Commentary: Simulation Training in Neurological Surgery

Burchiel, Kim J. MD

Section Editor(s): Harrop, James S. MD; Bendok, Bernard R. MD

doi: 10.1227/NEU.0000000000000114

Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon

Correspondence: Kim J. Burchiel, MD, Department of Neurological Surgery, Oregon Health and Science University, 3303 SW Bond Ave, CH8N, Portland, OR 97239-3098. E-mail:

Article Outline

Simulation in our field has been discussed for the past several decades. There is clear progress, as exemplified by this issue of Neurosurgery. There is also a clear need for this technology. What are the factors that are driving this need, and how has neurological surgery begun to meet this challenge?

The foremost rationale to promote simulation training is our intrinsic desire to improve the quality and safety of our specialty. Simulation is one manifestation of “best practice” because it distills procedures to their essentials and allows acquisition and refinement of technique in an educational environment free of the pressures, demands, and risks of patient care.

The future of health care will be increasingly driven by data transparency and the desire of our patients to be assured of the competency of their physician or surgeon. Our patients will want to know if their neurosurgeon was rigorously trained to perform the particular procedure under discussion. Their expectation will be that simulation was an explicit aspect of their surgeon's training, as it is for other technically demanding professions. Musicians, sports figures, and astronauts, all engage in “intentional practice,” ie, rehearsals for their ultimate performance. The comparison of simulators for surgeons and flight simulators for pilots has certainly been made. Despite the differences in the complexity and breadth of tasks between surgeons and pilots, the public will intuitively make that analogy and expect that we surgeons used similar training devices. The current issue exemplifies what can be done and how we can integrate this approach into our primary training and postgraduate programs.

Our program director society, the Society of Neurological Surgeons, has already made great strides in the area of simulation, and this progress has resulted in more cohesive and objective methods of surgical skills training.

Currently, all first-year neurosurgery residents attend a regional boot camp that prepares them in the 6 Accreditation Council for Graduate Medical Education competencies and for the minor surgical procedures they will be called on to perform in their initial year of training. Simulation at the boot camps is heavily integrated into the teaching of the placement of intracranial pressure monitors, external ventricular drains, shunt taps, cervical traction tongs, and lumbar drains and surgical positioning, all of which prepare the residents for their first clinical year. Satisfactory performance in a simulation environment (albeit less technical) in the competencies of professionalism and communication has allowed our first-year residents to function under indirect supervision with a faculty mentor immediately available in the hospital. This aspect of the boot camp training has been recognized by the Accreditation Council for Graduate Medical Education as a valid indicator of a resident's competency in these 2 areas, which greatly improves their training experience and satisfaction. The educational rationale and outcome of the neurosurgery boot camps have been reviewed elsewhere.1-4

Recently, the Society of Neurological Surgeons has conducted a series of next-level resident courses, the junior resident courses. These courses are also held regionally, and the technical goals are appropriate to a second- or third-year resident. Simulation has found an even more impressive role in these courses. The Society of Neurological Surgeons plans additional higher-level courses in the future, and you can be assured that simulation will play an enhanced role in these more advanced experiences.

Our major neurosurgical societies, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, are already developing strategies to produce the next generation of surgical simulators. Although simulation is not yet used for board certification in our specialty, my prediction is that when simulation systems have reached the requisite level of sophistication, it is likely that this methodology will be incorporated into the oral examination of the American Board of Neurological Surgeons. Similarly, as these systems become more ubiquitous, it is highly likely that the Residency Review Committee for Neurological Surgery will require that such systems are available in every residency program. It is also clear to me that the acquisition of technical skills, as measured in a validated simulation environment, will become a further training “milestone” in the future.

In these ways, simulation will become a nexus of neurosurgical training and maintenance of competency. It will become an integral part of our training programs, the accreditation of those programs, the certification of future neurosurgeons, and the process of lifelong learning in our specialty.

What you will see in this issue are the formative steps in what will certainly become a process of exponential growth in the development of neurosurgical simulation. It is an exciting future, and one that will be witness to unprecedented excellence in the science and practice of neurological surgery.

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Dr Burchiel is President of the Society of Neurological Surgeons. The author has no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

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1. 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(3):759–764.
2. Selden NR, Origitano TC, Burchiel KJ, et al.. A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery. 2012;70(4):971–981.
3. Strong MJ, Selden NR. Simulation in neurosurgical education: present and future considerations. Contemp Neurosurg. 2012;34(18):1–5.
4. Selden N, Anderson V, McCartney S, Origitano TC, Burchiel KJ, Barbaro N. Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training [published online ahead of print April 16, 2013]. J Neurosurg. doi: 10.3171/2013.3.JNS122114.
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