Neurosurgical Education for Young Neurosurgeons – the Current Era Hira Burhan, Muhammad Raji Mahmud, Angelos Kolias, Amro Al-Habib
Imparting neurosurgical education and training is significantly influenced by the availability of resources allocated to a nation’s healthcare industry. Countries with higher HDI (human development index) have better resources and are well equipped to adapt to the technological advances emerging in today’s era. The HDI is a measure that encompasses key elements of human development, including a long healthy life, being knowledgeable, and having a decent standard of living [1]. While in certain parts of the world the use of robots, intra-operative MRI, and O-arms are routine in any brain or spine suite, the majority of the world is still lacking basic resources for an adequate neurosurgical department - let alone training and educational resources. These technical developments have significantly improved the options and efficacy of surgical procedures, but they have also created disparities in the standards of neurosurgical care and education among low- and middle-income countries (LMICs) and high-income countries (HICs).
Young neurosurgeons face significant challenges seeking the best training [2]. The lack of resources undoubtedly plays a major role in this. However, some doctors may have a mindset that allows them to settle for what is easily available, submitting themselves to the prevailing circumstances, rather than thinking of ways to overcome any hurdles. This is where critical thinking and research comes into play. It is said that HICs have adopted “evidence-based” practice in their healthcare systems, which is lacking in most of sub-Saharan Africa and parts of Asia. This view seeps into the minds of some young doctors and trainees to the extent that they often follow the same protocols without reasoning. Of course the high case load, lesser salaries, and scarce research funding are other important factors. However, these factors cannot limit the ability of the human mind - and also the ability of humans collaboratively - to address such problems.
Each year numerous neurosurgical conferences are organized around the world with lectures and hands-on sessions to promote the spread of neurosurgical education. They are of extreme value for young neurosurgeons who are either working in rural areas or are not associated with teaching hospitals. Attending these conferences allows for an interaction and networking with faculty and experts from around the world and provides a stage to discuss advances as well as obstacles in achieving optimal patient outcomes. One significant drawback of the conferences is the expense incurred by a young neurosurgeon to travel and stay, which limits their presence most of the time.
The use of social media tools and teleconferencing through online symposiums and webinars has revolutionized the way education is being imparted today [3]. During 2009 to 2013, the WFNS Young Neurosurgeons Forum (YNF), then chaired by the second author of this article, was the first in the WFNS to initiate a series of webinars, with far-reaching audiences even at the time [4, 5]. It is now one of the most-used mediums for conducting online conferences and courses and to establish a global network of neurosurgeons. Accessibility through smartphones has made it easier for thousands of participants to take part in these webinars, which has the advantage of being recorded and watched at a later time. Dedicated forums and channels have now been established to reach thousands of participants just a click away [6]. Recently, monthly webinars organized by the YNF gathered 88 persons online and was watched by 1,300 individuals on YouTube. In a recent study, the authors identified from the Internet the main digital platforms that could easily be adopted in LMICs with a high educational impact [7]. These include the WFNS Young Neurosurgeons Forum Stream, Brainbook, NeuroMind, UpSurgeOn, the Neurosurgical Atlas, Touch surgery, the 100 UCLA Subjects in Neurosurgery, Neurosurgery Survival Guide, EANS (European Association of Neurosurgical Societies) Academy, Neurosurgical.TV, 3D Neuroanatomy, the Rhoton Collection, and Hinari [7]. These platforms consist of webinars, 3D interactive neuroanatomy and neurosurgery content, videos, and e-learning programs supported by neurosurgical associations or journals.
Founded in 1955, the World Federation of Neurosurgical Societies (WFNS) has been serving as a conduit for knowledge, training, research and career opportunities for young neurosurgeons. Over the years, the adoption of available digital technology has led to improvised educational resources. The recent report on WFNS Young Neurosurgeons Forum [7] highlights the collaboration with digital platforms, and the joint communication with continental societies such as the EANS and the Asian Congress of Neurological Surgeons (ACNS), which have extended the reach to young neurosurgeons worldwide. Moreover, the provision of grants for abstract presentation in WFNS meetings and symposiums encourages young neurosurgeons to participate actively and to feel accomplished.
The ACNS has also played a significant role in providing education for young neurosurgeons. The Asian Medical Students and Residents Society for Neurosurgery, under the auspices of the ACNS, is dedicated for education of young neurosurgeons and medical students - reaching thousands of members across the globe in its regular interactive webinars [8].
It is commendable that senior neurosurgical consultants have shown keen interest in this mode of teaching. Perhaps over time, online education will be the preferred method of education for neurosurgical programs. Nevertheless, it may not be able to completely replace the hands-on skill that can only be gained through physical practice and consistency. Given that technology is not the same all around the world, we need to bridge the gap by creating an open networking platform to exchange ideas and strategies. Some of the technology and equipment can be provided to training centers in LMICs for subsidized prices or through donation. To improve care worldwide, technology and equipment can be developed into versions with more affordable prices. Examples are cell phones and computers that are widely available now at a fraction of previous prices.
Mentoring is an important element in education and career development for young neurosurgeons. In 2010 the WFNS YNF initiated the Mentoring Without Borders program, which matched young neurosurgeons which seasoned mentors [11]. To standardize mentorship, the mentors were requested to go through a simple module [12]. This had some impact beyond mentoring: it led to a few informal offers of fellowships to the mentors’ centers.
Because of the non-uniformity of training curricula in various parts of the world - in terms of duration, quality and content in each year or level of training - there is a significant disparity in skills among young neurosurgeons worldwide. The Foundation for International Education in Neurological Surgery (FIENS) and other bodies such as the Continental Association of African Neurosurgical Societies (CAANS) are working on harmonization of neurosurgical curricula [13]. Among other benefits, this will help ensure minimum standards of training and will ease trainee exchanges. Starting from the level of medical students, the WFNS YNF has helped develop basic curriculum for neurosurgical electives through collaboration with International Federation for Medical Student’s Collaboration (IFMSA).
Center twinning and adoption programs between HICs and LMICs has helped raise the standards of training and care in those counties. Twinning such as that between Duke University Medical Center and New Mulago Hospital and the CURE Hospital (both in Uganda) are a success story [14]. Instrument brokering, from companies or institutions to young neurosurgeons in LMICs, was also facilitated by the WFNS YNF in the past. Continuity of such initiatives will assist young neurosurgeons tremendously, since a huge challenge still exists.
There is still need for updated knowledge on the current challenges for medical student education worldwide. The WFNS YNF has recently sent out a survey covering many areas related to neurosurgery education. There was an overwhelming interest in the survey with more than 900 people responding worldwide. The response results will be informative and will hopefully provide some direction for neurosurgery education worldwide. The results shall be presented at the WFNS interim meeting in Beijing 2019 - so stay tuned!
REFERENCES
[1] United Nations Development Programme. Human Development Reports. http://hdr.undp.org/en/content/human-development-index-hdi. Accessed Online on January 30, 2019.
[2] Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J. The challenges and opportunities of global neurosurgery in East Africa: The neurosurgery education and development model. Neurosurg Focus. 2018 Oct;45(4):E8. Doi: 10.3171/2018.7.Focus18287.
[3] Barbosa Pereira JL, Kubben PL, De Albuquerque LA, Batalini F, De Carvalho GT, De Sousa AA. E-Learning for neurosurgeons: getting the most from the new web tools. Asian J Neurosurg. 2015;10(1):48.
[4] Mahmud, MR, First Quarterly WFNS YNF Quarterly Online Symposium by Leonidas Quintana: Neurosurgical Services for Disasters: Telemedicine /Telesurgery and the Mobile Emergency/Neurosurgical Unit, 29th January 2011. https://www.slideshare.net/riverospintone/telemedicine-in-emergencies-and-disasters
[5] Mahmud, MR, First Quarterly WFNS YNF Quarterly Online Symposium by Russell Andrews: Neurosurgical Services for Disasters: Telemedicine / Telesurgery - Hardware and Logistics. 29th January 2011.
[6] Prasad M, Kumar V. Web resources for neurologists and neurosurgeons. Ann Neurosci. 2013;20(1):18-23.
[7] World Federation of Neurosurgical Societies. Update on the WFNS Young Neurosurgeons Forum | WFNS. https://www.wfns.info/newsletter/69. Accessed online on January 30, 2019
[8] Asian Medical Students and Residents Society for Neurosurgery. www.asianyns.org. Accessed online on January 30, 2019
[11] WFNS Mentoring Across Borders. http://wfnsynfmentoring.blogspot.com/2010/02/wfns-ynf-mentoring-across-borders.html. Accessed online on February 5, 2019
[12] WFNF Mentoring Across Borders’ Training Module. https://nanopdf.com/download/trainingmodule_pdf. Accessed online on February 5, 2019
[13] FIENS proposed Neurosurgical Curriculum. http://www.fiens.org/curriculum/. Accessed online on February 5, 2019
[14] Haglund MM, Kiryabwire J, Parker S, Zomorodi A, MacLeod D, Schroeder R, Muhumuza M, Merson M. Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg. 2011 Jun;35(6):1175-82. doi: 10.1007/s00268-011-1080-0
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