The SNS Presidential Address: Innovation in Neurosurgical Education

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- Colleagues and friends, thank you for joining us for another session of the Virtual Operating Room. Our guest today is Dr. Warren Selman from Case Western Neurosurgery. Warren doesn't require an introduction. He's truly one of the giants of neurosurgery. He's Chairman Emeritus at the program there. He is going to be kind enough to review his Presidential Address for the senior society that he recently gave, and I have heard really incredible reviews about this lecture. The lecture is about Innovation in Neurosurgical Education. Something very dear to him and myself. Warren, I wanna really thank you for being here. Very excited. I wanted, I was unfortunately unable to be there in person, so I'm very much looking forward to learning from you through your lecture. Please go ahead.

- Well, Aaron, thank you so much. It's I who owe you the the great thanks. I really am delighted to be able to participate in the virtual OR. You've had an impressive list of guests and really I am honored to be able to join their ranks. As you mentioned, I did, I gave this presentation as my Presidential Address for the 113th meeting of the Society of Neurological Surgeons, but I really think its message is intended for any neurosurgeon who would like to be a better teacher or educator of students at at any level. As you know, the Society of Neurological Surgeons was founded in 1920. It's composed of Neurosurgical Department Chairs, Residency Program Directors, and other educator leaders in America. It's the oldest neurosurgical professional organization in the world, and it serves as a representative body for neurosurgery to the Accreditation Council for Graduate Medical Education, and sponsors the Association of Residency Administrators in Neurological Surgery. The mission of the society really is quite simple. It's to advance the quality of care of neurosurgical patients by promoting excellence in education and research. And it was my highest honor to serve as the President of the society. On a very personal note, I did dedicate my presentation to my brother Steven Selman, who passed away just days before the meeting started. My brother taught and practiced medicine for over 40 years and retired as a Chairman of the Department of Urology at the University of Toledo Medical Center. He was a passionate educator and mentor and was an inspiration to me in every way imaginable. You know, due to the pandemic, our annual meeting scheduled over the last couple years. Excuse me, I guess I forgot to advance this slide, so let me show that when I was talking about my brother.

- I wanna just say may God bless him. I've heard about his greatness as well, so.

- Yeah, thank you very much.

- Rest in peace.

- Thank you, thank you so, so, so great. You know, due to the pandemic, our annual meeting scheduled over the last couple years was altered and the last meeting of the society was barely six months ago at that time. But I do remember sitting next to doctors Marasco and Grady as they were getting ready to give their Presidential Addresses. Now, these are two of the brightest and most thoughtful people I know who've given countless presentations, but both said they were anxious about this one because it was not just about neurosurgery, but about philosophy. Well, needless to say, that stuck with me throughout the past year as I thought, what philosophical issue could I address? So I thought, well, why not tackle the big question? Why am I here? These four words have been considered by the greatest philosophers from Aristotle to Zeno. The search for an answer to the question can be either a source of crippling anxiety or energizing inspiration. And I would like to share with you one example of the latter, which I believe we can and should take to heart. My inspirational answer to the question of why we are here, involves these two gentlemen and a story about a priest, a criminal, and some candlesticks. Victor Hugo's 1862 novel Le Miserables, depicts Jean Valjean's 19 year long struggle to lead a normal life after serving a prison sentence for stealing bread to feed his sister's children. If life turned around when Bishop Myriel, from whom he steals some valuable silverware, tells Inspector Javert that Valjean did not steal the treasure, but rather it had been given to him. Out of this encounter, Valjean becomes a repentant, honorable, and dignified man. So what does Jean Valjean have to do with the question of why as neurosurgeons are we here? Well, one could certainly say, that the grace and the mercy the bishop shows Valjean demonstrates the redemptive power of compassion. The traits so vital to us as neurosurgeons. In fact, Valjean is so overcome by the bishop's mercy and compassion that he wept as a new day dawned in his spirit. Now, while that is a beautiful and moving story, it is not our story. The one between these two men. The gentleman on the left doing the talking, is Dr. Francis Nulsen and the man doing the listening is Dr. John Jane. Dr. Nulsen was recruited to University Hospitals in Case Western Reserve University in 1953 as the Chief of the division of Neurosurgery. He quickly went to work building an absolutely remarkable department, which included what was to become a who's who of neurosurgical leaders who went on to become professors and chairs at institutions from coast to coast, including Don Becker, Bill Collins, Robert Spetzler, Franklin Wagner, Marty Weiss, Howard Jonas, Harry Young, and one John Jane. John Jane's experience is particularly noteworthy and has become the stuff that legends are made of. One of Dr. Nulsen's primary means of communication was his characteristic, handwritten scribble on a yellow tablet that would be handed to anyone not performing up to expectations. As I learned just a little too often during my residency with Dr. Nulsen. In fact, Dr. Nulsen's son, a surgeon himself, told me that he would use this even with his own children who could expect a note to be waiting on their desk after church each Sunday describing just how they could improve in the coming week. So I guess it should come as no surprise that Dr. Jane's answer to the question of why he was there could be found etched on just such a tablet. In the middle of this note, you'll see Dr. Nulsen explained to Dr. Jane just why he was here. As Dr. Jane recalled it, he had just arrived at Case Western Reserve and started operating and doing his research as any young attending would. But he said Dr. Nulsen pulled him aside and said, "You know, I think you've got the wrong idea here. You're not here to become famous. You are here to train the residents. What is wrong with you? You are an academic. You are here to train those who come after you". Now, perhaps it's best to let you hear in Dr. Jane's own words, just how this affected him.

- [Dr. Jane] At Reserve, and I got that note as I operate doing my research and Frank Nulsen took me aside he said, "You know", he said, "I think you've got the wrong idea. You are not here to become famous". He said, 'You're here to train the residents. What's wrong with you?" He said, "You're an academic, you're here to train those who come after you". And I tell you it was a Jean Valjean, you know, Jean Valjean from the play Les Miserables when he is criminalized, I felt like I was, from the moment I arrived, that I was in jail. Jean Valjean goes to this priest's house and he steals this candle and he's caught by the priest and brought back in chains and he's brought into the priest and and the police say, "Are these your candles?" The priest says, "He didn't steal them, they were a present to him". And Jean Valjean, that switches his life. He realizes that . Jean Valjean compared to me, I'm telling you, when I realized that of course, I was supposed to be a teacher and that was my prime role in life.

- So my hope is that all of you will adapt this as your answer to the question of why are you here? You are here to be teachers. And if being a teacher is the answer to why we are here, the next question is, how best do we do that? Well fortunately, the society has given considerable thought to that question. In fact, the year that I became president of this society, marked the 50th anniversary of the publication of the Special Emphasis Panels on the Education of a Neurosurgeon. The society convened these emphasis panels specifically to, as they said, "To elevate neurosurgical resident education". So let me first quote their conclusion. "The Neurosurgeon of the future, on completion of their prescribed training will be like El Greco's St. Paul with a book. Just after closing the book, his finger marks the last page read and on his face are the wonder and the will to understand after the book is closed". Now, to accomplish that, we must not be content to merely train the next generation. We must inspire them. Or in the words of the Special Emphasis Panel, "We must elevate neurosurgical resident education for that is why we are here". And for that I believe we're truly in the right place since the society has a long history of doing just that. So going back to the Special Emphasis Panels, how did they think we should accomplish this elevation of education? Well, you must remember that this was the sixties and the Three R's of those times were Rejection, Rebellion, and Reappraisal. In fact, the normally conservative Chair of the Special Emphasis Panel, Dr. Henry Schwartz, slipped into his alter ego mode and felt the way to elevate the education of a Neurosurgeon was to look at neurosurgery residency through the Purple Haze lenses of those Three R's. And in the spirit of reappraisal, the panel posed several questions. How do we develop teachers and investigators? Should a place be made for intense pursuit of some basic discipline? And if so, how is it to be provided? What would be the effect on the duration of training? How much of a core experience would be needed? Now these questions may sound familiar since we are still refining the answers today. Question is, would providing answers these questions instill the wonder and the will the panel hoped for? Well, I don't think so, not by themselves, or to put it into more philosophical terms, the answers to the Special Emphasis panel are a necessary condition, but not a sufficient condition. So let me briefly review the efforts of the society to provide answers to those pivotal questions which provide the foundation for what we will need to fulfill our why, to be inspirational teachers. The society's efforts in this regard were actually catalyzed in 2007 by the 81st President of the Society, Dr. John Popp, who noted that the complexities of getting a resident through training was much like Magellan's maiden voyage, where he found a complex series of channels and inlets, not the simple, straightforward westward passage that was imagined and depicted at that time. Now, to meet the challenges of this reality, Dr. Popp believed that making small incremental changes to residency training, simply was not an option anymore and put forth a modest proposal. Not, as he reminded us, in the Swiftian sense of suggesting that we would should eat our young, but as a means to achieve the elevation of neurosurgical education. And Dr. Popp felt that we must implement a new comprehensive curriculum which must have the following attributes. It would have a core that would be mastered by all, it would contain both cognitive and procedural elements, but most importantly, it must have the ability to evolve. That was so nicely summarized by our secretary, Dr. Selden. In response to this challenge in 2007, the society began work on a comprehensive sub-specialty focused curriculum, which drew in part on previous curricula created by the Congress of Neurological Surgeons and various individual residency programs. In 2011, the Curriculum Subcommittee married the core curriculum to the ABNS primary examination knowledge categories and measurements of residents performance. Then the Curriculum Subcommittee incorporated a tool for assessing the stages of a resident's cognitive knowledge acquisition, and technical skills development, resulting in the SNS Matrix Curriculum, which was brought to life by none other than our current historian, Dr. Kim, aka a Neo Burchiel, who asked us all to choose the red pill and view our curriculum in a whole new way. Now, as Dr. Selden also pointed out, the Matrix Project was the first of its kind in medical education and Neurological Surgery was then recognized by the ACGME as the forerunner in curriculum research. In 2020, in collaboration with the American Academy of Neurological Surgery, the Curriculum Subcommittee added a specific curriculum for research methodologies, thus addressing really all the curricular questions raised by the special emphasis panel. So now some 50 years after completion of the SNS task force on the Education of a Neurosurgeon, we have resurrected, if you will, next generation of the SNS Matrix Curriculum. The SNS Matrix Curriculum, Resurrections, which was developed by Dr. Bambakidis and his committee members and launched at this meeting, has been simplified for ease of use by program directors and other education. And it's certainly our hope that this will be implemented in many training programs, if not all throughout the country. Now, I would be remiss if I didn't own up to all the many failures to launch the Matrix on the ill-fated portal. Fortunately, Mr. Churchill has provided me with some guidance on how I can be waiving a victory sign for the Matrix launch at this meeting for, as he said, "Success is going from failure to failure without loss of enthusiasm". So with our new Matrix Curriculum at hand, what do we need to do to move from just training to inspiring? Well, let me go back to philosophy. In Dr Marasco's Presidential Address for the Century Anniversary of our Society, she referred to Simon Sinek's Primacy of the Why and that great organizations inspire others by communicating from the inside out, from the why to the what. Now I would submit that we owe a great debt to doctors Nulsen and Jane because they have made our why crystal clear. In Dr. Jane's words, "Our why is because our prime role in life is to be teachers". Doctors Burchiel and Bambakidis our neurosurgery Neos, and their committee members have given us the what in the form of the Matrix Curriculum. So in keeping with the Sinek theme, the question that remains to be answered is how? How do we instill the wonder and the will? I believe the answer can be found in Sinek's philosophy of teaching with an infinite mindset.

- [Dr. Sinek] Choose to live our lives with an infinite mindset. Which means I'm gonna leave this world, this school, in better shape than I found it. It means I'm gonna devote my life to see that those around me rise. We've all had teachers and some of you are those teachers, where 20 or 30 years from now I can go to one of your students and say, "You're a remarkable human being. You've accomplished so much on your life. How did you become the person you are today?" And they will tell me your name.

- So what I'm asking you to do should be pretty straightforward. All you have to do is teach in a way that your residents or students will tell me your name. Unfortunately, the reality of the situation today is that even if you commit yourselves to being the best and most inspirational teacher, and we have some of the great one in our midst in these times, there are several obstacles that can make it difficult to fulfill that mission. Honestly, I think that if Dr. Nulsen and Jane were having their conversation today, even if Dr. Jane were touched by the hand of God and Dr. Nulsen added a new commandment and inscribed the 11th commandment on that yellow tablet, "Thou shall teach with an infinite mindset", he would have difficulty achieving his goal. And so why is that? And more importantly, what can be done about it? Well, if we look at resident training, we can see that from the time Halstead developed the first surgical residency program in 1889, surgical training was dependent on a large volume of cases, endless hours in the hospital, and mentors with ample time to teach with an infinite mindset. Unfortunately, those days appear to be gone forever. The current challenges to teachers in academic centers and elsewhere are known to us all, as most recently highlighted in our Vice President's symposium on "Tipping the Three-Legged Stool". And these include restricted work hours, reduction in operative experience, increased public scrutiny, ever present in increasing productivity pressure, and ever expanding administrative burdens. Not only can these threaten education and training, but they can literally suck the life out of even the most dedicated and passionate teacher. So to instill the wonder and the will we will need as Dr. Popp stressed, to evolve our curriculum and teaching methods and we will need to continually reimagine medical education and surgical training. Now again, the society has been leading the way in educational innovations with boot camps and novel simulations. Our Grossman lecturer this year, Dr. Mark Griswold and his colleagues were charged with re-imagining medical education in the 21st century. And they began with anatomy. Well, one of the biggest challenges for students learning anatomy is understanding the body in three dimensions, which has traditionally relied on cadavers. Our school of medicine no longer teaches anatomy with cadavers. They developed an augmented reality-based curriculum to replace cadavers, called Hollow Anatomy. And what they found was that students learn faster and retain better than when using traditional methods of cadavers. Now, since neuroanatomy has become the first thing we test residents on in their path to board certification, we wondered what inspiring ways would there be to teach this? Now some of our members have already come up with an interesting idea for innovation in neuroanatomy education called Extreme Neuroanatomy. ♪ When I'm lost in the brain ♪ ♪ And I can't find my way ♪ ♪ Which could make for a bad operation ♪ ♪ I recall this refrain ♪ ♪ Which I'll sing if I may ♪ ♪ With a bit of unique syncopation ♪ ♪ Pterion and inion and euryon and nasion ♪ ♪ Asterion opisthion obellion and basion ♪ ♪ And bregma lambda civus vomer foramen ovale ♪ ♪ Hypothesis paraphysis and corpus pineale ♪

- So while I applaud the effort to innovate, this will clearly require more rigorous evaluation. If not voice lessons from my former partner, Dr. Cohen. Thank goodness my other colleague, Dr. Miller's piano skills could hide a lot of his vocalist's shortcoming. Now another idea would be something we have been working on at Case, with my colleague Dr. Brian Rothstein, and that is Hollow Neuroanatomy. The module which we just designed will have to be tested not only for our students, but also for resident education. But I do think that simulation with mixed reality is an area that we must continue to develop in order to inspire. Now, if we look at what has been published about The Role of Simulation Neurosurgical Education, we can see that there was initial enthusiasm for simulation in neurosurgical training with about three quarters of the program directors feeling that it would be quite helpful. Follow-up studies, however, were disappointing, noting poor reliability and no evidence that improved simulator performance translated into any clinical benefit. Well fortunately, Churchillian like enthusiasm prevailed yet again in the face of early failures. And subsequent work has been more promising. In a recent systematic literature review of over 30 studies with simulators of various types, the authors found that simulation use was associated with improvements in procedural knowledge and technical skill and speed giving hope that we can incorporate simulations into our training as we continue to adapt and evolve as we help our residents navigate the passage between incoming students and highly skilled professionals. So in summary, I hope that I've convinced you of the infinite good that comes from adopting Dr. Jane's answer to the question of why we are here, that we are here to be teachers. Now I'm convinced that the way we instill the wonder and the will and enact the modest proposal requires something from us as individuals and something from this society as well. As individuals. As individuals, we need nothing more than to model Dr. Jane in embracing our why while standing on our desk like Mr. Keating so that we continue to see things in a different way and continue to evolve and innovate as educators. As I have shown, the Society has done much, but we continue to need to do more in order to honor the traditions of the founding members as outlined in our original bylaws, to develop graduate education, I believe we must model the American College of Surgeons and establish a robust series of educational programs designed to elevate neurosurgical educators. We must elevate the art and science of education just as we do research and patient care. And as President, I have asked the Society to take the first step and develop the Society of Neurological Surgeons Neurosurgical Educator Development Program. And as to the question of how we will fund this, I will adapt the philosophy of another great leader, President Lincoln, when he was asked how.

- But, how?

- I am president of the United States of America clothed in immense power! You will procure me these funds.

- So I will spare you my great rendition of Daniel Day playing President Lincoln that I did at the actual meeting. But I did say, "Buzzard's guts, Mr. Treasurer, you will procure me those funds". And so in closing, I believe that if we develop innovative educators, who teach with an infinite mindset, that the future looks bright for inspiring the wonder and the will. Thank you.

- Warren, really enjoyed the lecture. Very thoughtful as always. Compared to other lectures that I have watched, I have a few questions that I think I would appreciate your opinion. I know there are no easy answers to any of these questions. If they were easy ones, you and I wouldn't be sitting where we are, but I want to just throw it at you because I think you'll be as credible if not the most credible person to give us just your personal thoughts. Nobody knows the future, nobody has a crystal ball. But these are tough questions in general. So the first question is how do we get more of neurosurgeons engaged in neurosurgical innovation? How can we make them believe in it? That really doing research to improve neurosurgical education is important. Education is not just the fact that well I'm interested in education, so I'm gonna let people explain more in the operating room and have more, you know, ground rounds and just review films. I mean, we know those work, but we gotta innovate. We gotta go to the next level. Simulation, virtual reality, all of those are good, but people have to have that sort of a personal interest and ownership in improving neurosurgical education as a dedicated field. Could you advise me what your thoughts are there?

- Well I, you know, again, as you said, there are no easy answers to those questions. By and large, everyone talks about the importance of education. But you know, when it comes down to push comes to shove, we, you know, we have to take care of patients, we have to develop new treatments and those are the things that tend to get rewarded both professionally and academically. So if someone dedicates their life to teaching it, it's very hard for them to see how they're gonna advance either in academic medicine or personally. I mean, obviously the rewards of teaching have to be, you know, inward and knowing that you are training the next generation. But I think we as neurosurgeons and as a society need to understand that to move that needle of how we're gonna educate the next generation, probably we need to study how we best educate, you know, what works and what doesn't for adult learners, for people, you know, there's obviously many educational theories. Some people learn best visually, some texturally, some reading, some alone. So how do we in a residency program incorporate new ideas of adult education and learning? How do we test them? We have to be able to train our neurosurgeons to say, "You know what, I know how to design a study that's gonna look at if I do this with a group of residents versus this, who's gonna progress better? Who's gonna be better for that?" So I think we need to make the whole science of education something that's inspires people themselves. And then once we start doing that and seeing, yes, we can change the way we educate, and again, I think it's the Neurosurgical Educator Training Program, much the same as we have the Neuroscientist Training Program. A a lot of effort has been put into that. I think we need to have that same taskforce mentality that we need to develop a core of educators.

- I agree. I'm sorry, go ahead Warren.

- No, I was, I saw your, the lips moving. I couldn't hear you though.

- That's okay. No, very well said. I think we talk about precision medicine, but we don't talk about precision education. How can we really be more flexible in engaging and catering to individuals that learn differently? And really we have to do that more effectively, not just, it's a bad analogy, but not every meningioma is the same. Not every brain tumor is the same. Every, not every individual learns the same way. We gotta keep the personality and the ways people learn very much in mind in terms of catering to their needs and improving the care of future patients. Second question that comes to mind that is very important is the effect of pandemics. In pandemic, recent pandemic. Obviously during that time, a year or two, it affected the training of the senior and chief residents, undoubtedly. We know that unfortunately it has all affected the discipline, the engagement and enthusiasm in all industries. And equally in neurosurgery, peoples somewhat feel like the pandemic really affected their families, their enthusiasm for their jobs, and can potentially have a more long-lasting effect. And so again, how do we deal with such an event, unfortunately has happened. Do you have any thoughts there?

- Well, I think, you know, some of it, is a reflection of our being very social creatures and neurosurgeons in particular seem to be. And so when you can probably get some of the same things done in a residency program, some of the teaching, but you know, the zoom fatigue and others it is overwhelming. I think as people come back and interact, that natural spirit of collaboration, cooperation, even competition if you will, I think will get people energized. You know, I've sort of seen that people as they get back more and more together, the conversations grow again, the new ideas. And I think it's that blossoming of social interaction that will make things return more normal. Even in our training and our taking care of patients, obviously, you know, if things continue and the pandemic makes it so hard for people to do their work, that's going to continue to be a problem in the future. If you can't staff the ORs and we're constantly waiting and operating late at night, it's gonna start to devolve again. So hopefully, we'll get, you know, the workforce back to its right size strength and allow us to do what we did in the past.

- Yeah, I agree. Although I hope I'm wrong, I think there's gonna be a lag period. In other words, it would be sometimes still before we get into that pre-pandemic era where people had that sort of intense enthusiasm about moving their surgery forward and being able to go to the next level. I sure I hope should this lag period is as short as possible and we can move forward and keep in mind that just like you very eloquently mentioned, why are we here? Who am I and what is our ultimate goal in our legacy to improve the transfer of information and also the training of better generation of neurosurgeons. Obviously the whole study and method of training, the Cushing method of training, it is not really applicable. I mean I think we have made a great set of strides the past hundred years, in improving neurosurgical education and I think it's the time, right time to do that. And if we don't do it, somebody else will do it for us. And that will be much more painful. We have learned that in many other areas of neurosurgery as I'm sure you know. Lastly, I want emphasize your important, did want to mention about simulation. In fact our team, the Atlas team, is closely working with the Nvidia team. They have virtual, we have created a virtual twin of the operating room. Nvidia has a huge force behind creating the virtual twin of the United States for auto driving cars. So we have partnered with them and we have made great stride and hopefully I'll have a chance to show that to you in the Congress Meeting in October. We have been able to create the operating room, all the characters, all the craniotomies. And we're working with this, with our PhysX team to be able to create the texture of the brain. And we're pretty close in that. Currently there are even new tools that can create some haptic feedback. We have created robotic microscope within the OR that can allow you visualization through brain mobilization. So I think the new era with the technology of high-powered GPUs, especially in Nvidia and their interest, I think we're gonna see something much faster than once we thought because of the big challenges of haptics in the brain. So I think the future in haptics and brain surgery is much sooner than once thought. So we're hoping that will be something we can report back to you and get your feedback. 'Cause as an expert in neurosurgical education and what you have done for neurosurgery, Warren, I sincerely appreciate your mentorship. So with that, I wanna really thank you for your time, Warren, for what you have done for neurosurgery in every level and your support of the Neurosurgical Atlas from the very beginning and hope to have you with us again in the near future. Do you have any closing talks or points for us? Please.

- Just wanna thank you again for being able to participate. You also have done an outstanding job through the Atlas and I'm very excited about seeing what you've done with the new simulation because I do think that is gonna be one of the ways that we inspire.

- I agree, I agree. As they always say, if you can define leadership and ultimate mentorship in one word, what would it be? And it's about inspiring and it's nothing higher than that. Can you inspire the next generation to do better than what we have done? And can we leave neurosurgery in a better shape than once we found it? And I think something you and I have a very, very special enthusiasm for. So again, my condolences on your brother. Make God bless him. Make God bless you for the great work you have done, including this lecture. We'll be in touch.

- Thanks Aaron, thank you.

- Thank you, thank you.

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