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Neurosurgery Residents Goals and Objectives - Stanford Dura ...


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  • 1. The Neurosurgery Training Program covers a period of four clinical years and two research years of enfolded fellowship following the PGY-I year. We admit two or three applicants per year. The PGY- 1 year is comprised of rotations teaching basic clinical skills in adult and pediatric surgery, adult and pediatric neurology, neuroradiology, neuropathology, stereotactic radiosurgery, and endovascular neurosurgery. Four of the six years after the PGY-I year are spent in clinical neurosurgery and two years are devoted to basic or clinical research within an enfolded fellowship. Three hospitals support the Neurosurgery Training Program: Stanford University Medical Center (SUMC), Lucile Packard Children's Hospital (LPCH) and the Palo Alto Veterans Administration Hospital (PAVAH). These three hospitals (SUMC, LPCH, and PAVAH) form our fully integrated Neurosurgery Service. Full-time faculty members direct the training programs at each hospital. Over 2,400 neurosurgical operations covering the full spectrum of neurosurgical problems are performed at SUMC, LPCH, and PAVAH. The training goals of the Neurosurgery Residency Program at Stanford include the acquisition of clinical skills in Neurosurgery and a deep commitment to academic and research pursuits. Development of clinical skills includes accurate and concise diagnosis, proficient surgical techniques, excellent patient management, personal maturity, a humanistic approach to patients, and possession of adequate funds of medical and neurosurgical knowledge. Academic skills to be developed include the ability to perform and evaluate clinical and basic research, facility in writing and public speaking; creativity and innovation are sought. The Neurosurgery Training Program is constructed with the intent of providing each resident with progressive surgical and patient management responsibility commensurate with his/her level of experience and core competencies. Core competencies (I-VI) to be fostered are as follows: Patient Care that is compassionate,appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients,their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and systemof health care and the ability to effectively call on systemresources to provide care that is of optimal value By the end of the training program, the resident should be well versed in the theoretical aspects o f neurosurgery, be fully trained in the bedside care of neurosurgical patients, be a proficient technical neurosurgeon, and be able to critically evaluate neurosurgical clinical and basic research in a process of practice based learning and improvement. The resident should demonstrate effective interpersonal and communication skills in delivering care in a professional and efficient manner. 1. Chronological rotation assignments of residents PGY-I: Intern: General Surgery and Clinical Neurosciences General Surgery at Stanford and affiliated hospitals: 6 months Adult and Pediatric Surgery, ER/Trauma, Vascular/Cardiac, ICU, ENT/Ortho (SUMC, LSPCH, PAVAH, Santa Clara Valley Medical Center). Clinical Neurosciences at SUMC and LSPCH: 6 months
  • 2. Adult and Pediatric Neurology, NICU, Neuroradiology, Neuropathology, Stereotactic Radiosurgery, Endovascular Neurosurgery PGY-II: NS-1 Junior Resident I: 12 months at SUMC and LSPCH PGY-III: NS-2 Junior Resident II: 6 months each at PAVAH and LPCH PGY-IV: NS-3 Enfolded Fellowship: Clinical and/or basic science research PGY-V: NS-4 Enfolded Fellowship: Clinical and/or basic science research PGY-VI: NS-5 Senior Resident at SUMC and LPCH PGY-VII: NS-6 Chief Resident at SUMC and LPCH Thirty six months of clinical neurological surgery are required. Residents will complete between 36 and 60 months of clinical neurosurgery, depending on their choice of fellowship experience (clinical or basic research) in PGY IV and V. 2. Duties, Goals and Objectives of the residents in each year PGY-I: Internship in General Surgery In complete fulfillment of ABNS requirements for training in General Surgery, Neurology and Allied Clinical Neurosciences, this year combines six months of traditional general surgery internship with six months of residency training in Neurology and other clinical neurosciences. During this year the resident acquires expertise in the diagnosis and treatment of general medical, general surgical, and neurological diseases and conditions. The six month-long surgical rotations include Adult General Surgery, Pediatric Surgery, Cardiac or Vascular Surgery, Surgical Intensive Care, ER/Trauma and ENT or Orthopedic Surgery. The resident learns to manage a busy clinical service efficiently. This includes obtaining a medical history, performing a physical exam, ordering appropriate tests, interpreting test results, performing daily care, writing accurate and concise daily notes, discharge planning and dictating discharge summaries. The resident builds a fund of knowledge in general medicine and surgery. During the remaining six months, the resident acquires knowledge and experience in neuroradiologic and neuropathologic diagnosis and radiosurgical and endovascular treatment of neurosurgical disease. This includes three months of Neurology and three months of a combination of Neuroradiology, Neuropathology, Stereotactic Radiosurgery, and Endovascular Neurosurgery at SUMC/LPCH. The Neurology experience includes rotations in the Neuro Intensive Care Unit, Adult Neurology Clinic, Adult Inpatient Service, and Pediatric Neurology Clinic. Neuropathology is taught through a combination of readout sessions, post-mortem brain cutting sessions, and special tutorials provided by the Neuropathology Division. Similarly, the Neuroradiology rotation consists of participation in readout sessions, tutorials and conferences. The resident studies Neuroangiography and observes endovascular procedures with the Endovascular Neurosurgery Service. The resident participates in case selection and post-treatment followup in the Radiosurgery Clinic, studies MRI and CT anatomy and radiobiological principles in helping with treatment planning, and observes patient treatment with the Cyberknife. PGY-II: NS-1, Junior Resident I at SUMC, LPCH, and PAVAH
  • 3. The first year of neuosurgical residency is spent in clinical Neurosurgery as Junior Resident I at SUMC and LPCH. The trainee works with the Chief Resident, the Senior Resident, and interns and medical student clerks rotating through the service. The resident joins fulltime and clinical neurosurgical faculty in the initial assessment, operative treatment, and post-operative care of patients. The resident works in the outpatient clinic two half days a week and sees many of the inpatient consultations. Subspecialty clinics in which the resident conducts pre-operative assessment and postoperative follow-up include cerebrovascular, tumor, spine/peripheral nerve, pediatric, functional (epilepsy, pain, movement disorders), and general neurosurgery. Evening and weekend coverage for SUMC, LPCH, and PAVAH is shared with the PGY-III and PGY-VI residents (every fourth night/weekend). The resident becomes familiar with the diagnosis, surgery, and both preoperative/postoperative care of patients with neurosurgical problems. This includes ICU care of critically ill patients, emergency management of neurosurgical conditions, and neurosurgical consultations. The resident also learns to manage an outpatient clinic, including the diagnosis of neurosurgical problems, communication with patients, the decision process for surgery, and postoperative care. Emphasis is placed on improvement of communication skills for relating to patients and families and on issues of medical ethics. The resident learns to supervise interns and teach medical students. During this year, the resident acquires familiarity with the basic principles of operative neurosurgical technique, including patient positioning, surgical exposure and surgical closure. The resident also acquires proficiency in performing minor procedures (lumbar puncture, ventriculostomy, muscle/nerve biopsy, halo placement, tracheostomy), craniotomy for trauma, tumor, hematoma, and abscess, basic cervical and lumbar spinal surgery, peripheral nerve surgery, and stereotactic biopsy. During this year, the resident begins to explore clinical research interests, submit abstracts regarding this research to regional and national meetings, and present clinical data at local, regional, and national conferences. The resident is expected to broaden a fund of basic and clinical neuroscience knowledge and take Part I (written) Neurosurgical Boards for self-assessment. PGY-III: NS-2, Junior Resident II at PAVAH, LPCH, and SUMC The second neurosurgical year is divided evenly between PAVAH and LPCH. For sixmonths at the PAVAH, the resident is the primary resident for all neurosurgical care. The resident acquires increased independence in managing neurosurgical problems by acting as patients’ primary neurosurgeon during inpatient, outpatient, and consultative care. Proficiency in general neurosurgery, particularly that required by the degenerative diseases commonly encountered in the veteran population, is emphasized at PAVAH. The resident develops skills in neoplastic and degenerative spine surgery, craniotomy for straightforward aneurysms, tumors, and vascular malformations, carotid endarterectomy, and transsphenoidal surgery. The resident supervises and teaches Neurology residents and medical students rotating on the VA service. The resident works under the supervision of two fulltime VA faculty members and eleven (11) additional fulltime Stanford faculty members who both cover challenging subspecialty cases and provide night and weekend coverage. The resident evaluates all inpatient and outpatient consults, works up all new cases for admissions, participates in all operations as primary surgeon or first assistant, and directs post-operative care. The resident usually operates two (2) full days at PAVAH and attends the outpatient PAVAH clinic ½ day a week. The evening and weekend coverage for PAVAH, SUMC, and LPCH is shared with the PGY-II and PGY-VI residents (every fourth night/weekend). For the other six months of PGY-III, the resident serves as the primary resident on the LPCH Pediatric Neurosurgery Service. Under the supervision of two highly experienced pediatric neurosurgeons and the Chief Resident, the second year resident acquires more advanced diagnostic and patient management skills relevant to diseases of infants and children. Understanding of the unique conditions and the special considerations required in treating neurosurgical diseases in children is obtained. The resident is involved in initial assessment and case selection in clinic, preoperative evaluation, surgery, postoperative care, and outpatient followup. During this year, the resident should actively pursue clinical research interests, submit abstracts regarding this research to
  • 4. regional and national meetings, and present clinical data at local, regional, and national conferences. The resident is also expected to expand basic knowledge of neuroscience, neurology, and neurosurgery, and to take the Written Neurosurgical Boards for self-assessment. PGY-IV: NS-3, Enfolded Fellowship I: Clinical and/or Basic Science Research PGY-V: NS-4, Enfolded Fellowship II: Clinical and/or Basic Science Research During these two years, the resident completes an enfolded fellowship consisting of clinical and/or basic research. Basic science research may be performed in the Neurosurgical Research Laboratories, another laboratory at Stanford, or in special cases, a laboratory at another institution or in industry. In some cases, clinical research may be complemented by advanced subspecialty surgical training in Functional Neurosurgery, Stereotactic Radiosurgery, Endovascular Neurosurgery, and Spine Neurosurgery. In clinical or basic science research, the resident develops academic skills, including critical review of existing literature, hypothesis driven research, creative and rigorous experimental design, precise performance of procedures, interpretation of data, synthesis of experimental results with existing literature, and preparation of reports for publication and presentation at regional and national meetings. Some may choose to pursue an advanced degree such as a PhD or MPH during this time. The resident continues to accumulate a fund of basic and clinical neuroscience knowledge and takes the written Part I Neurosurgical Board exam for credit. Each resident is required to pass the written boards before beginning the PGY-VII Chief Resident year. PGY-VI: NS-4, Senior Resident at SUMC and LPCH This year is spent as a senior level trainee in Neurosurgery at SUMC and LPCH where the resident assists the fulltime and clinical neurosurgical faculty in the OR, helps manage the inpatient service, works in the outpatient clinic two half days a week, and sees ER and inpatient consultations. The resident assumes increased responsibility for all aspects of patient management at SUMC/LPCH, working with the Chief resident, junior residents, interns, and medical students on the service. During this year the resident has a significant amount of responsibility in the operating room. Outpatient clinic rotations include cerebrovascular, tumor, spine/peripheral nerve, pediatric, and general neurosurgery. Evening and weekend coverage for SUMC, LPCH, and PAVAH is shared with the PGY-II and PGY-III residents (every fourth night/weekend). During this year the resident is expected to become proficient in diagnosing and managing outpatient and inpatient neurosurgical diseases and problems, including the subspecialty areas of vascular, tumor, spine/peripheral nerve, pediatric, functional and general neurosurgery. The resident becomes proficient in supervising the junior residents, interns and medical students and hones skills in communicating with patients, families, colleagues, and other staff. Guided by faculty, the resident learns to balance the analytical and scientific aspects of medicine and surgery with humanitarian concerns. The resident is expected to begin developing expertise in microsurgery, including craniotomy for aneurysm, vascular malformation, tumor, epilepsy, and microvascular decompression, and transsphenoidal procedures. The resident should develop operative skills in carotid endarterectomy, sympathectomy, functional neurosurgery, craniofacial reconstruction, craniosynostosis repair, and complex spine surgery, including removal of spinal tumors and repair of spinal dysraphism. The resident continues to accumulate a fund of basic and clinical neuroscience knowledge and takes the written Neurosurgical Boards for credit, unless it has been passed previously at a score above the 50th percentile. PGY-VII: NS-5, Chief Resident at SUMC and LSPCH
  • 5. This final year as Chief resident in Neurosurgery is spent primarily at SUMC and LPCH. The two Chief Residents cooperatively lead the entire resident team at all three hospitals and manage the entire neurosurgical service at SUMC and at LPCH. Although the two Chief Residents alternate Chief call throughout the year, primary responsibility for the clinical service and for administrative duties is alternated at the midpoint of the year. The chief residents lead daily patient rounds in the ICU and on the ward. The Chief Residents are responsible for ensuring that all in-patient and emergency room consultations are evaluated initially and presented to a staff physician. Under direct faculty supervision, the Chief Residents perform the vast majority of the difficult operative procedures carried out at SUMC. Challenging cases are sufficiently numerous to provide intensive surgical and peri-operative management experience to both Chief Residents. At the Chief Resident’s discretion, less challenging cases are assigned to the senior and junior residents at SUMC or LPCH. The Chief Residents also assist in organizing weekly Neurosurgery Grand Rounds and monthly Morbidity and Mortality Conference. During this year, the resident becomes proficient in independently managing an inpatient and outpatient neurosurgical service, including supervision of the neurosurgical housestaff, rotatin g interns and medical students. The resident further hones comprehensive neurosurgical operative skills, including microscopic surgery for difficult aneurysms, vascular malformation, tumors, epilepsy and pituitary lesions; carotid endarterectomies and vascular reconstructive procedures, including EC-IC bypass; complex spinal reconstruction; and pediatric neurosurgical procedures. The resident should be able to supervise and teach junior residents and interns, both in the operating room and on the wards. The resident continues to pursue basic or clinical research and to refine academic skills. At the conclusion of the PGY-VII year, the neurosurgical resident should be fully qualified to join the neurosurgical faculty at an academic institution or an activ e private practice group.