AANS Neurosurgeon : Resident's Forum

Volume 24, Number 2, 2015

Screening in Outpatient Clinics: A Missing Piece of Our Current Neurosurgical Resident Training Model?

Tyler J. Kenning, MD

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Our current process for the training of neurosurgical residents is frequently heavily weighted toward the care of acutely ill patients and toward the development of technical expertise in the neurosurgical operative suite. It is indisputable that achieving mastery in both of these arenas is essential to the development of the well-trained neurological surgeon. A coincident cognitive skill must also be acquired, however, in order to guide the medical management, as well as the well-executed surgical therapies, that are necessary for the complete care of neurosurgical patients. This cognitive skill has most often been termed “judgment,” by which we mean a true probabilistic awareness that a given diagnosis is indeed correct and the consequent comprehension of the risk-benefit analysis of the possible therapeutic interventions to be considered.

This acquisition of neurosurgical judgment by the resident trainee mandates their robust exposure to outpatient care in the neurosurgical clinic. The neurosurgical resident must develop a qualitative and quantitative understanding of the difference between the natural history of a given pathological entity and the clinic course of this same disease process. The natural history of a disease is the expected course of events that is unaltered by therapy, while the clinical course is the pathway modified by recognition and treatment of that identical disease process. Recognizing that nearly every treatment, both medical and surgical, has associated anticipated benefit and generally recognized morbid risks, the wise neurosurgeon must be able to judge both the proper timing and the appropriate type of treatment that most positively moves the natural history of the disease toward a more beneficial clinical course.

While both the natural history and the clinical course of the same disease can be distinctly different, depending on the impact of well-reasoned and well-executed treatment, the roads for both natural history and clinical course may wind through perilous and uncertain terrain. The neurosurgical resident must develop a familiarity with this terrain at each stage of the pathological process, whether or not the process has been modified by treatment. The outpatient clinic is a unique setting where it is possible to often observe the beginning, the middle and sometimes the end of the patient’s clinical course.

If the neurosurgical resident is to become skilled in the practice of patient screening, i.e. the employment of knowledge and evidence-based clinical filters for disease recognition and treatment selection, at any stage in the course of a disease process, that resident will find a significant work experience in the outpatient clinic invaluable. This educational value requires the mentorship of experienced staff neurosurgeons. Aside from the neurosurgical clinic, no other clinical vantage point will provide an equivalent perspective on the disease processes and the potential utility of therapeutic interventions. Highly developed interpersonal skills are useful for all neurosurgical residents in every clinical setting and in every patient encounter. The outpatient clinic is the unique arena where the resident refines, by virtue of repetitive effort, their abilities to counsel, to cajole and to comfort their patient. These acquired communication skills will be assets of immense value for the remainder of the neurosurgical resident’s professional lifetime.

One might reasonably ask, in the era of resident work-hour restrictions, how can we add an additional recommendation that the neurosurgical resident have a significant exposure to working in the neurosurgical clinic? Isn’t residency training now a temporal zero-sum equation? Might time spent in the neurosurgical clinic mean that important time will be lost from in-patient care and from operative experience? The answer to these questions: not necessarily. To achieve this goal of a proper outpatient clinic exposure, we must improve our neurosurgical residency training programs by making them more educationally dense, more efficient and more productive. To facilitate this educational improvement, the neurosurgical residents who are allotted less time in the hospital must devote more time to reading and to study when they are not “on-duty.” Implementation of these measures may make the neurosurgical residency training experience different from everyone’s perspective. And, it may just make it a good deal better.

Tyler J. Kenning, MD, is assistant professor in the department of neurosurgery at Albany Medical Center, Albany, N.Y., and co-director of its pituitary and minimally invasive cranial base surgery program. The author reported no conflicts for disclosure.


  1. muhammad tariq Jamil says:

    I am professor of neurosurgery and int vista member cns.Every body is born illiterate when his hearing ,vision and mind starts working till we reach to present state where we are so that we are grateful to our creator.The second thing which I want to remind is presidential addres s of Robert Ratcheson at cns 1985 annual meeting at Hawai “factors retarding medical education.Every trainer should be kind ,affectionate and supporting and should not forget that he was a trainee.

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  2. helen hamill says:

    I am NOT a neurologist or a neurosurgeon, but i feel by virtue of experience of having a chiari malformation, living with the appointments, the disjunct care team of specialists, that i would LOVE to help any system where due to time restrictions, overloaded regional waiting lists, lack of “linked-up” thinking, i have plenty to say.
    I feel that it is crucial to you and to us, as partners, within the failing system, that we make most effective use of time/resources/funds.
    We have a vital input there.
    I exist, i feel in a medical limbo.


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