Robert W. Bina, G. Michael Lemole Jr. and Travis M. Dumont

W ithin neurosurgery, the national mandate of the 2003 duty hour restrictions (DHR) by the Accreditation Council for Graduate Medical Education (ACGME) has been controversial at best. Ensuring the proper education, training, socialization, and psychological well-being of residents while fulfilling our primary purpose of patient care has generated an 11-year debate. Many of the formal medical disciplines have studied the effects that DHR have had on resident education and have developed strategies to address the often conflicting needs of education and

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Chris J. Neal and Michael K. Rosner

A s the first few generations of residents graduate under the work-hour restrictions imposed by the Accreditation Council for Graduate Medical Education in 2003, competency in various procedures will come under increased scrutiny in the credentialing process. Further efforts must be made during the training period to maximize resident education and proficiency. One aspect of such efforts is to understand the number of procedures that must be performed before a trainee can be considered safe and competent. Comparing the ability to perform a task more

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Christopher Miller, Paige Lundy and Sarah Woodrow

to train at an early point in their career and develop the necessary knowledge base and skills to continue as a member of the international surgical workforce throughout their career. The individual at any given US training program most responsible for resident education is the program director. Therefore, a strong understanding of their opinions on exposure to LMIC environments is crucial to understand and expand this type of resident training. To do this, program directors at Accreditation Council for Graduate Medical Education (ACGME)–approved training sites

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Changing our culture

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Deborah L. Benzil

these issues. Let me cite just a few examples. In the arena of positive change in resident education, Tom Origitano initiated a Boot Camp project to provide rapid training to early-level residents to avoid unnecessary “rookie errors.” Now his concept has expanded significantly to the benefit of all! 15 Similarly, Bob Harbaugh and Tony Asher have been early innovators in the realm of registries to promote quality outcomes research. Their brainchild, NeuroPoint Alliance (NPA), now serves as a model for specialty collaboration in assessing and promoting quality outcomes

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Guillermo Aldave, Daniel Hansen, Valentina Briceño, Thomas G. Luerssen and Andrew Jea

be used to determine appropriate training durations. 16 , 26 Our study seems to suggest that resident rotations in pediatric neurosurgery of ≥ 4 months provided statistically significantly more skills proficiency than rotations of lesser duration. In addition to fulfilling the requirements of the governing bodies of neurosurgical resident education, we plan to use this tool to improve resident feedback. By providing timely and structured feedback to residents, deliberate goal-oriented practice, as described in the acquisition of expertise in other disciplines

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William E. Gordon, William M. Mangham, L. Madison Michael II and Paul Klimo Jr.

the very least resident education results in indirect costs related to longer OR time. Previous papers have examined the potential economic value of residents in other specialties, but none have appraised neurosurgical residents. 8–12 We undertook this study to provide a quantitative glimpse of the economic impact an on-call junior resident can have over a consecutive 2-year period. Methods Resident On-Call System Institutional review board approval for this study was obtained before data collection. At our institution, a single on-call junior resident (PGY 2, 3

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Seunggu J. Han, Rajiv Saigal, John D. Rolston, Jason S. Cheng, Catherine Y. Lau, Rita I. Mistry, Michael W. McDermott and Mitchel S. Berger

Object

Given economic limitations and burgeoning health care costs, there is a need to minimize unnecessary diagnostic laboratory tests.

Methods

The authors studied whether a financial incentive program for trainees could lead to fewer unnecessary laboratory tests in neurosurgical patients in a large, 600-bed academic hospital setting. The authors identified 5 laboratory tests that ranked in the top 13 of the most frequently ordered during the 2010–2011 fiscal year, yet were least likely to be abnormal or influence patient management.

Results

In a single year of study, there was a 47% reduction in testing of serum total calcium, ionized calcium, chloride, magnesium, and phosphorus. This reduction led to a savings of $1.7 million in billable charges to health care payers and $75,000 of direct costs to the medical center. In addition, there were no significant negative changes in the quality of care delivered, as recorded in a number of metrics, showing that this cost savings did not negatively impact patient care.

Conclusions

Engaging physician trainees in quality improvement can be successfully achieved by financial incentives. Through the resident-led quality improvement incentive program, neurosurgical trainees successfully reduced unnecessary laboratory tests, resulting in significant cost savings to both the medical center and the health care system. Similar programs that engage trainees could improve the value of care being provided at other academic medical centers.

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Sarah I. Woodrow, Mark Bernstein and M. Christopher Wallace

Object. Patient care and educational experience have long formed a dichotomy in modern surgical training. In neurosurgery, achieving a delicate balance between these two factors has been challenged by recent trends in the field including increased subspecialization, emerging technologies, and decreased resident work hours. In this study the authors evaluated the experience profiles of neurosurgical trainees at a large Canadian academic center and the safety of their practice on patient care.

Methods. Two hundred ninety-three patients who underwent surgery for intracranial aneurysm clipping between 1993 and 1996 were selected. Prospective data were available in 167 cases, allowing the operating surgeon to be identified. Postoperative data and follow-up data were gathered retrospectively to measure patient outcomes. In 167 cases, a total of 183 aneurysms were clipped, the majority (91%) by neurosurgical trainees. Trainees performed dissections on aneurysms that were predominantly small (<1.5 cm in diameter; 77% of patients) and ruptured (64% of patients). Overall mortality rates for the patients treated by the trainee group were 4% (two of 52 patients) and 9% (nine of 100 patients) for unruptured and ruptured aneurysm cases, respectively. Patient outcomes were comparable to those reported in historical data. Staff members appeared to be primary surgeons in a select subset of cases.

Conclusions. Neurosurgical trainees at this institution are exposed to a broad spectrum of intracranial aneurysms, although some case selection does occur. With careful supervision, intracranial aneurysm surgery can be safely delegated to trainees without compromising patient outcomes. Current trends in practice patterns in neurosurgery mandate ongoing monitoring of residents' operative experience while ensuring continued excellence in patient care.