Neurosurgery (2015)

Initial

There are a number of online resources for Neurosurgery, available through ebrain. Neurosurgery SAC has mapped individual Initial Stage syllabus topics to ebrain, which are available here. ebrain is a resource that can be used by both trainees and trainers to support continuous professional development. (Please note that the ISCP is not responsible for the content of external sites)

Initial Stage Overview

The purpose of the initial stage (early years) is to allow the trainee to develop the basic and fundamental surgical skills common to all surgical specialties, together with a broad foundation of theoretical knowledge; clinical experience, skills and competences in:

• Basic and applied clinical neurosciences
• Basic neurosurgical care
• Neuro-intensive care
• Emergency (A&E) medicine

Initial Neurosurgical Training ST2 & 3

During ST2 & 3 trainees will concentrate on acquiring core surgical skills and knowledge, together with specific competencies in the non-operative and operative management of the core neurosurgical conditions.

The outcome of early years training is to achieve the initial stage competences including:

• Competence in the management of patients presenting with a range of symptoms and elective and emergency conditions as specified in the core syllabus for surgery.
• Competence in the management of patients presenting with an additional range of elective and emergency conditions, as specified by the Neurourgery specialty component of the early years syllabus.
• Professional competences as specified in the syllabus and derived from Good Medical Practice documents of the General Medical Council of the UK

On completion of initial neurosurgical training, trainees will be competent in all aspects of the assessment and initial clinical management of the major disorders of the nervous system specified in the core neuroscience syllabus.

They will be competent in the resuscitation, assessment, operative preparation and post-operative care of patients presenting with core neurosurgical conditions. They will be competent to undertake a range of basic procedures without direct supervision.

Core Neuroscience Training: ST1

The first year of the training programme will concentrate on core neuroscience training. During this year trainees will consolidate their knowledge and understanding of the applied neurosciences underpinning clinical practice.

See Core Neuroscience Knowledge in the righthand panel

Management of Common Neurological Disorders

Trainees will be able to resuscitate when necessary; assess through a full neurological history and examination; establish a differential diagnosis; initiate and interpret investigations for patients presenting with a wide range of common neurological disorders. (See righthand panel)

Clinical Placements and Teaching in ST1

Clinical placements for ST1 neurosurgical trainees will include:

• One six-month full-time attachment in neurosurgery and one six-month attachment in an acute neurology service incorporating experience in clinical neurophysiology and neuro-rehabilitation or
• Four month attachments in neurosurgery, neurology and neuro-intensive care providing the same clinical experience as above.

Teaching for ST1 neurosurgical training will include:

• Regular exposure to neuroradiology and neuropathology through multi-disciplinary team meetings and case discussions.
• A core neuroscience teaching programme incorporating the core neuroscience subjects with an emphasis on the assessment and management of the common neurological presentations.

Clinical Placements in ST2 & 3

The timing of clinical placements in ST2 & 3 is flexible and at the discretion of the programme director. The following principles apply:

• All trainees will undertake at least one full-time, six month placement in neurosurgery in ST2 & 3
• By the end of ST3 all trainees will have undertaken a minimum of twelve months' full-time training in basic neurosurgery
• Trainees will undertake one or more placements in complementary surgical disciplines up to a maximum of twelve months
• By the end of ST3 trainees will have obtained four months' experience in an emergency department (A & E) receiving multiply-injured patients, head-injury patients of all severities and patients presenting with acute neurological disorders
• By the end of ST3 all trainees will have had direct involvement in the care of patients receiving neuro-intensive care. This may be obtained as part of an ST1 programme or through placements in ST 2 & 3

Click on Workplace Based Assessments to view the assessment forms including DOPS and PBAs

By the end of early years training, trainees, including those following an academic pathway, will have acquired to the defined level, generic skills to allow team working and management of specialty-specific patient cases so as to:

• perform as a member of the team caring for surgical patients
• receive patients as emergencies and review patients in clinics and initiate management and diagnostic processes based on a reasonable differential diagnosis
• manage the peri-operative care of their patients and recognise common complications and either be able to deal with them or know to whom to refer
• be a safe and useful assistant in the operating room
• perform some simple procedures under minimal supervision and perform more complex procedures under direct supervision

In addition they will have attained the knowledge, skills and behaviour as defined in the following (common) modules of the syllabus:

Module 1: Basic science knowledge relevant to surgical practice (These can all be contextualised within the list of presenting symptoms and conditions outlined in module 2)

• Anatomy
• Physiology
• Pharmacology - in particular safe prescribing
• Pathological principles underlying system specific pathology
• Microbiology
• Diagnostic and interventional radiology

Module 2: Common surgical conditions

• To assess and initiate investigation and management of common surgical conditions which may confront any patient whilst under the care of surgeons, irrespective of their speciality
• To have sufficient understanding of these conditions so as to know what and to whom to refer in a way that an insightful discussion may take place with colleagues whom will be involved in the definitive management of these conditions

This defines the scope and depth of the topics in the generality of clinical surgery required of any surgeon irrespective of their ST3 defined speciality

Module 3 Basic surgical skills

• To prepare oneself for surgery
• To safely administer appropriate local anaesthetic agents
• To handle surgical instruments safely
• To handle tissues safely
• To incise and close superficial tissues accurately
• To tie secure knots
• To safely use surgical diathermy
• To achieve haemostasis of superficial vessels
• To use a suitable surgical drain appropriately
• To assist helpfully, even when the operation is not familiar
• To understand the principles of anastomosis
• To understand the principles of endoscopy

Module 4: The principles of assessment and management of the surgical patient

• To assess the surgical patient
• To elicit a history that is relevant, concise, accurate and appropriate to the patient's problem
• To produce timely, complete and legible clinical records
• To assess the patient adequately prior to operation and manage any pre-operative problems appropriately
• To propose and initiate surgical or non-surgical management as appropriate
• To take informed consent for straightforward cases

Module 5: Peri-operative care of the surgical patient

• To assess and manage preoperative risk
• To manage patient care in the peri-operative period
• To conduct safe surgery in the operating theatre environment
• To assess and manage bleeding including the use of blood products
• To care for the patient in the post-operative period including the assessment of common complications
• To assess, plan and manage post-operative fluid balance
• To assess and plan perioperative nutritional management

Module 6: Assessment and early treatment of the patient with trauma

• To safely assess the multiply injured patient
• To safely assess and initiate management of patients with:
• traumatic skin and soft tissue injury
• chest trauma
• a head injury
• a spinal cord injury
• abdominal and urogenital trauma
• vascular trauma
• a single or multiple fractures or dislocations
• burns

Module 7: Surgical care of the paediatric patient

• To assess and manage children with surgical problems, understanding the similarities and differences from adult surgical patients
• To understand common issues of child protection and to take action as appropriate

Module 8: Management of the dying patient

• Ability to manage the dying patient appropriately.
• To understand consent and ethical issues in patients certified DNAR (do not attempt resuscitation)
• Palliative Care: Good management of the dying patient in consultation with the palliative care team.

Module 9: Organ and tissue transplantation

• To understand the principles of organ and tissue transplantation
• To assess brain stem death and understand its relevance to continued life support and organ donation

Module 10: Health promotion

• General aspects
• Obesity
• Dementia
• Exercise and physical fitness

Professional behaviour and leadership skills

• To provide good clinical care
• To be a good communicator
• To teach and to train
• To keep up to date and know how to analyse data
• To understand and manage people and resources within the health environment
• To promote good health
• To understand the ethical and legal obligations of a surgeon

Standards for depth of knowledge during early years surgical training

In the early years of training, the appropriate depth and level of knowledge required can be found in exemplar texts tabulated below. Trainees are expected to have mastery at the depth within the texts and to be able to make use of that knowledge in the context of surgical practice defined in the core surgical component of the curriculum.

The curriculum requires a professional approach from surgical trainees who will be expected to have a deep understanding of the subjects, to the minimum standard laid out below. It is expected that trainees will read beyond the texts below and make critical use, where appropriate of original literature and peer scrutinised review articles in the related scientific and clinical literature such that they can aspire to an excellent standard in surgical practice.

The texts are not recommended as the sole source within their subject matter and there are alternative textbooks and web information which may better suit an individual's learning style. Over time it will be important for associated curriculum management systems to provide an expanded and critically reviewed list of supporting educational material.

In addition to these standard texts, sample MRCS MCQ examination questions are also available at www.intercollegiatemrcs.org.uk, which will demonstrate the level of knowledge required to be able to successfully pass the MRCS examination.

Standards for clinical and technical skills

The practical application of knowledge is evidenced through clinical and technical skills. Each topic within a stage has a competence level ascribed to it in the areas of clinical and technical skills ranging from 1 to 4:

1. Has observed

Exit descriptor; at this level the trainee:

• Has adequate knowledge of the steps through direct observation.
• Demonstrates that he/she can handle instruments relevant to the procedure appropriately and safely.
• Can perform some parts of the procedure with reasonable fluency.

2. Can do with assistance

Exit descriptor; at this level the trainee:

• Knows all the steps - and the reasons that lie behind the methodology.
• Can carry out a straightforward procedure fluently from start to finish.
• Knows and demonstrates when to call for assistance/advice from the supervisor (knows personal limitations).

3. Can do whole but may need assistance

Exit descriptor; at this level the trainee:

• Can adapt to well known variations in the procedure encountered, without direct input from the trainer.
• Recognises and makes a correct assessment of common problems that are encountered.
• Is able to deal with most of the common problems.
• Knows and demonstrates when he/she needs help.
• Requires advice rather than help that requires the trainer to scrub.

4. Competent to do without assistance, including complications

Exit descriptor, at this level the trainee:

• With regard to the common clinical situations in the specialty, can deal with straightforward and difficult cases to a satisfactory level and without the requirement for external input.
• Is at the level at which one would expect a UK consultant surgeon to function.
• Is capable of supervising trainees.

The explicit standards form the basis for:

• Specifying the syllabus content;
• Organising workplace (on-the-job) training in terms of appropriate case mix and case load;
• Providing the basis for identifying relevant teaching and learning opportunities that are needed to support trainees' development at each particular stage of progress; and
• Informing competence-based assessment to provide evidence of what trainees know and can do.

Standards for the professional skills and leadership syllabus

The methodology used to define the standards for this component of the syllabus is through a series of descriptors that indicate the sorts of activities that trainees should be able to successfully undertake at two specific time points, namely the end of "early years" training (i.e. entry into ST3) and the end of surgical training (i.e. CCT).

The Framework for Appraisal, Feedback and Assessment

The curriculum is consistent with the four Good Medical Practice domains contained in the GMC's Framework for Appraisal and Assessment:

• Knowledge skills and performance
• Safety and quality
• Communication, partnership and teamworking
• Maintaining trust

The knowledge, skills and performance aspects are primarily found within the specialty specific syllabus. All domains are reflected within the professional behaviour and leadership syllabus, which also reflect the Academy's common competence and leadership competence frameworks.

Requirement to meet the ST3 in Neurosurgery

At present (6/2009), neurosurgery continues with run through training that is specialty specific. Most trainees will be entering ST3 from neurosurgery programs, although it is hoped that in time, some 'Core' trainees will be attracted into the specialty from attachments in CT2. However, those that do so will need to address the issue of competencies outside of surgery (qv).

In order to meet the job specifications of an ST3 trainee, an early years trainee must take a clear role in the Neurosurgery team, managing clinic and ward based patients under supervision, including the management of acute Neurosurgical admissions. They will need to be able to take part in an outpatient clinic and in some centres see patients themselves with the consultant available for advice.

Therefore in early years training, IN ADDITION to the generic competencies for all surgeons, it is necessary to address the specifics of a developing interest in Neurosurgery during these years. This means spending 6-12 months in neurosurgery in a service which gives trainees access to the appropriate learning opportunities. They will also have to have completed either a 6 months module in clinical neurology, or four months of neurology and four in an allied clinical neuroscience such as neuro-intensive care. Also by the time a trainee enters ST3 they need to be familiar with the operating room environment both with respect to elective and emergency cases.

Trainees must attend MDT and other Departmental meetings and ward rounds, prepare elective operating lists (both inpatient, day-case), and will be expected to have performed some surgery under appropriate supervision. They must manage all patients in a neurosurgery ward environment, pre-operatively and post-operatively. This includes recognising and initiating the management of common complications and emergencies, over and above those already laid out in the generic component of the curriculum, particularly module 2.

The range of conditions a trainee needs to manage are laid out below and in the depth demonstrated in a text book such as Clinical Neurosurgery (Lindsay), Schmidek and Sweet or Youmans

Cranial trauma: including the resuscitation, assessment, investigation and continuing care of head-injured patients; the prevention and detection of secondary intracranial and systemic insults; insertion of an intracranial pressure monitor; burr-hole drainage of a chronic subdural haematoma.

Spinal Trauma: the resuscitation and assessment, investigation and care of patients suffering spine injuries. The initial external stabilisation of the spine including placement of skull traction. Spontaneous intracranial haemorrhage: including the resuscitation, assessment and investigation of patients suffering a subarachnoid haemorrhage; the management of post-haemorrhagic hydrocephalus; the detection and management of delayed cerebral ischaemia; the management of systemic complications; diagnostic lumbar puncture.

Hydrocephalus: in particular the management of hydrocephalus complicating intracranial haemorrhage, head injury and intracranial space-occupying lesions; insertion and tapping of CSF reservoirs; insertion and maintenance of lumbar and external ventricular drains.

Intracranial tumours: including the assessment and peri-operative management of patients with intracranial tumours; the detection and management of post-operative cerebral swelling, intracranial haematomas and intracranial sepsis; the management of post-operative seizures; the management of post-operative metabolic and endocrine disorders.

Acute spinal disorders: including the assessment and peri-operative management of patients presenting with spinal cord, cauda equina and spinal root compression: the management of spinal shock; the ward management of patients with spinal instability; the detection and initial management of post-operative complications including compressing haematomas, CSF fistula and spinal sepsis.

Entry into ST3

Entry into ST3 will usually involve a competitive selection process. The current person specifications for entry into ST3 in Neurosurgery are shown on the Modernising Medical Careers website. The essential components are completion of the common component of the core surgical training programme (as evidenced by successful ARCP, WPBA and completion of the MRCS examination) and completion of the Neurosurgery specific components of the early years training as evidenced by a successful ARCP and completion of the appropriate WPBA.