Robert Harbaugh, MD, FAANS, presents on “The Science of Practice – A New Algorithm for EBM.”

In today’s educational environment, meeting the traditional challenges of training young neurosurgeons and preparing them for independent practice is becoming increasingly difficult. New regulatory and socioeconomic pressures limit the time available for resident education and put stress on the traditional resident-teacher relationships. In addition, the accelerating rate at which medical knowledge is being generated creates an environment in which there is more to learn and less time to learn it.

Educational methods must be as efficient and effective as possible to ensure that we continue to meet the challenge of producing the highest quality physicians. To that end, we advocate the use of problem-based learning in resident education. This is not a new suggestion: In fact, William Osler advocated the use of problem-based learning (under the name of “independent study”) more than 100 years ago in 1913 (1).

Defining Problem-based Learning
What, exactly, is problem-based learning? It is the process of active learning in which a student will be presented with a problem (usually a clinical case scenario) and are given a period of time to research and independently solve the problem before reconvening with the instructor for feedback (2, 3). There are multiple variations on how this process can be carried out. For instance, students may be placed in groups or participate as individuals; there can be competition between groups or individuals for mastering the material, etc. The goal of this type of educational approach is to encourage the student to attain the necessary information and apply it appropriately to solve the problem.

Elias B. Rizk, MD, MS, discusses “Calculating Sample Size” at the Science of Neurosurgical Practice course.

This approach has been used widely for medical students and to a lesser extent with residents with good success (2, 4, 5). It should be noted that this is also the approach that is the basis for traditional neurosurgical resident education. Throughout the history of neurosurgical training, residents have been expected to evaluate a patient, formulate a differential diagnosis, collect data to refine the diagnosis and develop a plan of management to present to the attending neurosurgeon. Except in emergency situations, it is expected that the resident would independently read or seek advice from a more senior colleague or both prior to presenting the patient to their attending. This process is the essence of neurosurgical resident education.

However, apprenticeship alone is no longer adequate for neurosurgical education. We demand the application of evidence-based principles to patient interactions in order to appropriately select among many treatment approaches (6, 7). An understanding of evidence-based principles is essential regardless of practice setting. All neurosurgeons need to read, interpret and decide on the reliability and relevance of journal articles throughout their careers. Academic neurosurgeons require a thorough understanding of evidence-based principles to plan and carry out clinical research.

The Problem of Putting EBM into Practice
Despite the fundamental importance of understanding clinical trial design and biostatistics for evidence-based medicine, multiple studies have shown that practicing physicians have a poor understanding of common statistical tools and tests, as well as a limited ability to understand or interpret the results of clinical trials (8–10). In addition, highly sophisticated statistical methods are being used with increasing frequency, further complicating our understanding and interpretation of the medical literature (11). Some neurosurgery residency programs have attempted to address the need for education in biostatistics and clinical trial design through dedicated journal clubs or, less often, a formal evidence-based medicine (EBM) curriculum. However, journal clubs are often used primarily for “keeping up with the literature” rather than critically evaluating it (12–15). As a consequence, some unstructured critical appraisal may be included, but rigorous teaching of the skills necessary to evaluate the literature is often neglected. Reviewing an article without a true understanding of its limitations may give neurosurgeons a false sense of competence in their ability to critically assess their knowledge base. It has been argued that the traditional journal club format may be inadequate for improving evidence-based thinking and in developing competence in the principles of EBM and introducing them into clinical practice (16).

Dedicated training modules can be an effective method to improve the EBM skills of trainees (17). Given the importance of this goal for resident education, a recent course on the Science of Neurosurgical Practice was sponsored by the American Association of Neurological Surgeons (AANS), The Society of Neurological Surgeons (SNS) and the Neurosurgery Research and Education Foundation (NREF).

Teaching the Science of Neurosurgical Practice
The Science of Neurosurgical Practice course employed a problem-based learning approach, as well as other principles of active learning for a resident seminar that, in the past, would have consisted largely of didactic presentations. Prior to arrival at the course, residents were required to submit a potential clinical research idea. The residents attending the course were assigned to small groups by the course instructors. Then, short didactic sessions, presented by experts in neurosurgery and the principles of EBM, focused on imparting skill-directed knowledge. These brief, didactic presentations were followed by group activities that consisted of using the skill-directed knowledge just presented to analyze the data and dissect the methodology of a recent neurosurgical article in order to answer specific problems posed by the faculty. Answers obtained by the students from their analyses were submitted to a faculty referee for grading and feedback. At the end of the course, each group proposed a clinical research project, including a detailed study design and data analysis plan, for review and grading by the faculty. The group that achieved the highest scores on all aspects of the course received a certificate of recognition from the NREF for its efforts.

 
As noted, this course was built around a problem-based learning algorithm, but incorporated several other important aspects of adult active learning — competition; small-group affiliations that allowed each student to bring their areas of expertise and experience to bear; extrinsic rewards and immediate application of new skills to real-world, relevant examples (3). The spirit of friendly competition and comradery fostered by the course design were instrumental in increasing engagement in learning and using the educational material during and after the course. By using these techniques, the course was able to take groups composed largely of EBM novices and, over the course of three days, turn them into groups composed of neurosurgery residents with a much clearer understanding of EBM principles who could critically assess the neurosurgical literature and design robust, achievable and meaningful clinical trials. Pre-course and post-course testing on the subject matter presented confirmed that the course was an extremely effective method of imparting this crucial knowledge to residents who attended.

In conclusion, the use of problem-based learning has a long and successful history within neurosurgical resident education. The AANS/SNS/NREF Science of Neurosurgical Practice Course used this approach and other important features that facilitate adult active learning. We believe that this method of teaching neurosurgical residents the principles of EBM, biostatistics and clinical trial design will pay great dividends in allowing them to understand and contribute to the rapidly expanding library of neurosurgical knowledge.

Nicholas Brandmeir, MD, is currently a 5th year resident at Penn State Hershey Medical Center. He was a participant in the 2014 Science of Neurosurgical Practice Course and was a member of the work group recognized for outstanding achievement. Elias B. Rizk, MD, MSc, is a neurosurgeon at Penn State Hershey Medical Center. He completed his neurosurgical residency at Milton S. Hershey Medical Center, followed by a fellowship in neurosurgery and pediatrics, Children’s Hospital of Alabama in Birmingham, Ala. Robert E. Harbaugh, MD, FAANS, is president of the AANS. He is the distinguished professor and chair of the Penn State Department of Neurosurgery and the director of the Penn State Institute of the Neurosciences. The authors reported no conflicts to disclose.

References

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