Neurosurgical education
The neurosurgical training curriculum in Australia and New Zealand is changing. Why?

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Summary

The Neurosurgical Advanced Training curriculum of the Royal Australasian College of Surgeons (RACS) is currently undergoing change. Given the high standard of neurosurgery in Australia and New Zealand, it may be questioned why such change is necessary. However, the curriculum has not kept pace with developments in professional practice, educational practice or educational theory, particularly in the assessment of medical competence and performance. The curriculum must also adapt to the changing training environment, particularly the effects of reduced working hours, reducing caseloads due to shorter inpatient hospital stays and restricted access to public hospital beds and operating theatres, and the effects of subspecialisation. A formal review of the curriculum is timely.

Introduction

In common with comparable programmes in other countries, neurosurgical training in Australia and New Zealand is based on a Halstedian preceptorship, which implements Osler’s principle of learning by practical experience.1 This pattern of training has remained unchanged since the development of neurosurgery as a discipline in the first half of the 20th century.

Neurosurgical education in Australia and New Zealand has a proud record, based on the rigorous application of Halsted’s preceptorship, combined with an exit examination. A summative assessment in neurosurgery was introduced by the RACS for its Fellowship in 1956.

Although no direct evaluation of Australian or New Zealand neurosurgical performance has been made, the frequency with which trainees are accepted into overseas fellowship positions suggests that the Australian and New Zealand neurosurgical training programme is well regarded. However, the RACS is currently undertaking significant modification to the neurosurgical training programme, and some may question the need for such change in view of the high standard already achieved in these two countries. This paper will argue that one of the fundamental drivers of change is the need to achieve constructive alignment of the curriculum with a new model of competency-based assessment.

The means of assessment is critical. Sir William Osler expressed the opinion that “perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling-blocks and rocks of offence in the pathway of the true student” (William Osler 1899, cited by Pickard2). Osler’s statement anticipates the potential harm of inappropriate assessment. Given that assessment drives learning, Newble’s assertion that “developing assessment procedures is almost certainly the most critical educational task” 3 is well-founded. It is therefore important to review the assessment techniques used to test competence in neurosurgery, to ensure that the quality of learning is enhanced and not harmed.4 Such a review is timely, given the current developments in educational theory and practice in relation to the assessment of competence and performance. Furthermore, government insistence on the RACS justifying its role in providing surgical training has rarely been more acute.

Section snippets

How do neurosurgeons learn? How should they be tested?

Neurosurgery is not simply knowledge, or even the technical application of that knowledge. Practice at an acceptable level requires neurosurgeons to perform in the domains of ‘managers of patient care’, ‘managers of themselves’ and ‘managers of their environment’.[5], [6], [7] These domains are highly specific.

The complexity of these domains highlights the falsity of the ‘ballistic’ model of competence, in which a doctor is launched into practice, reaches a certified level of competence

Neurosurgical curriculum of the RACS

Successful completion of the neurosurgical curriculum should qualify graduates for professional practice and life-long learning. The importance of this is clearly apparent to the Australian and New Zealand people and it is important that the RACS ensures that these goals are met. It is for this reason that the neurosurgical curriculum is currently undergoing change. As stated by the RACS, the objectives of neurosurgical training are “to provide trainees with clinical and operative experience in

Reflection upon neurosurgical credentialing exams outside Australia and New Zealand

There has been little in the way of published literature on the evaluation of neurosurgical training internationally, although there has been a suggestion that validation of curriculum and assessment has been overlooked.2

Constructive alignment of the neurosurgical curriculum

There is a gulf between the stated objectives of RACS neurosurgical training and the implicit objectives (vide supra). The stated objective of ‘familiarity with all aspects of neurosurgical care’ is necessary, but not sufficient, for competent practice. The objectives emphasise breadth over depth with no reference to competence or performance. No specific competencies are identified, and insight is not assessed. The current curriculum has been poorly aligned with the expected aim (by the

Assessment in training

In university settings, it is well established that assessment exerts a strong influence on students’ learning.22 However, no data are available for postgraduate medical assessments. It is appropriate that this should be measured in neurosurgery, because the effect may be negative or positive in its educational impact. It is not the method of assessment that is the most important characteristic but rather the sum of the assessment content.23 The aim of assessment should be testing overall

Conclusion

Although the RACS should be rightly proud of a neurosurgical training system that is respected internationally, it is appropriate to review the current curriculum in the light of recent developments in educational theory. The effect of the various aspects of the curriculum upon trainees’ approaches to learning should be researched, in order to improve the curriculum, to aid learning, and to optimise the contribution of professional insight into trainees’ achievement of competent performances in

References (28)

  • D. Long

    Competency-based training in neurosurgery: the next revolution in medical education

    Surg Neurol

    (2004)
  • J.D. Pickard

    Experience with the United Kingdom examination in Neurosurgery

    Acta Neurochir (Suppl.)

    (1997)
  • D.I. Newble

    Assessment

  • P. Ramsden

    Learning to Teach in Higher Education

    (2003)
  • P. Hager et al.

    What is competence?

    Med Teach

    (1996)
  • R.B. Hays et al.

    Selecting performance assessment methods for experienced physicians

    Med Educ

    (2002)
  • G. Miller

    The assessment of clinical skills/competence/performance

    Acad Med

    (1990)
  • D.A. Schön

    Educating the reflective practitioner. Toward a New Design for Teaching and Learning in the Professions

    (1987)
  • F. Borduas et al.

    The longitudinal case study: from Schön’s model to self-directed learning

    Contin Educ Health Prof

    (2001)
  • J.-.J. Rethans et al.

    The relationship between competence and performance: implications for assessing practice performance

    Med Educ

    (2002)
  • P.G. Bashook et al.

    Certification and the maintenance of competence

    BMJ

    (1983)
  • B.S. Bloom et al.

    Taxonomy of Educational Objectives: the Classification of Educational Goals, by a committee of college and university examiners

    (1956)
  • R.B. Hays et al.

    Is insight important? Measuring capacity to change performance

    Med Educ

    (2002)
  • F. Marton et al.

    On qualitative differences in learning. 1: Outcome and process

    Brit J Educ Psychol

    (1976)

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