Planning and Executing the Neurosurgery Boot Camp: The Bolivia Experience

Doing More with Less

Planning and Executing the Neurosurgery Boot Camp: The Bolivia Experience Jared D. Ament1, Timothy Kim2, Judah Gold-Markel3, Isabelle M. Germano4, Robert Dempsey5, John P. Weaver6, Arthur J. DiPatri Jr7, Russell J. Andrews8, Mary Sanchez3, Juan Hinojosa3, Richard P. Moser3,6, Roberta Glick3,9

BACKGROUND: The neurosurgical boot camp has been fully incorporated into U.S. postgraduate education. This is the first implementation of the neurosurgical boot in a developing country. To advance neurosurgical education, we developed a similar boot camp program, in collaboration with Bolivian neurosurgeons, to determine its feasibility and effectiveness in an international setting.

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METHODS: In a collective effort, the Bolivian Society for Neurosurgery, Foundation for International Education in Neurological Surgery, Solidarity Bridge, and University of Massachusetts organized and executed the first South American neurosurgical boot camp in Bolivia in 2015. Both U.S. and Bolivian faculty led didactic lectures followed by a practicum day using mannequins and simulators. South American residents and faculty were surveyed after the course to determine levels of enthusiasm and their perceived improvement in fund of knowledge and course effectiveness.

Bolivia. This humanitarian model provides a sustainable solution to education needs and should be expanded to other regions as a means for standardizing the core competencies in neurosurgery.

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RESULTS: Twenty-four neurosurgery residents from 5 South American countries participated. Average survey scores ranged between 4.2 and 4.9 out of 5. Five Bolivian neurosurgeons completed the survey with average scores of 4.5e5. This event allowed for Bolivian leaders in the field to unify around education, resulting in the formation of an institute to continue similar initiatives. Total cost was estimated at $40 000 USD; however, significant faculty, industry, and donor support helped offset this amount.

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CONCLUSION: The first South American neurosurgical boot camp had significant value and was well received in

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Key words ACGME core competencies - Boot camp - International neurosurgery education - Neurosurgical education -

Abbreviations and Acronyms ACGME: Accreditation Council for Graduate Medical Education PGY: Postgraduate training year SNS: Society of Neurological Surgeons From the 1University of California Davis Medical Center, Sacramento, California; 2Yale University, New Haven, Connecticut; 3Solidarity Bridge, Evanston, Illinois; 4Mount Sinai

WORLD NEUROSURGERY 104: 407-410, AUGUST 2017

INTRODUCTION

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dvances in adult learning theory, which emphasizes curricula that are pertinent to the specific needs of the learner in their particular work environment has translated to the medical field.1,2 In 2002, the Accreditation Council for Graduate Medical Education (ACGME) and the residency review committee (RRC) mandated that residency education integrate six core competencies into the training curriculum: 1) patient care, 2) medical knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication skills, 5) professionalism, and 6) system-based practice.3 However, the 2 primarily behavioral competencies, interpersonal and communication skills and professionalism, have proven difficult to incorporate into surgical training and, in particular, the field of neurosurgery.

The perceived abstract nature of these tenets and lack of previous formal education in these by neurosurgical educators themselves present challenges in the further development of these competencies.4 As a result, in 2007, partly to tackle such challenges, the Society of Neurological Surgeons (SNS), the oldest neurosurgical professional group in the world, created the Neurological Surgery Residency Education Task Force. This group comprised members from the SNS, American Association of Neurological Surgeons, American Board of Neurological Surgery, Neurological Residency

School of Medicine, New York, New York; 5University of Wisconsin, Madison, Wisconsin; University of Massachusetts Medical School, Worcester, Massachusetts; 7Ann and Robert H. Lurie Children’s Hospital, Northwestern University, Chicago, Illinois; and 9Rosalind Franklin Medical School, Rush University Medical Center, Chicago, Illinois, USA; and 8World Federation of Neurosurgical Societies, Nyon, Switzerland 6

To whom correspondence should be addressed: Jared D. Ament, M.D., M.P.H. [E-mail: Jared.ament@ucdmc.ucdavis.edu] Citation: World Neurosurg. (2017) 104:407-410. http://dx.doi.org/10.1016/j.wneu.2017.05.046 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

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Review Committee of the American College of Graduate Medical Education, and Congress of Neurological Surgeons.5 And, in 2009, based on the Task Force’s recommendations, neurosurgical training was modified across all programs in the United States.

The first year of postgraduate training (PGY-1) was modified such that the curriculum was tailored more specifically to the neurosurgical field, thereby eliminating the previously required preliminary year in general surgery.6 This also meant that neurologic surgery was now responsible for teaching many of the introductory cognitive and practical skills normally covered during an internship.5,6 With the guidance of the newly established SNS Committee on Residency Education, the SNS “boot camp” was created as a result.

Courses were designed to meet the needs of a PGY-1 resident while focusing on the 6 core ACGME competencies. In 2009, the pilot course was offered to new residents from 5 different U.S. Pacific Coast residency programs. It received overwhelmingly positive feedback and support from both the residents and faculty members who participated. In July 2010, the SNS boot camp courses were expanded nationally and the SNS created a standardized national curriculum that was taught at 6 regional centers.6 This course is now a mandatory requirement for all residents entering an ACGMEaccredited U.S. neurosurgical training program. There was 94% attendance by the inaugural class of residents in 2010 and 100% attendance in the following years.4 Through residents’ feedback and evaluations, these boot camp courses seemed to successfully fulfill their objective, as well as provide critical knowledge and persisted through their first year of training.7 Given the success of the boot camp in the United States, there has been an impetus to expand this type of standardized curriculum internationally, especially in nonindustrialized countries with limited training programs and resources. On a world scale, Bolivia ranks 119th on the 2015 Human Development Index (http:// hdr.undp.org/en/data); for comparison, Colombia is 97th, Chile is 42nd, and the United States is 8th on the same index.8 There are approximately 10.8 million people living in Bolivia with a mean life expectancy of 68.3 years. Public health expenditure represents 6.1% of the nation’s GDP. With approximately 1 neurosurgeon for every 200,000 people and the majority of the population living outside urban centers, access to neurosurgery is a growing global health concern.8 The practice of neurosurgery has been in existence in Bolivia for thousands of years.9 However, formal neurosurgery was only introduced in the late 1940s with the arrival of neurosurgeons trained in the United States and other parts of South America.

Despite Bolivia being the poorest nation in South America,

neurosurgeons perform high-level procedures with limited means. Yet the quality and consistency of neurosurgical residency training remains highly variable. Thus, in an effort to improve neurosurgical training in South America, U.S. leaders in the field held the first South American neurosurgical residency boot camp in Bolivia in October 2015.

METHODS The first international/South American neurosurgical boot camp was held in conjunction with the 11th Congress of the Neurological Society of the Cono Sur and in a collective effort with the Bolivian Society for Neurosurgery, FIENS, the Institute for the Development of Neurosurgery, Solidarity Bridge, and University of Massachusetts, both U.S.-trained boot camp faculty and Bolivian faculty led didactic lectures and case scenarios followed by a full practicum day that included hands-on stations using mannequins and simulators. The course was modeled on the successful implementation of the mandatory neurosurgical boot camp in the United States.6,7 The design of the course allowed participants (trainees and teachers) to attend with minimal disruption to their regular responsibilities and training. The initial 12 didactic lectures (Table 1) were given by U.S. and Bolivian faculty in both Spanish and English with simultaneous translation. This was also followed by case discussions led by U.S. and Bolivian neurosurgeons using scenarios prepared by the SNS, allowing residents to analyze clinical information and propose treatment options while receiving simultaneous feedback from experienced neurosurgeons. The 8 practical skill stations (made possible by the assistance and donations from Medtronic Inc., Stryker, Globus Medical, Artisan Medical, Atlas Medical) were separated into beginner and intermediate sections (Figure 1 and Table 2).

All neurosurgical residents in South America were invited, and postgraduate neurosurgical residents from 5 different countries (Bolivia, Chile, Peru, Ecuador, Argentina) attended.

At the course’s conclusion, both days of the boot camp were individually evaluated by lecturers and participants using questionnaires. The goal was to determine perceived improvement in fund of knowledge and overall course effectiveness. A Likert rating scale (1 ¼ not satisfactory, 2 ¼ satisfactory, 3 ¼ good, 4 ¼ very good, 5 ¼ excellent) was used for this evaluation, with assessment of means and standard deviations. Narrative and qualitative evaluations were also collected through surveys and direct questioning/filming of the students and faculty (Solidarity Bridge filming www.youtube.com/watch?v¼-yoSs7uSAzI).

Table 1. Didactic Lectures Professionalism and Quality of Care

Basic Reviews

Assessment

Management

Professionalisms, Leadership, Supervision and Pearls

Cerebral Vascular Anatomy

Neurological and Neurotrauma Assessment

Intracranial Pressure Management

Patient Safety and Clinical Communications/Handoffs

Ventricular Anatomy

Emergency Cranial Radiology Assessment

Making the Incision: Surgical Pause to Scalp Blood Supply

Quality Improvement/Safety and Surgical Checklists

Surgical Anatomy of the Spine

Emergency Spinal Radiological Assessment

Emergency Evaluation and Management of Hydrocephalus Shunt Patients

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Table 3. Resident Evaluation Category

Average Result

1. Lectures (Day 1) a. I learned something new

4.2

b. I can apply what I learned in my profession

4.5

c. Quality of the instructors

4.9

2. Discussion groups—cases (Day 1) a. I learned something new

4.4

b. I can apply what I learned in my profession

4.7

c. Quality of the instructors

4.8

3. Practical stations (Day 2)

Figure 1. Dr. Richard Moser (University of Massachusetts Medical School) supervising drilling techniques at the first South American Boot Camp, October 2015.

Costs were mitigated by industry support, registration fees, and donations. Expenses included promotion and organization, course site infrastructure, lodging, food, teaching station setup and equipment, and on-site technical support. Infrastructure consisted of use of Caja Nacional Hospital’s auditorium, classrooms, microscopes, and custodial support for 3 days. Promotion was through the Bolivian Neurosurgery Society. Puente de Solidaridad and its sister organization Solidarity Bridge provided staffing and funding for office materials, supplies, promotion, language interpretation, and outreach.

a. I learned something new

4.5

b. I can apply what I learned in my profession

4.8

c. Quality of the instructors

4.5

1—not satisfactory.

2—satisfactory.

3—good.

4—very good.

5—excellent.

The most common feedback was to make this an annual course and expand it to include other cities/countries in South America. Notably, Bolivian leaders in the field have become

Table 4. Bolivian Faculty Evaluation Category

Average Result

1. Lectures (Day 1)

RESULTS Twenty-four neurosurgery residents from 5 South American countries participated. All residents completed the postcourse survey that was designed to measure enthusiasm. Average scores were between 4.2 and 4.9 (Table 3). Five Bolivian neurosurgeons completed the survey with average scores of 4.5e5 (Table 4).

Table 2. Practical Skill Stations Beginner

4.9

4. Organization of the event

Intermediate

a. I learned something new

5.0

b. I can apply what I learned in my profession

4.5

c. Quality of the instructors

4.75

2. Discussion groups—cases (Day 1) a. I learned something new

5.0

b. I can apply what I learned in my profession

5.0

c. Quality of the instructors

5.0

3. Practical stations (Day 2)

Lumbar Drain/Puncture

Craniotomy, Dural Opening/Closing, Skull Plating

a. I learned something new

5.0

b. I can apply what I learned in my profession

5.0

Pediatric Shunt Tap

Spine Station

c. Quality of the instructors

5.0

Third Ventriculostomy

Basic and Intermediate Drilling Under a Microscope

Intracranial Pressure Monitor and Ventriculostomy Tong Traction and Gardner Skull Positioning

WORLD NEUROSURGERY 104: 407-410, AUGUST 2017

4. Organization of the event

4.75

1—not satisfactory.

2—satisfactory.

3—good.

4—very good.

5—excellent.

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unified around education, resulting in the formation of an institute to continue similar initiatives in the future.

The total cost was estimated at $40,000 USD. This included airfare, lodging, and planning for US-based faculty. This was partially defrayed by faculty and industry contributions of $26,000 USD and $19,750 USD, respectively. Bolivian faculty and residents’ airfare, housing, and incidentals were covered by the individual or their respective institution/program. A total of $1680 was also generated in registration fees ($70 per participant).

DISCUSSION With a robust amount of literature now supporting the incorporation of boot camp style training as part of the ACGME curriculum, it is natural to consider the exportation and evolution of these programs.2-7 Given the significant variability in the training, knowledge, and skill levels among neurosurgical residents in nonindustrialized nations, the Bolivian boot camp represents an initial effort toward standardization and, hopefully, improved patient care. By its very design, the course overcomes educational gaps, allowing residents to experience multimodal and dynamic learning techniques at their respective levels. Responses to the first South American neurosurgical boot camp suggest that it was well received and imparted significant value. This sentiment was ubiquitous, shared by residents from several countries in addition to the participating Bolivian and U.S. faculty neurosurgeons. The enthusiasm translated into tangible and constructive progress, with Bolivian leaders unifying around education and forming the Bolivian Institute of Neurosurgery.

Some inherent limitations should be noted. Although the boot camp operated on marginal costs compared with U.S. standards, it was only feasible because of generous philanthropy and industry

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2. Duffy FD, Holmboe ES. Self-assessment in lifelong learning and improving performance in practice: physician know thyself. JAMA. 2006;296:1137-1139.

ACKNOWLEDGMENTS We are grateful for the generosity of faculty who donated their time and the following industries for their technical support: Medtronic Inc, Stryker, Globus Medical, Artisan Medical, and Atlas Medical. Finally, we thank Solidarity Bridge for providing the necessary infrastructure free of charge.

5. Selden NR, Barbaro N, Origitano TC, Burchiel KJ. Fundamental skills for entering neurosurgery residents: report of a Pacific region “boot camp” pilot course, 2009. Neurosurgery. 2011;68:759-764.

6. Selden NR, Origitano TC, Burchiel KJ, Getch CC, Anderson VC, McCartney S, et al. A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons Boot Camp Courses. Neurosurgery. 2012;70:971-981.

3. Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL, et al. The professionalism curriculum as a cultural change agent in surgical residency education. Am J Surg. 2012;203:14-20.

4. Fontes RB, Selden NR, Byrne RW. Fostering and assessing professionalism and communication skills in neurosurgical education. J Surg Educ. 2014;71:e83-e89.

8. Human Development Reports. United Nations Development Programme. Available at: http://hdr. undp.org/en/data. Accessed March 13, 2017.

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support. This may not be reproducible in some settings or sustainable if multiple boot camps were running around the world every year. It is also difficult to quantify true cost-effectiveness, although substantial value seems like a reasonable conclusion.

The postcourse survey also only measured enthusiasm and lacked a critical assessment of skill development. The latter ought to be a goal of future initiatives. The success of the Bolivian boot camp was also highly dependent on local resources. The nongovernmental organization Puente Solidaridad/Solidarity Bridge has a long history of conducting surgical missions and educational efforts in Bolivia. Members assess and coordinate local facilities, propagate information, and assist with regional logistics. Expansion of the boot camp effort will rely, in part, on identifying similarly well-situated entities.

The authors contend that this effort represents an inexpensive and possibly sustainable solution to educational needs in nonindustrialized countries and that it should be expanded to other nations. It is noteworthy that industry support was critical and necessary for its success. Furthermore, the course was modeled to address the 6 ACGME core competencies. While this appears transportable, prima facie, it does warrant further investigation to ensure cultural sensitivity. Further quantitative evaluation is needed to determine the cost-effectiveness and actual skill development to support broad-based expansion.

7. Selden NR, Anderson VC, McCartney S, Origitano TC, Burchiel KJ, Barbaro NM. Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training: clinical article. J Neurosurg. 2013;119:796-802.

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9. Dabdoub CF, Dabdoub CB. The history of neurosurgery in Bolivia and pediatric neurosurgery in Santa Cruz de la Sierra. Surg Neurol Int. 2013;4:123.

Conflict of interest statement: Medtronic Inc, Stryker, Globus Medical, Artisan Medical, and Atlas Medical provided financial support for the actual boot camp; not directly to individuals, as did various faculty members.

Received 30 March 2017; accepted 8 May 2017 Citation: World Neurosurg. (2017) 104:407-410. http://dx.doi.org/10.1016/j.wneu.2017.05.046 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2017.05.046