Neurosurg Focus Volume 49 • July 2020 1

NEUROSURGICAL

FOCUS Neurosurg Focus 49 (1):E12, 2020

LETTERS TO THE EDITORNeurosurgical Forum

Surgical logbooks in neurosurgery: a simple way to enhance training

TO THE EDITOR: I have read the article by Deora et al.1 on neurosurgery training in lower-middle-income countries (Deora H, Garg K, Tripathi M, et al. Residency perception survey among neurosurgery residents in low-er-middle-income countries: grassroots evaluation of neu-rosurgery education. Neurosurg Focus. 2020;48[3]:E11). I want to congratulate the authors on their effort to gather trainee feedback internationally. The authors have ana-lyzed teaching patterns, subspecialty exposure, examina-tion patterns, work hours, surgical training, and medium of learning in their article.

The authors noted that despite working long hours, res-idents were dissatisfied with their operative training and hands-on exposure. As a surgical resident, one of the most

important aspects of training is the surgical skills they de-velop through the period. The authors in their study state that more than 60% of the respondents felt the need for better hands-on exposure during the training. This is a concern with regard to the competence of graduating resi-dents safely performing independent procedures.

In the United Kingdom (UK), the accreditation board proposes the candidate should have completed 1200 cases with 50 index cases across specialties.2 Following suc-cessful completion of an examination, registration to the specialist register should satisfy criteria in clinical and op-erative experience, competence, research, quality improve-ment, medical education, training, management, leader-ship, and participation in conferences.3 This sets high standards in surgical competency and expertise, improving patient safety and outcome.

A surgical logbook that is maintained and validated by trainers will enable us to ensure a higher quality of train-

FIG. 1. Comprehensive report of procedures. EVD = external ventricular drain; VP = ventriculoperitoneal; AVM = arteriovenous malformation; ICH = intracerebral hemorrhage; A = assisted; S-TS = supervised-trainer scrubbed; S-TU = supervised-trainer unscrubbed but in theatre; P = performed; T = training a trainee; S-S = supervised (scrubbed); S-U = supervised (in theatre); S-H = supervised (in hospital); UC = under my care; O = observed; U = undefined; PCC = performed with consultant colleague; PPT = performed in part by trainee; PAT = performed: assisted by trainee.

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Neurosurgical forum

Neurosurg Focus Volume 49 • July 20202

ing in surgical specialties, especially neurosurgery. Moni-toring of the type of case is considered one way to ensure a general level of experience and competence before be-ginning postresidency practice. It provides an objective record of residents and medical schools, and evidence that the level of operative participation is significant in techni-cal skills development.4 The E-Logbook (www.elogbook.org) is an initiative by the Royal Colleges in the UK to record and monitor the training of its residents and build a surgical portfolio helping them through appraisals, re-validations, and recertifications. It is a free resource that can be used by practicing surgeons across the globe. Each procedure is tagged with the level of involvement of the trainee, and also breaks down each step of the surgery to record participation in operative stages. A comprehen-sive report at the end of residency can help evaluate one’s strengths and weakness and guide further improvement (Fig. 1).

The need of the hour in training centers is to inculcate the western concept of “surgical minimums” or a com-pulsory operative log for each level of resident training, enabling a finishing surgical resident to be “competent” at a minimum and preferably “proficient” in essential proce-dures.5 This would ensure that each trainee has performed a basic requisite of essential procedures both under super-vision and with reasonable independence.6

To conclude, as rightly pointed out by the authors, post-graduate surgical training in these countries, although grueling and tiresome, needs quantitative and qualitative enhancement. Implementing a surgical logbook is a good step to begin with. It will help us provide the society with competent neurosurgeons trained to perform basic proce-dures with reasonable confidence, expertise, and minimal complications in an independent setting.

Ajay Hegde, MCh, FRCSEdInstitute of Neurological Sciences, Glasgow, United Kingdom

References 1. Deora H, Garg K, Tripathi M, et al. Residency perception

survey among neurosurgery residents in lower-middle-income countries: grassroots evaluation of neurosurgery education. Neurosurg Focus. 2020;48(3):E11.

2. Intercollegiate Surgical Curriculum Programme. The Intercollegiate Surgical Curriculum. Educating the surgeons of the future. Accessed May 20, 2020. https://www.iscp.ac.uk/static/public/syllabus/syllabus_ns_2015.pdf

3. Joint Committee on Surgical Training. Certification Guidelines and Checklists. Accessed May 20, 2020. https://www.jcst.org/-/media/files/jcst/certification-guidelines-and-checklists/certification-guidelines--ns-2017-final.pdf

4. Harrington CM, Kavanagh DO, Ryan D, et al. Objective scoring of an electronic surgical logbook: Analysis of impact and observations within a surgical training body. Am J Surg. 2017;214(5):962–968.

5. Bell RH Jr. Why Johnny cannot operate. Surgery. 2009;146(4):533–542.

6. Vilanilam GC, Easwer HV, Menon G, Vikram K. “Magister neurochirurgiae”: A 3-year ‘crash course’ or a 5-year ‘punc-tilious pedagogy’? Neurol India. 2017;65(2):434–437.

DisclosuresThe author reports no conflict of interest.

CorrespondenceAjay Hegde: dr.ajayhegde@gmail.com.

INCLUDE WHEN CITING DOI: 10.3171/2020.3.FOCUS20207.

ResponseWe thank Dr. Hegde for the interest he has shown in our

article. He has pointed out that in our survey, most of the respondents expressed a desire for more hands-on train-ing despite evidently working long hours. He has rightly suggested that maintaining a logbook detailing the types of procedures performed and the level of involvement of the trainee in each procedure would be helpful in objec-tively evaluating the training experience, so that a certain minimum standard in technical ability of the trainees can be ensured at the conclusion of the residency. This is the practice that is being followed in the UK and has stood the test of time.

However, it is important to acknowledge that the work-ing conditions in developed countries like the UK are sub-stantially different from those that our survey addressed. It is easier to ensure uniformity of training experience in a small nation with a common language and plentiful re-sources, where certification to residency programs will only be granted once they satisfy certain minimum statu-tory requirements. Similar standards are also mandated by law for residency programs in low-middle-income countries (LMICs), yet the implementation is not as rigor-ous, because the interests of providing a clinical service often override the concerns of a training program.1 Most of the residents in LMICs must also assume administra-tive roles and arrange logistics too, due to lack of person-nel dedicated to these indispensable tasks.2,3 Additionally, neurotrauma emergencies claim a substantial chunk of the resident’s time in LMICs due to lack of the requisite num-ber of specialized trauma centers.

However, with economic progress and increasing avail-ability of resources, residency training is getting its due attention, indicated by the growing number of cadaveric workshops and courses organized solely for the residents. The importance of these supplemental teaching activities in crucially enriching the training experience was ac-knowledged by the respondents in our survey. Regarding surgical logbooks and detailing documentation of training experience from a trainee’s perspective, uniformity is still a long way away.

Fortunately, at least in India, consensus is slowly build-ing towards establishment of a national accreditation board that would replace an individual institution’s exam-ination pattern. It would be an important step toward en-suring uniformity in training and minimum competency.

We are hopeful that with the increasing penetration of high-speed internet, the near future would see enthusias-tic adoption of e-logbooks, which will allow comparative evaluation of training programs.

Harsh Deora, MCh, DNBNational Institute of Mental Health and Neurosciences, Bangalore,

Karnataka, India

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Neurosurg Focus Volume 49 • July 2020 3

Kanwaljeet Garg, MChAll India Institute of Medical Sciences, New Delhi, India

Manjul Tripathi, MChPostgraduate Institute of Medical Education and Research,

Chandigarh, IndiaShashwat Mishra, MCh

All India Institute of Medical Sciences, New Delhi, IndiaBipin Chaurasia, MS

Bangladesh State Medical University, Dhaka, Bangladesh

References 1. Mishra S. The “reverse” evaluation! Neurol India.

2017;65(2):433. 2. Garg K, Deora H, Mishra S, et al. How is neurosurgical

residency in India? Results of an anonymized national survey of residents. Neurology India. 2019;67(3):777–782.

3. Yagnick NS, Deora H, Tripathi M, et al. Letter to the Editor. Doing more with less and the barebones neurosurgical setup. J Neurosurg. 131(3):987–988, 2019.

INCLUDE WHEN CITING DOI: 10.3171/2020.3.FOCUS20218.

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