neurosurgical education: educating the next...
TRANSCRIPT
Neurosurgical Education:
Educating the Next Generation
Stacey Quintero Wolfe, MD FAANS
Associate Professor and Residency Program Director
Director of Neurointerventional Surgery
Wake Forest Baptist Medical Center
Disclosures
• No conflicts of interest
Thanks to Larry Chin, MD FAANS, for his contribution and collaboration
Wake Forest Baptist Medical Center
Developing Excellence in
Neurosurgery
• Workforce
• Training
• Opportunities for improvement?
Wake Forest Baptist Medical Center
US Neurosurgical Residency:
Limited training positions
• Medicine: 6,465
• Neurosurgery: 210
Wake Forest Baptist Medical Center
Exceedingly high standards
Wake Forest Baptist Medical Center
Attrition
• 86% Rate of Graduation
• 79.4% ABNS board certification
Wake Forest Baptist Medical Center
1990s Overall Attrition: 14%
• Difference by gender
• Male attrition: 13%
• Female attrition: 24%
• Male ABNS pass: 81%
• Female ABNS: 63%
1171
111
1059
190
35
156
-100
100
300
500
700
900
1100
1300
1500
Total Women Men
Completed Attritioned
Wake Forest Baptist Medical Center
2000s Overall Attrition: 6.7%
Renfrow et al, JNS 2016
• PGY 1-4
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Ongoing Gender Variability
• Gender inequity
• Male attrition: 5.3%
• Female attrition: 17%
• Significance???
1857
200
1657
135
40
93
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Total Women Men
Completed Attritioned
Renfrow et al, JNS 2016
Wake Forest Baptist Medical Center www.aamc.org
Workforce:
Medical School Graduates 2016: 50%
Wake Forest Baptist Medical Center AANS Data 2016.
Neurosurgery Resident Match 2017: 17%
Wake Forest Baptist Medical Center ABNS Data 2016.
Board Certified Neurosurgeons 2016: 6%
Wake Forest Baptist Medical Center
Women in Neurosurgical Match
• 1990s: 10.7%
• 2000s: 12%
• 2013: 15.5%
• 2016: 16%
• 2017: 17%
• 30% gen surg
Renfrow et al, JNS 2016
Wake Forest Baptist Medical Center
Neurosurgery
Overall
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017
Female
Male
Not reported
0%
10%
20%
30%
40%
50%
60%
2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017
Female
Male
Not Reported
Match: Gender differential
Courtesy of Jay Wellons
Wake Forest Baptist Medical Center
Opportunities with the goal of
Excellence
• Improve recruitment
• Rooney Rule (2003)
• NFL coaching searches must consider at least 1 minority
• Minority coaches increased to 22% from 6%
• NOT Affirmative action
• Improve retention
• Education
• Mentorship
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Good educational practice
• Learner-faculty contact
• Active learning techniques (ie- Participatory)
• Cooperation between learners (ie- Team)
• Instant feedback
• High standards
• Understands and addresses diverse learning styles
Wake Forest Baptist Medical Center
Kolb learning styles
• Assimilating (Observe and think)
• Reflective observation, abstract conceptualization
• Diverging (Observe and experience)
• Reflective observation, concrete experience
• Accommodating (Do and Think)
• Active experimentation, abstract conceptualization
• Converging (Do and Experience)
• Active experimentation, concrete experience
NRS
ORTHO
Richard et al., J Surg 71: 110-118, 2014
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Fleming VARK learning styles
• Visual
• Pictures, videos, flowcharts, diagrams
• Underlining, highlighting, different colors
• Look at notes to review
• Aural
• Attend classes/lectures
• Discuss topics with others
• Remember interesting examples and stories
• Read/Write (Higher USMLE 1 scores)
• Lists, handouts, textbooks, notes
• Kinesthetic
• Real-life examples
• Engage all senses
• Hands on, trial and error Kim et al, J Surg Ed, 2016
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Flipped classroom techniques
• Small groups
• Teacher/facilitator
• Preassigned videos
/technology
• Pre- and post-test
In Theory In Neurosurgery
• Have Residents:
• Teach a technique to faculty (No powerpoint!)
• Write board-style test questions and explanations
• Draw surgical anatomy from memory
• Narrate the case before the surgery (scrub sink) and highlight pearls after
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Anders Ericsson
• 10,000 hour rule (popularized by Gladwell)
• Average hours of practice for violin students to become an Expert
• Differs by specialty- piano students required longer
• Two types of Expertise: Routine and Adaptive
• Adaptive Expert = Deliberate Practice
• Expert coaching
• Stretch outside comfort zone
• Full attention and conscious action
• Feedback and modification
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Neurosurgery: 10,000 hours?
• US Operative experience increased from a median
of 995 to 1,273 cases from 2012-2017
• 3,312 hours (about 14.1% of total residency)
• Range 1652 hrs to 4972 hrs (21% total residency)
• Based on ACGME and CMS data
West et al, In submission
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Master coaching
• Requires depth and breadth of knowledge
• Master observers (not orators)
• Teaches perfection of basic skills
• Targeted information and instant feedback
• Adaptability to student
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Master coaching in Neurosurgery
• Review fundamental surgical skills: bipolar technique, bone
removal technique, suction, etc
• Never let residents get sloppy
• Resident should visualize and describe entire operation
before performing
• Unsupervised practice (independent struggle) plays a small
role
• Feedback should be instant and continuous
• Difficult parts of operations can be broken into components
that can be practiced without affecting patient care
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Dunning-Kruger effect
• Poor performers overestimate their ability
• Unable to distinguish good from bad performance in others
• Experts underestimate their abilities
• Improving metacognition requires improving skills
Kruger J, Dunning D: Unskilled and Unaware of it. J Personality Social Psychol 77:1121-1134, 1999
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O-Score: Ottawa Surgical Competency Operating
Room Evaluation, Gofton et al, 2012
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Objective Structured Assessment of
Technical Skills (OSATS)
• 6 faculty, 8 residents completed evaluations for 299 procedures
• 55 VPS/revisions, 19 ETVs, 18 tumor craniotomies
• No significant difference between faculty and resident self-assessment scores overall
• Faculty members scored senior residents significantly higher than junior residents only for the
"knowledge of instruments" domain (p = 0.05)
• For expert procedures only, faculty scored seniors significantly higher than juniors (p = 0.04)
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Zwisch Model
Show and tell
Active Help
Passive Help
Supervision only
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Ignition: Motivation and Culture
• Break it into Chunks
• Slow it down
• Repetition
• Embrace the struggle
Deep Practice Ignition
• Embrace the long-term
commitment
• Identify with excellence
• Motivate by praising the
effort not the result
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Generationalism
• 5 generations working side by side in 2020
1960-1980 1981-2000
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Generational attitudes to work
• Work hard because of loyalty
• Expect long-term job security
• Expect to pay their dues
• Virtuous self-sacrifice
• Respect authority
Baby Boomers Generation X
• Work hard when there is
balance
• Does not anticipate job
security
• Paying dues?
• Self-sacrifice
endured…maybe
• Question authority
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Millennial learning styles
• Open communication
• Want to know reason why (clinical relevance) and not
learning for learnings sake (Baby Boomers)
• Want frequent feedback
• Prefer faculty know their names- Mentoring very important to
them
• Prefer a more casual learning environment
• Prefer face to face or combination learning over totally web
based
• Like case based learning, work in teams
• Desire acknowledgement for job well done
Lourenco, J Am Coll Rad 14: 92-95, 2017
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Millennial faculty development
• Different models of academic success
• Alternate models of compensation besides money (flexibility,
vacation)
• Work/life integration more important than work/life balance
• Encourage teamwork and team building
• Multiple mentors for different aspects of career
• Collaborative mentoring style and avoid top-down approaches
• Provide frequent feedback (no news is not good news) and
accept it as well
• Foster early leadership opportunities and give back as a mentor
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Gender learning styles
• Overlap with Millenial learning styles
• Gender is a more personality than chromosome in regard to education
• Early identification of gender roles
• Dramatic loss of female interest in
science and math in 6th and 9th grade
• Confidence
• Role models
***Editorial
• Teach your girls confidence
• Be a role model in your local schools
Wake Forest Baptist Medical Center
The Confidence Gap • Shipman and Kay, The Atlantic 2014
• Confidence is likely the single most different
characteristic between men and women
• Men will apply for a job when they meet 50% of the
qualifications
• May require ego-checking
• Women will not apply until they have exceeded
qualifications (Perfectionism/Underestimate themselves)
• Very coachable, but require positive affirmation
• Both desire explanation (Millenials)
Wake Forest Baptist Medical Center
Men
• Require more explanation
(develop trust)
• Deflect criticism or take as
a challenge
• Overestimate abilities,
don’t relay doubts
• Discussion
Women
• Gravitate towards a team
• Personalize criticism as
indication of self-worth
• Lack of confidence leads
to risk avoidance and lack
of experience
• Encouragement
Gender Differences in
Neurosurgical Training
Wake Forest Baptist Medical Center
Lead From The Front
• “The most important thing I learned is that soldiers watch what their
leaders do. You can give them classes and lecture them forever, but it is
your personal example they will follow.” – General Colin Powell
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Know Your People
• Motivations
• Learning Styles
• Limitations
• Resources
• Ask the question
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Foster Character
• Millenials have an innate desire to be involved and to please
• However, the initiative to do that has often not been
fostered
• Need specific goals and instructions
• Need clear and timely feedback
• They have not been allowed to fail
• Shy from such situations
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Mentorship
• Understand the differences
• Help your trainees to understand
• Help your patients to understand
• Sponsorship
• Coaching
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Summary
• Leadership: Intentional Implementation
• Expect Excellence
• Consider diversity
• Initiate Deliberate practice to train Adaptive Experts
• Develop Master Coaching in faculty
Thank You
Wake Forest Baptist Medical Center
Career Paths Women in Neurosurgery
• 379 Graduates
• 1964-2013
• 16 retired
• 8 career change (2%)
• 3 deaths
Private Practice
71% Academics
26%
Affiliated Academics
3% Academic Jobs: 1 in 2 occupied by fellowship trained Private Practice Jobs: 1 in 5 occupied by fellowship trained
Renfrow et al, Neurosurgery 2017
N= 349
Wake Forest Baptist Medical Center
Fellowship Training (25%) Women in Neurosurgery
Pediatric, 33%
Oncology, 15%
Spine, 13%
Vascular, 10%
Endovascular, 7%
Functional, 11%
Peripherial Nerve, 9%
General, 7%
Skull Base, 2%
One in four female neurosurgery graduates pursued fellowship training (N=103)
Renfrow et al, Neurosurgery 2017
Wake Forest Baptist Medical Center
Affiliated Academic (3%)
Private Practice (71%)
Assistant (46%) *Male overall 33%
Associate (36%) *Male overall 19%
Professor (18%) *Male overall 43%
Academic (26%)
Academic Rank Women in Neurosurgery
Renfrow et al, Neurosurgery 2017
Wake Forest Baptist Medical Center
Academic Rank
• Tomei, et al J Clin Neuroscience 2013
• 10.9% full professorships were female
• Neurosurgery
• 11.8% (vs 88.2%) Assistant Professor
• 12.4% (vs 87.6%) Associate Professor
• 6% (vs 94%) Professors
Wake Forest Baptist Medical Center
Similar gender disparity in other
surgical subspecialties
• Of 124 medical deans, only 14 (11%) were women
• Only 9% of all department chairs were women Andrews, NEJM 2007
• Analysis of >90,000 academic physicians shows gender disparity in
associate and professor ranks even after adjusting for age and research
• Orthopedic Surgery Ence et al, Ortho Forum 2016
• 12.9% Assistant Professor
• 11.3% Associate Professor
• 6.4% Professors
• Significantly fewer females in senior rank 29.9% vs 39.6%
• Cardiology Blumenthal et al, Circulation 2017
• 30.6% vs 15.9% Full Professors
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Research and Publications
• Male neurosurgeons have overall higher research
productivity (h-Index 13.3 vs 9.5) Tomei, et al J Clin Neuroscience
2013
• Similar in ortho, spine, ENT, cardiology, surgery Singh et al
Spine J 2017, Mueller et al, BMC Surg 2017
• Female research productivity increases throughout
the career, with higher publication rates later in life Mayo Clinic 2007, Eloy et al Otolaryngol 2013
But
• NIH funding equal Valsangkar et al, J Am Coll Surg 2016
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Salary Inequities
• Jena et al, Jama Int Med 2016
• N=10,241 academic physicians at 24 public medical
schools
• $51,315 absolute difference ($206,641 vs $257,957)
• $19,878 when adjusted for age, experience, specialty,
rank and clinical/research productivity
• Adjusted salaries of female full professors compare
to those of male associate professors
• BUT… DO WE ASK?
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Factors in ongoing gender disparity
• Asymmetric family responsibilities
• Lack of mentors
• Lack of institutional support, especially early career
physician-scientists
• Lower levels of secretarial support
• Meetings before 8a and after 5p
• No on-site childcare
• Attrition of female academics at higher levels
• Overt or perceived gender discrimination
• Unconscious gender bias
Blumenthalet al, Circulation 2017