- Email: [email protected]
The Role of Simulation in Neurosurgical Education: A Survey of 99 United States Neurosurgery Program Directors
Education & Training
Bernard R. Bendok, M.D. Associate Professor of Neurological Surgery Northwestern University Feinberg School of Medicine
The Role of Simulation in Neurosurgical Education: A Survey of 99 United States Neurosurgery Program Directors Aruna Ganju1, Salah G. Aoun1, Marc R. Daou1, Tarek Y. El Ahmadieh1, Alice Chang1, Lucy Wang1, H. Hunt Batjer1, Bernard R. Bendok1,2
OBJECTIVE: With the reduction of resident work hours and the increasing focus on patient safety, it has become evident that simulation has a growing role to play in surgical education. We surveyed the program directors of 99 U.S. Neurosurgery programs in an effort to better understand how simulation can be implemented in Neurosurgery and to gain insight into key issues that are currently being discussed amongst Neurosurgical educators.
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METHODS: A 14-item questionnaire was emailed to 99 Neurosurgery residency program directors. Questions assessed the clinical impact of simulation, the role of simulation in academia, the investments required in time and money, and the model best suited for simulation.
INTRODUCTION
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and considerable funds on simulators. Cadavers were the least preferred models to use compared to virtual simulation and noncadaveric physical models. CONCLUSIONS: Simulation should be integrated in Neurosurgery training curricula. The validation of available tools is the next step that will enable the training, acquisition, and testing of neurosurgical skills.
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RESULTS: The survey response rate was 53.5%. Seventytwo percent of respondents believed that simulation would improve patient outcome, 74% that it could supplement conventional training, but only 25% that it could replace it. The majority strongly believed that it could help preparing complex cases and could be of use to attending faculty. Forty-five percent thought that residents should achieve pre-defined levels of proficiency on simulators before working on patients. Seventy-four percent of respondents declared they would make simulator practice mandatory if available, and the majority was willing to invest daily time
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Key words - Academic training - Curriculum - Neurosurgical simulation - Program directors - Resident education - Work hour Abbreviation and Acronym ACGME: Accreditation Council of Medical Education
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With the implementation of the 80-hour work-week in 2003 by the Accreditation Council of Medical Education (ACGME) (11), and because of subsequent pressures from a variety of sources to further reduce resident work hours (9), it is increasingly evident that graduate medical education cannot occur solely using traditional means. This is especially true for the surgical specialties where proficiency is strongly dependent on operating room experience (12); for a field such as neurological surgery, the lengthy and complex operations can take years to master. By 2009, it was apparent that the new restrictions had not decreased medical errors or increased patient safety as was initially projected (14, 16, 17); database studies on the impact of the new ACGME standards, including community hospital patients (n 1,511,945 patients) (14), Veteran Affairs hospital patients (3,128,636 patients) (17), and Medicare patients
From the Departments of 1Neurological Surgery and 2Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA To whom correspondence should be addressed: Bernard R. Bendok, M.D. [E mail: [email protected]] Citation: World Neurosurg. (2013) 80, 5:e1 e8. http://dx.doi.org/10.1016/j.wneu.2012.11.066 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878 8750/$
see front matter ª 2013 Elsevier Inc. All rights reserved.
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Table 1. List of the Questions Emailed to the Neurosurgery Program Directors Organized by Topic Clinical implications of simulation training Resident use of a simulator to practice neurosurgical techniques will improve patient outcomes
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
In the era of work hour restrictions, simulators can be a beneficial supplement to conventional “hands on” OR training
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
In the era of work hour restrictions, simulators could potentially replace certain aspects of conventional surgical training
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation could assist in preparation for complex neurosurgical cases
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation could be useful to attending neurosurgeons
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Neurosurgery residents should achieve a predefined degree of proficiency on a simulator before being allowed to work on patients
Yes
No
Role of simulation in Neurosurgery residency training Simulation could provide an objective measurement of surgical skill
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Resident use of a simulator to practice neurosurgical techniques will improve operating room neurosurgical skills
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
If made available at your training center, you would encourage residents to practice neurosurgical techniques using a simulator
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
If made available at your training center, you would mandate residents to practice neurosurgical techniques using a simulator
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation should become an integral aspect of academic residency programs
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Willingness of program directors to invest resources and time in Neurosurgical simulators How much money would you be willing to invest on a virtual simulator for your department?
<$1,000
$1,000e$2,000
$2,000e$5,000
$5,000e$10,000
>$10,000
How much daily time do you expect residents to train on a virtual simulator?
<30 minutes
30 minutese1 hour
1e2 hours
2e3 hours
>3 hours
Type of simulator to develop and use In your opinion, simulation development research efforts should focus primarily on which type of simulation?
Cadaveric models
(8,529,595 patients) (18), unanimously showed no positive effect on the surgical mortality rate (3). The new regulations may have actually increased patient complications and morbidity (8). Recent resident surveys show that the majority of respondents believe that the new work hour regulations will have a negative
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Physical noncadaveric models
Virtual simulation
impact on their residency training (7). Reports of a decrease in surgical case load and surgical exposure have started to emerge (10), as well as of reports of a negative impact on the continuity of care (4). Two possible solutions for this problem include increasing the length of graduate medical training or
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EDUCATION & TRAINING
Figure 1. Graph displaying the answers of the program directors to the question: Resident use of a simulator to practice neurosurgical techniques will improve patient outcomes.
supplementing hospital-acquired experience with additional training, without direct patient interaction. The former is being implemented in Europe where training length is determined by demonstration of competence (4). Given the fact that neurologic surgery training is the longest of all residency programs, simulation is being considered by neurosurgical educators as a surrogate for hands-on in-hospital patient-based training. The growing interest of the neurosurgical community in simulation is evident by the increasing number of simulation courses sponsored by the Congress of Neurological Surgeons and the American Association of Neurological Surgeons (1), and by the implementation of neurosurgery intern “Boot Camp,” a 2-day training course sponsored by the Society of Neurological Surgeons (13). Although there is recognition that simulation may compensate for the reduced work hours, the path by which simulation will facilitate Neurosurgery faculty, residents, and fellow education is still unclear. In an attempt to better delineate the potential role of surgical simulation in neurosurgical education, we surveyed the residency program directors of the 99 U.S. neurological surgery residency programs. We hoped to gain insight into the following questions: Should simulation become an integral part of Neurosurgical
Figure 2. Graph displaying the answers of the program directors to the question: In the era of work hour restrictions, simulators can be a beneficial supplement to conventional “hands on” operating room training.
WORLD NEUROSURGERY 80 [5]: e1 e8, NOVEMBER 2013
Figure 3. Graph displaying the answers of the program directors to the question: In the era of work hour restrictions, simulators could potentially replace certain aspects of conventional surgical training.
academia and how? Is simulation of value only to residents or perhaps to faculty as well? What is the investment required? And what possible outcomes of simulation can be expected? What shape and form should simulation take? The answers to these questions may help define the future development and use of simulation, as well as guide current simulation efforts.
METHODS A 14-item questionnaire (Table 1) was emailed to the residency program directors of the 99 U.S. neurosurgery training programs. Six questions evaluated the clinical implications of simulation training. Five questions assessed the role of simulation in academic programs. Two questions assessed the willingness of program directors to invest time and money on simulator practice. Finally, one question studied the type of device best suited for simulation training. The questionnaire was built using Google Docs, and was sent individually via personalized email to each program director detailing the goals and motives of the survey. A 5-point Likert-type scale was used ranging from 1 to 5, with a 1 signifying strong disagreement and a 5 signifying strong agreement. A reminder was sent 1 week later to encourage participation. Answers were anonymous. Results were collected automatically and formatted into viewable graphs using the Google Docs program (Google, Mountain View, California, USA).
Figure 4. Graph displaying the answers of the program directors to the question: Simulation could assist in preparation for complex neurosurgical cases.
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Figure 5. Graph displaying the answers of the program directors to the question: Simulation could be useful to attending neurosurgeons.
RESULTS The survey was undertaken to gauge the view of neurosurgical educators vis-a`-vis the current and future roles of simulation in an attempt to provide guidance for current simulation efforts. Fortyfive responses were received during the first week following the initial email survey; the second email survey resulted in an additional 8 respondents for a total of 53 respondents with a corresponding response rate of 53.5%.
Issues Pertaining to the Clinical Implications of Simulation Training Six survey questions assessed the impact of simulation on patient management and surgical skills. When program directors
Figure 7. Graph displaying the answers of the program directors to the question: Simulation could provide an objective measurement of surgical skill.
were asked whether or not they believed that the use of simulators by residents would improve patient outcome (Figure 1), 72% agreed whereas 6% disagreed. When asked if simulators could provide a viable supplement to conventional hands-on surgical training (Figure 2), 74% agreed whereas 11% disagreed. On the other hand, only 25% believed that simulators could completely replace certain aspects of conventional training (Figure 3). Eighty-three percent supported the role of simulation in the preparation for complex surgical cases (Figure 4) and 68% felt that simulation may be of value to attending faculty as well as residents (Figure 5). Forty-five percent believed that Neurosurgery residents should attain a predefined degree of proficiency on a simulator before being allowed to work on patients whereas 55% did not agree with this concept (Figure 6).
Issues Pertaining to the Role of Simulation in Neurosurgical Residency Training Seventy percent of program directors believed that simulation can provide an objective measurement of surgical skill (Figure 7). Eighty-six percent believed that simulators would improve neurosurgical skills whereas 4% did not (Figure 8). Ninety-four percent of participating program directors responded that they would encourage their residents to practice on a simulator if made available at their center (Figure 9) whereas 74% would
Figure 6. Graph displaying the answers of the program directors to the question: Neurosurgery residents should achieve a predefined degree of proficiency on a simulator before being allowed to work on patients.
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Figure 8. Graph displaying the answers of the program directors to the question: Resident use of a simulator to practice neurosurgical techniques will improve operating room neurosurgical skills.
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EDUCATION & TRAINING
Figure 9. Graph displaying the answers of the program directors to the question: If made available at your training center, you would encourage residents to practice neurosurgical techniques using a simulator.
actually make this training a mandatory requirement (Figure 10). Seventy percent of responders believed that simulation training should become an integral part of academic residency programs (Figure 11).
Issues Pertaining to the Willingness of Program Directors to Invest in Neurosurgical Simulators The willingness of program directors to invest in simulation was surveyed. The majority of respondents (51%) expected less than 30 minutes of daily simulator training from their residents (Figure 12). Forty-three percent of directors expected their residents to train on a simulator from 30 minutes to 1 hour per day. In regards to the financial investment, program directors acknowledge that capital is needed to pursue this goal: although 13% of program directors would spend less than $1,000 on a simulator, others were willing to spend considerably more (Figure 13). Twenty-five percent would allocate between $2,000 and $5,000, 32% between $5,000 and $10,000, and 30% more than $10,000.
Issues Pertaining to the Type of Simulator to Develop and Use Program directors were queried about simulator mode that research and development efforts should focus on (Figure 14). Options include cadaveric specimens, physical models, or virtual
Figure 10. Graph displaying the answers of the program directors to the question: If made available at your training center, you would mandate residents to practice neurosurgical techniques using a simulator.
WORLD NEUROSURGERY 80 [5]: e1 e8, NOVEMBER 2013
Figure 11. Graph displaying the answers of the program directors to the question: Simulation should become an integral aspect of academic residency programs.
computerized reconstructions. Virtual simulators and physical models each were the preferred type of simulator of 42% of participants whereas cadaveric models were chosen by only 17% of responders.
DISCUSSION With the implementation of the new ACGME work-hour regulations, there is increasing evidence that newly graduated surgical residents may not be fully ready for independent clinical practice. This issue was at the core of discussions in a recent joint American College of Surgeons/ACGME meeting, where reports showed that graduating General Surgery residents may still need additional training before being able to independently function as faculty (2). Current measures to remedy these concerns and compensate for the restrictions on resident work-hours are developing rapidly; in a joint effort by the Society of Neurological Surgeons, the American Board of Neurological Surgery, and the ACGME Resident Review Committee, a new Neurosurgery “Matrix” curriculum has been created and is soon being implemented (3). The “Matrix” curriculum is designed to teach and assess core competencies in Neurosurgery, and is based on the
Figure 12. Graph displaying the answers of the program directors to the question: How much daily time do you expect residents to train on a virtual simulator?
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Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Professionalism, and Communication.
Figure 13. Graph displaying the answers of the program directors to the question: How much money would you be willing to invest on a virtual simulator for your department?
Dreyfus model of skill acquisition through formal instruction and practice (5). This new curriculum is consistent with the ACGME format for core competencies, the American Board of Neurological Surgery primary and oral exam contents, and the Resident Review Committee goals, and aims to train and track the progress of Neurosurgery residents from the status of early learners (postgraduate year 1e2) to competent (postgraduate years 3e6), then proficient (Chief ResidentseJunior staff), and finally expert physicians. The ACGME’s currently developing Milestones project complements the Matrix curriculum and will translate general competencies into specific outcomes to be met by all residents, and measure progress toward proficiency on specific predetermined end points. These endpoints include elements of
Expertise and virtuosity has been well defined by Dr. Anders Ericsson as allowing no shortcuts, and requiring well-informed mentors and at least 10,000 hours of deliberate practice or the equivalent of a decade of training to achieve (6). This concept has been validated in professional musicians, expert sportsmen, as well as high-level scholars. If we attempt to apply this concept to Neurological surgery in a hypothetical 7-year residency program, a resident would have to dedicate 5 hours daily to deliberate technical practice, 6 days a week without any vacation time to achieve 10,000 hours by graduation (3). Although “expertise” may be realistically impossible to attain before graduation in the current context of work-hours limitations, technical “proficiency” should and can be set as a national standard. The inclusion of technical simulation modules within the Milestones and Matrix projects could be an efficient way of ensuring that graduating Neurosurgery residents achieve technical and cognitive proficiency. In an effort to better define the means by which surgical simulation could better accomplish these goals, we surveyed residency program directors for their input on specific issues relevant to Neurosurgical simulation education. We targeted all known 99 Neurosurgery residency program directors in the United States in this survey. Program directors are considered to be the educational experts in the field, and are recognized as having the insight and experience to ensure that neurosurgical competence is achieved by their residents. The objective of this survey was to assist researchers and educators interested in simulation to better focus their efforts toward objectives believed to be of major importance and of crucial need to neurosurgical resident education today. The response rate was approximately 54% within 2 weeks after the initial invitation was sent. Although these questions are purely descriptive and not the product of a validated survey instrument, we believe that the answers represent the opinion of educational leaders in the field and can be used to guide future directions in neurosurgical simulation.
Issues Pertaining to the Foreseen Clinical Implications of Simulation Training
Figure 14. Graph displaying the answers of the program directors to the question: In your opinion, simulation development research efforts should focus primarily on which type of simulation?
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Improving outcome has always been the ultimate objective of medical and surgical patient management. The majority of participating program directors (72%) agreed that training residents on simulators would ultimately improve patient clinical outcome. This concept is crucial to the practical implications of medical simulation and partially accounts for the increase in funding opportunities and for the growing interest in simulation research. The fact that 74% of participants felt that simulation can supplement conventional surgical training whereas only 25% felt that simulation could completely replace it reflects current beliefs that simulators may facilitate the acquisition of basic skills and increase the operating room proficiency of junior residents even if the fidelity of current models has not yet been optimized. The transitional but evolving status of neurosurgical simulators in education is further reflected by the fact that program directors were divided almost evenly in deciding whether a predefined degree of simulator proficiency should be obtained before allowing residents access to live patient cases. Simulation is thus considered as a means to facilitate the transition toward live cases but is not yet unanimously trusted to completely replace
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EDUCATION & TRAINING
conventional surgical training or to serve as a conditional prerequisite for entry into the operating room. An explanation may be that an extremely limited number of simulators have been clinically validated, with most of them belonging to nonneurosurgical specialties such as general surgery and gynecology. On the other hand, program directors seem to recognize the potential advantages of simulating complex neurosurgical cases as 83% believe that it may provide assistance with preoperative preparations. This is already partially made possible for spine surgery by the use of computed tomography/magnetic resonance imagingebased navigational technologies wherein the position, size, and trajectory of instrumentation can be computed and simulated prior to surgery. Additional software and hardware advances and more realistic and refined reconstructions will be required before entire procedures or complex cases can be replicated reliably.
Issues Pertaining to the Role of Simulation in Neurosurgical Residency Academia We surveyed the role of simulation both as an assessment and as a training tool. Simulators have the potential to help experts and novices learn and acquire skills and to serve as evaluation tools in the certification and recertification processes. Simulation devices could potentially have a central role to play in developing a practical module for the board certification process. The majority of program directors seem to believe that simulation can efficiently fulfill the dual role of surgical skill evaluation (70%) and training tool (86%), a fact that could account for their willingness to encourage residents to practice on simulators (94%). More surprisingly, the majority (74%) of program directors would make simulator training mandatory for their residents; only 12% of respondents disagreed with this practice. These results are reflected in the fact that 70% of program directors are willing to make simulation training an integral part of neurosurgery residency.
Issues Pertaining to the Willingness of Program Directors to Invest in Neurosurgical Simulators In light of the current work-hour limitations, resident time is an increasingly precious resource to program directors. To assess the willingness of neurosurgical educators to invest in simulators, participants were surveyed as to the amount of time and money that they were willing to spend on simulation. Indirectly, this questionnaire item assesses the importance and value assigned to simulation in neurosurgical training. Ninety-four percent of responders expected a daily training time of less than 1 hour from their residents, with 51% requiring less than 30 minutes. Free time is a rare commodity during Neurosurgery residency; although residents may not have more time to devote to this endeavor, 30 minutes of focused daily practice can be effective at improving specific surgical skills (15, 19). Program directors seem to be aware that simulators can be extremely expensive,
REFERENCES 1. Aoun S, Bendok B, Mocco J, Levy E: Simulation in vascular neurosurgery. Congress Q 12:9-11, 2011. 2. Bass SBL, Klau MH, Dacey RG: Special panel presentation, “Successful models to prepare for
with 30% willing to spend more than $10,000 and 32% willing to spend between $5,000 and $10,000 to secure one for their program. Cost is currently a crucial impediment to simulation research efforts, and partially explains why the most successful and commonly used simulators in the fields of general surgery, anesthesia, and gynecology have been simple instruments designed to assist in the acquisition of basic skills, such as skin suturing, skin lesion removal, intubation, and basic laparoscopic applications. High fidelity and complex case reproduction implies an increase in cost; however, current advances in computerized 3D reconstruction may result in a decrease in simulator prices. With simulation still in its infancy in Neurosurgery, we believe that basic, targeted, and—most importantly—validated simulation models should be the mainstay of current research efforts. Such instruments would echo the sentiments of neurosurgery program directors, require minimal time for daily practice, and minimal monetary investments while providing an opportunity for effective surgical training.
Issue Pertaining to the Type of Simulator to Develop and Use Three modes of simulation devices are currently available: cadaveric models (human or animal), synthetic physical reproductions, and virtual computerized reconstructions. Each has its advantages and drawbacks. Cadaveric models are certainly the most anatomically representative and realistic, but they are expensive to acquire and maintain. Physical models have the advantage of durability, but their quality and anatomic fidelity can vary greatly. Nevertheless, if used in a targeted fashion and for specific well-defined purposes, they have the potential to serve as effective teaching materials. Virtual computerized reconstructions have emerged as a viable neurosurgical training tool with improved operative fidelity due to haptic feedback and more realistic texturing. The drawback of this mode of simulation is the high cost; often, these simulators require maintenance and software subscriptions. Our survey results suggest that most respondents are aware of the inconveniences of cadaveric models, as these were selected by only a minority (17%). It is not surprising that virtual simulation and physical models are perceived to be superior by 84% of program directors.
CONCLUSION It is increasingly evident that simulation should be integrated into current neurosurgery training paradigms. To ensure its success, simulation devices should be affordable, portable, and targeted. Of necessity, validation of these devices and the associated evaluation tools and their implementation in Neurosurgical curricula will enable the training, acquisition, and testing of neurosurgical skills.
and support transitions to practice.” Presented at: ACS/ACGME Joint Invitational Conference on Transition to Practice in Surgey 2012; Chicago, Illinois. 3. Batjer HH, Aoun SG, Rahme RJ, Bendok BR: Congress of Neurological Surgeons Honored Guest talk: honoring our public responsibility: creating
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milestone and matrix based training in an era of duty hour restrictions 2011; Washington DC.
4. Cohen-Gadol AA, Piepgras DG, Krishnamurthy S, Fessler RD: Resident duty hours reform: results of a national survey of the program directors and residents in neurosurgery training programs.
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Neurosurgery 56:398-403, 2005 [discussion 398403]. 5. Dreyfus SE, Dreyfus HL: A five-stage model of the mental activities involved in directed skill acquisition. Bolling AFB, DC: U.S. Air Force, Air Force Office of Scientific Research; 1980. 6. Ericsson KA, Prietula MJ, Cokely ET: The making of an expert. Harv Bus Rev 85:114-121, 2007. 7. Fargen KM, Chakraborty A, Friedman WA: Results of a national neurosurgery resident survey on duty hour regulations. Neurosurgery 69: 1162-1170, 2011. 8. Hoh BL, Neal DW, Kleinhenz DT, Hoh DJ, Mocco J, Barker FG 2nd: Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107 000 neurosurgical trauma patients in the nationwide inpatient sample database. Neurosurgery 70:1369-1382, 2012. 9. Jagannathan J, Vates GE, Pouratian N, Sheehan JP, Patrie J, Grady MS, Jane JA: Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. J Neurosurg 110:820-827, 2009.
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10. McCall T, Rao G, Kestle J: Work hour restrictions: impact on neurosurgical resident training at the University of Utah. AANS Bull 14:17-22, 2005. 11. Philibert I, Friedmann P, Williams WT: ACGME Work Group on Resident Duty Hours: Accreditation Council for Graduate Medical Education: new requirements for resident duty hours. JAMA 288: 1112-1114, 2002.
17. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. J Am Med Assoc 298:984-992, 2007.
12. Reznick RK, MacRae H: Teaching surgical skills— changes in the wind. N Engl J Med 355:2664-2669, 2006.
18. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. J Am Med Assoc 298:975-983, 2007.
13. Selden NR, Hadjipanayis CG, Origitano TC, Getch CC, Burchlel KJ, Barbaro NM: Boot camp courses for incoming PGY1 neurosurgery residents utilize simulation to improve training and safety. Congress Q (Summer):21-22, 2011.
19. Watterson JD, Beiko DT, Kuan JK, Denstedt JD: Randomized prospective blinded study validating acquistion of ureteroscopy skills using computer based virtual reality endourological simulator. J Urol 168:1928-1932, 2002.
14. Shetty KD, Bhattacharya J: Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med 147:73-80, 2007. 15. Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, Maddern GJ: Surgical simulation: a systematic review. Ann Surg 243:291-300, 2006. 16. Volpp KG: Designing a model health care system. Am J Public Health 97:2126-2128, 2007.
Citation: World Neurosurg. (2013) 80, 5:e1-e8. http://dx.doi.org/10.1016/j.wneu.2012.11.066 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2012.11.066
Bernard R. Bendok, M.D. Associate Professor of Neurological Surgery Northwestern University Feinberg School of Medicine
The Role of Simulation in Neurosurgical Education: A Survey of 99 United States Neurosurgery Program Directors Aruna Ganju1, Salah G. Aoun1, Marc R. Daou1, Tarek Y. El Ahmadieh1, Alice Chang1, Lucy Wang1, H. Hunt Batjer1, Bernard R. Bendok1,2
OBJECTIVE: With the reduction of resident work hours and the increasing focus on patient safety, it has become evident that simulation has a growing role to play in surgical education. We surveyed the program directors of 99 U.S. Neurosurgery programs in an effort to better understand how simulation can be implemented in Neurosurgery and to gain insight into key issues that are currently being discussed amongst Neurosurgical educators.
-
METHODS: A 14-item questionnaire was emailed to 99 Neurosurgery residency program directors. Questions assessed the clinical impact of simulation, the role of simulation in academia, the investments required in time and money, and the model best suited for simulation.
INTRODUCTION
-
and considerable funds on simulators. Cadavers were the least preferred models to use compared to virtual simulation and noncadaveric physical models. CONCLUSIONS: Simulation should be integrated in Neurosurgery training curricula. The validation of available tools is the next step that will enable the training, acquisition, and testing of neurosurgical skills.
-
RESULTS: The survey response rate was 53.5%. Seventytwo percent of respondents believed that simulation would improve patient outcome, 74% that it could supplement conventional training, but only 25% that it could replace it. The majority strongly believed that it could help preparing complex cases and could be of use to attending faculty. Forty-five percent thought that residents should achieve pre-defined levels of proficiency on simulators before working on patients. Seventy-four percent of respondents declared they would make simulator practice mandatory if available, and the majority was willing to invest daily time
-
Key words - Academic training - Curriculum - Neurosurgical simulation - Program directors - Resident education - Work hour Abbreviation and Acronym ACGME: Accreditation Council of Medical Education
WORLD NEUROSURGERY 80 [5]: e1 e8, NOVEMBER 2013
With the implementation of the 80-hour work-week in 2003 by the Accreditation Council of Medical Education (ACGME) (11), and because of subsequent pressures from a variety of sources to further reduce resident work hours (9), it is increasingly evident that graduate medical education cannot occur solely using traditional means. This is especially true for the surgical specialties where proficiency is strongly dependent on operating room experience (12); for a field such as neurological surgery, the lengthy and complex operations can take years to master. By 2009, it was apparent that the new restrictions had not decreased medical errors or increased patient safety as was initially projected (14, 16, 17); database studies on the impact of the new ACGME standards, including community hospital patients (n 1,511,945 patients) (14), Veteran Affairs hospital patients (3,128,636 patients) (17), and Medicare patients
From the Departments of 1Neurological Surgery and 2Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA To whom correspondence should be addressed: Bernard R. Bendok, M.D. [E mail: [email protected]] Citation: World Neurosurg. (2013) 80, 5:e1 e8. http://dx.doi.org/10.1016/j.wneu.2012.11.066 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878 8750/$
see front matter ª 2013 Elsevier Inc. All rights reserved.
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Table 1. List of the Questions Emailed to the Neurosurgery Program Directors Organized by Topic Clinical implications of simulation training Resident use of a simulator to practice neurosurgical techniques will improve patient outcomes
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
In the era of work hour restrictions, simulators can be a beneficial supplement to conventional “hands on” OR training
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
In the era of work hour restrictions, simulators could potentially replace certain aspects of conventional surgical training
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation could assist in preparation for complex neurosurgical cases
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation could be useful to attending neurosurgeons
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Neurosurgery residents should achieve a predefined degree of proficiency on a simulator before being allowed to work on patients
Yes
No
Role of simulation in Neurosurgery residency training Simulation could provide an objective measurement of surgical skill
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Resident use of a simulator to practice neurosurgical techniques will improve operating room neurosurgical skills
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
If made available at your training center, you would encourage residents to practice neurosurgical techniques using a simulator
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
If made available at your training center, you would mandate residents to practice neurosurgical techniques using a simulator
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Simulation should become an integral aspect of academic residency programs
Strongly disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Strongly agree
Willingness of program directors to invest resources and time in Neurosurgical simulators How much money would you be willing to invest on a virtual simulator for your department?
<$1,000
$1,000e$2,000
$2,000e$5,000
$5,000e$10,000
>$10,000
How much daily time do you expect residents to train on a virtual simulator?
<30 minutes
30 minutese1 hour
1e2 hours
2e3 hours
>3 hours
Type of simulator to develop and use In your opinion, simulation development research efforts should focus primarily on which type of simulation?
Cadaveric models
(8,529,595 patients) (18), unanimously showed no positive effect on the surgical mortality rate (3). The new regulations may have actually increased patient complications and morbidity (8). Recent resident surveys show that the majority of respondents believe that the new work hour regulations will have a negative
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Physical noncadaveric models
Virtual simulation
impact on their residency training (7). Reports of a decrease in surgical case load and surgical exposure have started to emerge (10), as well as of reports of a negative impact on the continuity of care (4). Two possible solutions for this problem include increasing the length of graduate medical training or
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Figure 1. Graph displaying the answers of the program directors to the question: Resident use of a simulator to practice neurosurgical techniques will improve patient outcomes.
supplementing hospital-acquired experience with additional training, without direct patient interaction. The former is being implemented in Europe where training length is determined by demonstration of competence (4). Given the fact that neurologic surgery training is the longest of all residency programs, simulation is being considered by neurosurgical educators as a surrogate for hands-on in-hospital patient-based training. The growing interest of the neurosurgical community in simulation is evident by the increasing number of simulation courses sponsored by the Congress of Neurological Surgeons and the American Association of Neurological Surgeons (1), and by the implementation of neurosurgery intern “Boot Camp,” a 2-day training course sponsored by the Society of Neurological Surgeons (13). Although there is recognition that simulation may compensate for the reduced work hours, the path by which simulation will facilitate Neurosurgery faculty, residents, and fellow education is still unclear. In an attempt to better delineate the potential role of surgical simulation in neurosurgical education, we surveyed the residency program directors of the 99 U.S. neurological surgery residency programs. We hoped to gain insight into the following questions: Should simulation become an integral part of Neurosurgical
Figure 2. Graph displaying the answers of the program directors to the question: In the era of work hour restrictions, simulators can be a beneficial supplement to conventional “hands on” operating room training.
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Figure 3. Graph displaying the answers of the program directors to the question: In the era of work hour restrictions, simulators could potentially replace certain aspects of conventional surgical training.
academia and how? Is simulation of value only to residents or perhaps to faculty as well? What is the investment required? And what possible outcomes of simulation can be expected? What shape and form should simulation take? The answers to these questions may help define the future development and use of simulation, as well as guide current simulation efforts.
METHODS A 14-item questionnaire (Table 1) was emailed to the residency program directors of the 99 U.S. neurosurgery training programs. Six questions evaluated the clinical implications of simulation training. Five questions assessed the role of simulation in academic programs. Two questions assessed the willingness of program directors to invest time and money on simulator practice. Finally, one question studied the type of device best suited for simulation training. The questionnaire was built using Google Docs, and was sent individually via personalized email to each program director detailing the goals and motives of the survey. A 5-point Likert-type scale was used ranging from 1 to 5, with a 1 signifying strong disagreement and a 5 signifying strong agreement. A reminder was sent 1 week later to encourage participation. Answers were anonymous. Results were collected automatically and formatted into viewable graphs using the Google Docs program (Google, Mountain View, California, USA).
Figure 4. Graph displaying the answers of the program directors to the question: Simulation could assist in preparation for complex neurosurgical cases.
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Figure 5. Graph displaying the answers of the program directors to the question: Simulation could be useful to attending neurosurgeons.
RESULTS The survey was undertaken to gauge the view of neurosurgical educators vis-a`-vis the current and future roles of simulation in an attempt to provide guidance for current simulation efforts. Fortyfive responses were received during the first week following the initial email survey; the second email survey resulted in an additional 8 respondents for a total of 53 respondents with a corresponding response rate of 53.5%.
Issues Pertaining to the Clinical Implications of Simulation Training Six survey questions assessed the impact of simulation on patient management and surgical skills. When program directors
Figure 7. Graph displaying the answers of the program directors to the question: Simulation could provide an objective measurement of surgical skill.
were asked whether or not they believed that the use of simulators by residents would improve patient outcome (Figure 1), 72% agreed whereas 6% disagreed. When asked if simulators could provide a viable supplement to conventional hands-on surgical training (Figure 2), 74% agreed whereas 11% disagreed. On the other hand, only 25% believed that simulators could completely replace certain aspects of conventional training (Figure 3). Eighty-three percent supported the role of simulation in the preparation for complex surgical cases (Figure 4) and 68% felt that simulation may be of value to attending faculty as well as residents (Figure 5). Forty-five percent believed that Neurosurgery residents should attain a predefined degree of proficiency on a simulator before being allowed to work on patients whereas 55% did not agree with this concept (Figure 6).
Issues Pertaining to the Role of Simulation in Neurosurgical Residency Training Seventy percent of program directors believed that simulation can provide an objective measurement of surgical skill (Figure 7). Eighty-six percent believed that simulators would improve neurosurgical skills whereas 4% did not (Figure 8). Ninety-four percent of participating program directors responded that they would encourage their residents to practice on a simulator if made available at their center (Figure 9) whereas 74% would
Figure 6. Graph displaying the answers of the program directors to the question: Neurosurgery residents should achieve a predefined degree of proficiency on a simulator before being allowed to work on patients.
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Figure 8. Graph displaying the answers of the program directors to the question: Resident use of a simulator to practice neurosurgical techniques will improve operating room neurosurgical skills.
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Figure 9. Graph displaying the answers of the program directors to the question: If made available at your training center, you would encourage residents to practice neurosurgical techniques using a simulator.
actually make this training a mandatory requirement (Figure 10). Seventy percent of responders believed that simulation training should become an integral part of academic residency programs (Figure 11).
Issues Pertaining to the Willingness of Program Directors to Invest in Neurosurgical Simulators The willingness of program directors to invest in simulation was surveyed. The majority of respondents (51%) expected less than 30 minutes of daily simulator training from their residents (Figure 12). Forty-three percent of directors expected their residents to train on a simulator from 30 minutes to 1 hour per day. In regards to the financial investment, program directors acknowledge that capital is needed to pursue this goal: although 13% of program directors would spend less than $1,000 on a simulator, others were willing to spend considerably more (Figure 13). Twenty-five percent would allocate between $2,000 and $5,000, 32% between $5,000 and $10,000, and 30% more than $10,000.
Issues Pertaining to the Type of Simulator to Develop and Use Program directors were queried about simulator mode that research and development efforts should focus on (Figure 14). Options include cadaveric specimens, physical models, or virtual
Figure 10. Graph displaying the answers of the program directors to the question: If made available at your training center, you would mandate residents to practice neurosurgical techniques using a simulator.
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Figure 11. Graph displaying the answers of the program directors to the question: Simulation should become an integral aspect of academic residency programs.
computerized reconstructions. Virtual simulators and physical models each were the preferred type of simulator of 42% of participants whereas cadaveric models were chosen by only 17% of responders.
DISCUSSION With the implementation of the new ACGME work-hour regulations, there is increasing evidence that newly graduated surgical residents may not be fully ready for independent clinical practice. This issue was at the core of discussions in a recent joint American College of Surgeons/ACGME meeting, where reports showed that graduating General Surgery residents may still need additional training before being able to independently function as faculty (2). Current measures to remedy these concerns and compensate for the restrictions on resident work-hours are developing rapidly; in a joint effort by the Society of Neurological Surgeons, the American Board of Neurological Surgery, and the ACGME Resident Review Committee, a new Neurosurgery “Matrix” curriculum has been created and is soon being implemented (3). The “Matrix” curriculum is designed to teach and assess core competencies in Neurosurgery, and is based on the
Figure 12. Graph displaying the answers of the program directors to the question: How much daily time do you expect residents to train on a virtual simulator?
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Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Professionalism, and Communication.
Figure 13. Graph displaying the answers of the program directors to the question: How much money would you be willing to invest on a virtual simulator for your department?
Dreyfus model of skill acquisition through formal instruction and practice (5). This new curriculum is consistent with the ACGME format for core competencies, the American Board of Neurological Surgery primary and oral exam contents, and the Resident Review Committee goals, and aims to train and track the progress of Neurosurgery residents from the status of early learners (postgraduate year 1e2) to competent (postgraduate years 3e6), then proficient (Chief ResidentseJunior staff), and finally expert physicians. The ACGME’s currently developing Milestones project complements the Matrix curriculum and will translate general competencies into specific outcomes to be met by all residents, and measure progress toward proficiency on specific predetermined end points. These endpoints include elements of
Expertise and virtuosity has been well defined by Dr. Anders Ericsson as allowing no shortcuts, and requiring well-informed mentors and at least 10,000 hours of deliberate practice or the equivalent of a decade of training to achieve (6). This concept has been validated in professional musicians, expert sportsmen, as well as high-level scholars. If we attempt to apply this concept to Neurological surgery in a hypothetical 7-year residency program, a resident would have to dedicate 5 hours daily to deliberate technical practice, 6 days a week without any vacation time to achieve 10,000 hours by graduation (3). Although “expertise” may be realistically impossible to attain before graduation in the current context of work-hours limitations, technical “proficiency” should and can be set as a national standard. The inclusion of technical simulation modules within the Milestones and Matrix projects could be an efficient way of ensuring that graduating Neurosurgery residents achieve technical and cognitive proficiency. In an effort to better define the means by which surgical simulation could better accomplish these goals, we surveyed residency program directors for their input on specific issues relevant to Neurosurgical simulation education. We targeted all known 99 Neurosurgery residency program directors in the United States in this survey. Program directors are considered to be the educational experts in the field, and are recognized as having the insight and experience to ensure that neurosurgical competence is achieved by their residents. The objective of this survey was to assist researchers and educators interested in simulation to better focus their efforts toward objectives believed to be of major importance and of crucial need to neurosurgical resident education today. The response rate was approximately 54% within 2 weeks after the initial invitation was sent. Although these questions are purely descriptive and not the product of a validated survey instrument, we believe that the answers represent the opinion of educational leaders in the field and can be used to guide future directions in neurosurgical simulation.
Issues Pertaining to the Foreseen Clinical Implications of Simulation Training
Figure 14. Graph displaying the answers of the program directors to the question: In your opinion, simulation development research efforts should focus primarily on which type of simulation?
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Improving outcome has always been the ultimate objective of medical and surgical patient management. The majority of participating program directors (72%) agreed that training residents on simulators would ultimately improve patient clinical outcome. This concept is crucial to the practical implications of medical simulation and partially accounts for the increase in funding opportunities and for the growing interest in simulation research. The fact that 74% of participants felt that simulation can supplement conventional surgical training whereas only 25% felt that simulation could completely replace it reflects current beliefs that simulators may facilitate the acquisition of basic skills and increase the operating room proficiency of junior residents even if the fidelity of current models has not yet been optimized. The transitional but evolving status of neurosurgical simulators in education is further reflected by the fact that program directors were divided almost evenly in deciding whether a predefined degree of simulator proficiency should be obtained before allowing residents access to live patient cases. Simulation is thus considered as a means to facilitate the transition toward live cases but is not yet unanimously trusted to completely replace
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conventional surgical training or to serve as a conditional prerequisite for entry into the operating room. An explanation may be that an extremely limited number of simulators have been clinically validated, with most of them belonging to nonneurosurgical specialties such as general surgery and gynecology. On the other hand, program directors seem to recognize the potential advantages of simulating complex neurosurgical cases as 83% believe that it may provide assistance with preoperative preparations. This is already partially made possible for spine surgery by the use of computed tomography/magnetic resonance imagingebased navigational technologies wherein the position, size, and trajectory of instrumentation can be computed and simulated prior to surgery. Additional software and hardware advances and more realistic and refined reconstructions will be required before entire procedures or complex cases can be replicated reliably.
Issues Pertaining to the Role of Simulation in Neurosurgical Residency Academia We surveyed the role of simulation both as an assessment and as a training tool. Simulators have the potential to help experts and novices learn and acquire skills and to serve as evaluation tools in the certification and recertification processes. Simulation devices could potentially have a central role to play in developing a practical module for the board certification process. The majority of program directors seem to believe that simulation can efficiently fulfill the dual role of surgical skill evaluation (70%) and training tool (86%), a fact that could account for their willingness to encourage residents to practice on simulators (94%). More surprisingly, the majority (74%) of program directors would make simulator training mandatory for their residents; only 12% of respondents disagreed with this practice. These results are reflected in the fact that 70% of program directors are willing to make simulation training an integral part of neurosurgery residency.
Issues Pertaining to the Willingness of Program Directors to Invest in Neurosurgical Simulators In light of the current work-hour limitations, resident time is an increasingly precious resource to program directors. To assess the willingness of neurosurgical educators to invest in simulators, participants were surveyed as to the amount of time and money that they were willing to spend on simulation. Indirectly, this questionnaire item assesses the importance and value assigned to simulation in neurosurgical training. Ninety-four percent of responders expected a daily training time of less than 1 hour from their residents, with 51% requiring less than 30 minutes. Free time is a rare commodity during Neurosurgery residency; although residents may not have more time to devote to this endeavor, 30 minutes of focused daily practice can be effective at improving specific surgical skills (15, 19). Program directors seem to be aware that simulators can be extremely expensive,
REFERENCES 1. Aoun S, Bendok B, Mocco J, Levy E: Simulation in vascular neurosurgery. Congress Q 12:9-11, 2011. 2. Bass SBL, Klau MH, Dacey RG: Special panel presentation, “Successful models to prepare for
with 30% willing to spend more than $10,000 and 32% willing to spend between $5,000 and $10,000 to secure one for their program. Cost is currently a crucial impediment to simulation research efforts, and partially explains why the most successful and commonly used simulators in the fields of general surgery, anesthesia, and gynecology have been simple instruments designed to assist in the acquisition of basic skills, such as skin suturing, skin lesion removal, intubation, and basic laparoscopic applications. High fidelity and complex case reproduction implies an increase in cost; however, current advances in computerized 3D reconstruction may result in a decrease in simulator prices. With simulation still in its infancy in Neurosurgery, we believe that basic, targeted, and—most importantly—validated simulation models should be the mainstay of current research efforts. Such instruments would echo the sentiments of neurosurgery program directors, require minimal time for daily practice, and minimal monetary investments while providing an opportunity for effective surgical training.
Issue Pertaining to the Type of Simulator to Develop and Use Three modes of simulation devices are currently available: cadaveric models (human or animal), synthetic physical reproductions, and virtual computerized reconstructions. Each has its advantages and drawbacks. Cadaveric models are certainly the most anatomically representative and realistic, but they are expensive to acquire and maintain. Physical models have the advantage of durability, but their quality and anatomic fidelity can vary greatly. Nevertheless, if used in a targeted fashion and for specific well-defined purposes, they have the potential to serve as effective teaching materials. Virtual computerized reconstructions have emerged as a viable neurosurgical training tool with improved operative fidelity due to haptic feedback and more realistic texturing. The drawback of this mode of simulation is the high cost; often, these simulators require maintenance and software subscriptions. Our survey results suggest that most respondents are aware of the inconveniences of cadaveric models, as these were selected by only a minority (17%). It is not surprising that virtual simulation and physical models are perceived to be superior by 84% of program directors.
CONCLUSION It is increasingly evident that simulation should be integrated into current neurosurgery training paradigms. To ensure its success, simulation devices should be affordable, portable, and targeted. Of necessity, validation of these devices and the associated evaluation tools and their implementation in Neurosurgical curricula will enable the training, acquisition, and testing of neurosurgical skills.
and support transitions to practice.” Presented at: ACS/ACGME Joint Invitational Conference on Transition to Practice in Surgey 2012; Chicago, Illinois. 3. Batjer HH, Aoun SG, Rahme RJ, Bendok BR: Congress of Neurological Surgeons Honored Guest talk: honoring our public responsibility: creating
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milestone and matrix based training in an era of duty hour restrictions 2011; Washington DC.
4. Cohen-Gadol AA, Piepgras DG, Krishnamurthy S, Fessler RD: Resident duty hours reform: results of a national survey of the program directors and residents in neurosurgery training programs.
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Neurosurgery 56:398-403, 2005 [discussion 398403]. 5. Dreyfus SE, Dreyfus HL: A five-stage model of the mental activities involved in directed skill acquisition. Bolling AFB, DC: U.S. Air Force, Air Force Office of Scientific Research; 1980. 6. Ericsson KA, Prietula MJ, Cokely ET: The making of an expert. Harv Bus Rev 85:114-121, 2007. 7. Fargen KM, Chakraborty A, Friedman WA: Results of a national neurosurgery resident survey on duty hour regulations. Neurosurgery 69: 1162-1170, 2011. 8. Hoh BL, Neal DW, Kleinhenz DT, Hoh DJ, Mocco J, Barker FG 2nd: Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107 000 neurosurgical trauma patients in the nationwide inpatient sample database. Neurosurgery 70:1369-1382, 2012. 9. Jagannathan J, Vates GE, Pouratian N, Sheehan JP, Patrie J, Grady MS, Jane JA: Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. J Neurosurg 110:820-827, 2009.
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10. McCall T, Rao G, Kestle J: Work hour restrictions: impact on neurosurgical resident training at the University of Utah. AANS Bull 14:17-22, 2005. 11. Philibert I, Friedmann P, Williams WT: ACGME Work Group on Resident Duty Hours: Accreditation Council for Graduate Medical Education: new requirements for resident duty hours. JAMA 288: 1112-1114, 2002.
17. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. J Am Med Assoc 298:984-992, 2007.
12. Reznick RK, MacRae H: Teaching surgical skills— changes in the wind. N Engl J Med 355:2664-2669, 2006.
18. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. J Am Med Assoc 298:975-983, 2007.
13. Selden NR, Hadjipanayis CG, Origitano TC, Getch CC, Burchlel KJ, Barbaro NM: Boot camp courses for incoming PGY1 neurosurgery residents utilize simulation to improve training and safety. Congress Q (Summer):21-22, 2011.
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14. Shetty KD, Bhattacharya J: Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med 147:73-80, 2007. 15. Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, Maddern GJ: Surgical simulation: a systematic review. Ann Surg 243:291-300, 2006. 16. Volpp KG: Designing a model health care system. Am J Public Health 97:2126-2128, 2007.
Citation: World Neurosurg. (2013) 80, 5:e1-e8. http://dx.doi.org/10.1016/j.wneu.2012.11.066 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2012.11.066