COMMENTARY Commentary: Resident Operative Experience: Training an Expert Neurosurgeon James L. West, MD * Kyle M. Fargen, MD, MPH * Carol A. Aschenbrenner, MA ‡ John A. Wilson, MD * Charles L. Branch, MD * Stacey Q. Wolfe, MD * Wesley Hsu, MD * ∗ Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina; ‡ Division of Public Health Sciences, Department of Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina Correspondence: Wesley Hsu, MD, Wake Forest University School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27103. E-mail: whsu@wakehealth.edu Received, July 12, 2018. Copyright C  2019 by the Congress of Neurological Surgeons T he term “resident” evokes times past where a medical trainee was so consumed with the study and practice of patient care that he/she effectively lived within the hospital. There is no greater example of this idea than Harvey Cushing, who has been described as so consumed by his work that he would often miss important family or social events to operate. 1 However, there is growing recognition that optimal resident education must find a balance between medical training and physical/mental health. 2 In 2003, in response to rising concerns over the impact of physician fatigue on patient safety, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 80-h resident work week. 3 Response to this was mixed throughout the medical community, with many in the surgical community voicing concern over the potential impact of limiting resident work hours on patient continuity of care as well as resident operative experience. Eventually, a number of authors investigated the impact of these duty hour restrictions on the operative case logs of graduating residents, with the majority of studies revealing neither a significant decline in resident operative case numbers, nor a measurable benefit to patient safety. 4- 9 The study of the impact of the duty hours on neurosurgery has primarily focused on residents’ opinions of the duty hours as well as on board scores and academic productivity. 10- 12 These studies found that overall the majority of residents disagreed that the duty hour restric- tions had a positive impact on patient care, while also showing that after the implementation of work hour restrictions the average written neuro- surgical board examination score as well as the number of resident research abstracts presented at national meetings both declined significantly. Neurosurgery residency program directors are under increasing pressure to design and implement efficient strategies for resident education that include learning opportunities both in and outside the operating room. Despite the increasing sophistication and availability of virtual learning and cadaver laboratories, the foundation of neurosurgical education continues to be the hands-on opportunities and graduated autonomy that can only be experienced in the operating room. As with the training of an elite athlete, the development of technical excel- lence and optimal decision-making is based on supervised and repeated practice. The volume of these repetitions in the operating room must be maximized as much as possible within the constraints of resident duty hour regulations. Previous research by social psychologists who study the development of expertise can offer important lessons for neurosurgical training. In his book Outliers, Malcom Gladwell highlights the work of Anders Ericsson, a social psychol- ogist who has devoted a large portion of his career to studying experts and what commonalities underlie the development of success. 13 Unfor- tunately, many are only familiar with Ericsson’s work as written by Gladwell, who oversim- plified Ericsson’s hypothesis down to the idea that “Ten thousand hours is the magic number of greatness.” Given that this definition of the development of mastery is most familiar to the general population, we endeavored to estimate how many hours of operative experience neuro- surgery residents accumulate before graduating from residency. METHODS A retrospective analysis was performed of anonymized, publicly available neurosurgical resident case logs obtained from the ACGME. This study was deemed exempt from institutional review board approval given the publicly available nature of this de-identified data set. Calculation of Case Numbers Publicly available ACGME Case Log data from 2012 to 2017 14 - 18 was analyzed. The ACGME case log system requires the resident log at least one proce- dural code associated with each operation and the level of participation. Residents are instructed to log the current procedural terminology (CPT) code as the “primary” CPT code most representative of the operative case. This primary CPT code is then used to determine under which category the case is filed for credit in the resident’s operative log. In addition to the NEUROSURGERY VOLUME 84 | NUMBER 5 | MAY 2019 | E279 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/84/5/E279/5420419 by guest on 21 May 2020