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  1. 1. PEDIATRIC NEUROLOGICAL SURGERY FELLOWSHIP PROGRAM Introduction Pediatric Neurological surgery is a subspecialty of Neurosurgery that deals with infants and children. It includes, but is not limited to, the medical and surgical treatment of patients with congenital, degenerative, vascular, inflammatory and neoplastic disorders of the central and peripheral nervous system. The identity of Pediatric Neurosurgery was established by the early 1960s in major world cities such as London, Paris, Buenos Aires, Boston, Chicago and Toronto, each of which had free-standing children's hospitals served by dedicated pediatric neurosurgeons. However, it was not uncommon then for a children's neurosurgeon, who had accumulated experience with the nuances of Pediatric Neurosurgery, to also manage a part-time practice in Adult Neurosurgery. Nonetheless, the momentum was underway with respect to the identity of the full-time pediatric neurosurgeon. The practice of Pediatric Neurosurgery as a sub-discipline of Neurosurgery was set in the 1970s. The International Society for Pediatric Neurosurgery was created in 1972 and shortly thereafter the American Society of Pediatric Neurosurgeons was formed (1978), followed by both European and Japanese Societies for Pediatric Neurosurgery. Similarly, the American Association of Neurological Surgeons and the Congress of Neurological Surgery established a combined Section of Pediatric Neurosurgery. By the early 1980s, neurosurgical practice groups had made the transition away from delegating Pediatric Neurosurgery to the most junior practitioner in the group, who may or may not have possessed experience in children’s neurosurgery. Now it is understood that a neurosurgeon who is to take responsibility for a child’s structural disease within the nervous system must hold special qualifications. As a starting point, a one-year fellowship in Pediatric Neurosurgery may by itself be acceptable. In some jurisdictions, such as North America, the fellowship is designed so that the pediatric practitioner will also: 1. Acquire that experience in an accredited institution, 2. Pass a written examination, and 3. Receive a certificate of competence in the discipline of Pediatric Neurosurgery. Alternatively, in some European regions the pediatric neurosurgeon may have: -1-
  2. 2. Obtained instruction in pediatric neurosurgery via a formal lecture/seminar program, and Received a certificate of competence in the discipline of Pediatric Neurosurgery. Further, in North America, to maintain competence it is required that the practitioner be responsible for the operative care of a minimum of 125 cases per year, of which at least 50 percent should be conducted on children less than 12 years of age. One metaphor that is often used to describe the activities of a neurosurgeon who practices in a university environment is that of a three-legged stool. Such an individual provides excellent patient care, serves as an educator and is able to conduct research. If the research is outcome based, then the pediatric neurosurgical investigator can bring to his/her international colleagues those features of children’s neurosurgery that are unique or idiosyncratic to his/her population base or cultural environment. Children’s neurosurgery is the most rewarding professional activity within the discipline of Neurosurgery. Its practitioners have always held the belief that: Children are our Future. The following table shows the number of pediatric patients managed in the Section of Neurosurgery for the past two and a half years: 2002 2000 2001 First half Total pediatric admissions 170 202 97 (25.8%) (29.4%) (28%) Total pediatric surgical 170 203 83 -2-
  3. 3. procedures (29.9%) (33%) (29.4%) Total pediatric outpatient clinic 890 visits (59.6%) Prerequisites The prospective candidate must have completed formal residency training in Neurological Surgery and be board certified by the Saudi Council for Health Specialties (SCHS) or its equivalent. A candidate must have successfully completed a personal interview by members of the section concerned. Duration of Fellowship This Fellowship Program consists of two years of full-time structured supervised training in Pediatric Neurosurgery. An optional third year may be offered to meritorious fellows to undertake clinical research in the subspecialty. Number of Fellowship Positions One clinical fellow will be accepted each year. An additional fellow may be accepted if deemed necessary. Qualifications of the Fellowship Program Staff A. Fellowship Director Qualifications The fellowship director must be a SCHS (or equivalent) certified neurological surgeon possessing special expertise in the surgical and medical evaluation and management of pediatric problems. B. Responsibilities of the Fellowship Director As outlined in rules and regulations of the Academic & Training Affairs (ATA) Fellowship Training Program. C. Other Teaching Faculty Qualifications and Number 1. All clinical faculty members who are neurological surgeons shall be certified by the SCHS or possess equivalent qualifications. In addition to the program director, the teaching staff must include, at a minimum, one other board certified neurological surgeon who has special expertise in the area of Pediatric Neurosurgery and who concentrates his/her practice in Pediatric Neurosurgery. -3-
  4. 4. All members of the teaching staff must demonstrate a strong interest in the education of fellows, sound clinical and teaching abilities, support of the goals and objectives of the fellowship program, a commitment to their own continuing medical education, and participation in scholarly activities. The faculty must have regular documented meetings to review the fellowship training, the financial and administrative support of the program, the volume and variety of patients available for educational purposes, the performance of members of the teaching staff, and the quality of fellowship supervision. D. Other Personnel The fellowships program must be provided with the additional professional, technical, and clerical personnel needed to support its administration and educational conduct. General Objectives 1. The fellowship training must provide broad educational experience in Pediatric Neurological Surgery, which will complement the training in the neurosurgery residency to promote further acquisition of knowledge and skills in the subspecialty. 2. A minimum of six (6) months of fellowship training will be spent in a clinical Pediatric Neurosurgery experience under the direction of specified clinical faculty. This period of time must provide the trainee with an organized, comprehensive, supervised, full time educational experience in the field of Pediatric Neurosurgery. This should include comprehensive patient care, diagnostic modalities, the performance of surgical procedures, and the integration of non- operative and surgical therapies into clinical patient management. 3. Each fellowship should provide a broad exposure to clinical evaluation and appropriate patient selection for operative and non-operative management in both the inpatient and outpatient settings. 4. Each fellow should actively participate in the operative management of a wide range of pediatric disorders, including traumatic, degenerative, -4-
  5. 5. neoplastic and congenital conditions. Progressive responsibility in patient management should be provided. A broad exposure to modern pediatric surgical techniques is considered an integral part of the Pediatric Neurosurgery fellowship experience and training. 5. Clinical, anatomic, biomechanical, and neuroscience research constitute an integral component of the educational experience, and provision should be made for the successful completion of research projects. Full-time experience in research will require an extension of the fellowship beyond the basic six months of clinical training. Specific Objectives The Educational Program 1. All educational components of the fellowship program should be related to the specified goals and must not interfere with the training opportunities of residents who are members of the neurosurgical residency program. 2. The fellowship program and/or structure must be reviewed for re- accreditation by the Committee on Subspecialty Training in ATA. 3. A participant in an accredited fellowship program shall have broad exposure to the full spectrum of Neurosurgery, with sufficient senior clinical experience to warrant a focused experience to build upon his/her already acquired skills. It is anticipated that any fellow will have both the technical expertise and intellectual maturity to understand and apply the material. Program Content A. Clinical Components 1. A minimum of two (2) years of fellowship training must be spent in clinical activities in Pediatric Neurosurgery. That will include daily clinical rounds and at least two (2) full operating days weekly. 2. The responsibility or independence given to fellows in patient care must be dependent upon the fellow’s demonstrated knowledge, manual skill, experience in the complexity of the patient’s illness, as well as the perceived risks of the surgical management. 3. A portion of the fellowship experience should be allocated to training in an outpatient clinic or office setting that provides preoperative, perioperative and postoperative continuity of patient care. That includes at least two (2) to three (3) Pediatric Neurosurgery clinics weekly, one combined Spina -5-
  6. 6. Bifida clinic weekly, one combined craniofacial clinic monthly, and one combined antenatal clinic monthly. B. Other Components 4. The fellowship program should provide opportunities for the fellow to engage in research relative to the subspecialty. 5. The fellow should actively participate in scholarly activities and should contribute to the education of Neurosurgery residents by participating actively in Department of Neurosciences weekly postgraduate activities. 6. The fellowship program should have regular dedicated teaching conferences with participation of the fellow, the associated faculty, and the residents. Participation of other affiliated disciplines should be encouraged. A weekly one-hour dedicated Pediatric Neurosurgery education section will be initiated. C. Fellowship Policies Supervision 1. All patient care services must be supervised by appropriately qualified faculty in accordance with institutional guidelines. 2. The fellow who has completed an accredited Neurosurgery residency program may function independently as a junior staff neurosurgeon consistent with institutional and departmental/division policies. 3. The fellowship director must insure direct and documented proper supervision of the fellow at all times by attending physicians with appropriate experience for the severity and complexity of the patient’s condition. The fellowship trainee must be provided with rapid, reliable systems for communication with supervisors. Maintenance of Case Logs 1. The fellowship program director must maintain accurate case logs of the Pediatric Neurosurgery case material operated annually within the institution and the subspecialty experience of the graduating chief resident(s) throughout his/her training as well as that of the fellow. 2. The fellow must maintain an accurate prospective case log of his/her operative cases throughout the fellowship that documents all operative -6-
  7. 7. cases and the level of responsibility in the case (assistant versus primary surgeon). Duty Hours and Conditions of Work Duty hours and work conditions for subspecialty fellows must be consistent with ATA institutional and program requirements for residency training in Neurological Surgery. Evaluations 1. As specified earlier, there shall be written evaluations and constructive discussions of the fellow by the faculty relative to performance and accomplishments of stated goals. These evaluations must occur at a minimum of two (2) times per year and be maintained in a permanent file. 2. The fellow shall provide an evaluation of the faculty and fellowship program. This may be submitted to the fellowship program director at completion of the fellowship training. The ATA, if requested, should maintain this evaluation in a permanent file for review. Leaves Regulations governing leaves are as stipulated in the Policy for Fellowship Training Program. Evaluation and Promotion The fellow’s level of competence and performance will be evaluated at a frequency determined by the Postgraduate Education Committee and in the manner detailed in the Policy for Fellowship Training Program. A self- assessment examination covering the different topics in the subspecialty will be given at the end of the first and second years of fellowship training. A fellow’s advancement from year to year is contingent upon professional performance and personal growth. The criteria for promotion are enumerated in the Policy for Fellowship Training Program. Promotion depends on evaluation and the end-of-year examination. Completion A certificate of fellowship training at King Faisal Specialist Hospital & Research Centre will be awarded upon satisfactory completion of the requirements of the program and passing of the end-of-year examination. -7-