Neurosurgery Training as Non-Neurosurgeon

[Neuro-OPS]

Hello all! I'd be interested in hearing the thoughts of some surgeons on offering fellowship training for non-neurosurgeons in minimally invasive neurosurgical techniques (e.g. gamma knife, DBS), in a manner akin to radiology/neurology getting trained in neurointerventional techniques. I realize this is a radical view, but especially for some of these techniques (DBS) it seems possible to do a 2-year fellowship training and come out with a very specific surgical skill, even if a non-surgeon. Of course a surgeon would need to be available for emergencies, etc. Ignoring the "turf war battle" thoughts this might elicit, anyone see this as a practical training avenue in the future? For example, a movement disorder neurologist getting trained in doing STN DBS? I'm not a neurologist or a neurosurgeon, just to throw that out there!

Thanks for any thoughts, opinions!

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[ValentinNarcisse]

If you are doing the procedure, you need to be comfortable dealing with complications including ICH, SDH, stroke. A neurologist does not know how to suture — to go from that to safely placing DBS electrodes that won’t cause a hemorrhage, infected cranial hardware etc doing just a fellowship would be difficult to achieve. Of course neuroradiologists can do endovascular fellowship and rad Onc can do CK for brain and spine, but that’s separate issue.


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[Neuro-OPS]

Thanks for your comment!

 

[Neuro-OPS]

Just to push on this issue a little more - what would prevent a neurologist from being able to learn how to suture and to become skilled in DBS surgical and perioperative management over the course of a 2-year fellowship? I imagine a lot of the learning that takes place for a neurosurgeon in DBS/functional neurosurgery happens in the fellowship years as well, since this is such a specialized procedure. I understand the sentiment of needing a neurosurgeon or neuro-intensivist available should things go awry, but wouldn't that place this in a category similar to a neuroradiologist performing a clot removal intravascularly and needing neurosurgery available if they were to cause a stroke/SAH? I am certainly naive about all the specifics that probably go into thinking about this, but really trying to understand as this could alter my career trajectory!

Appreciate any thoughts.

 

[Little Green Mensch]

If you really want to do DBS, you should do a neurosurgical residency and functional fellowship. Why should a hospital pay to keep a neurosurgeon on staff to handle the occasional ICH from your DBS cases? Why not just hire the neurosurgeon instead?

As for CyberKnife/GammaKnife and endovascular techniques, the same logic applies. Who has the most institutional experience evaluating, treating, and caring for post-op patients with neurosurgical pathology (tumors, AVMs, aneurysms, etc.)? Neurosurgeons.

 

[Neuro-OPS]

Good thoughts "Little Green Mensch." But wouldn't the pathology for most of these post-op DBS patients NOT be neurosurgical (essential tremor, Parkinson's, dystonia)? I get your point though - when you enter the head invasively, it becomes neurosurgeon territory. Just with the expansion of these minimally invasive and noninvasive techniques, I thought it would be an interesting point of discussion. I wonder if I would get the same responses in a Neurology thread (imagine I would for the most part!)

Thanks again.

 

[Little Green Mensch]

Good thoughts "Little Green Mensch." But wouldn't the pathology for most of these post-op DBS patients NOT be neurosurgical (essential tremor, Parkinson's, dystonia)? I get your point though - when you enter the head invasively, it becomes neurosurgeon territory. Just with the expansion of these minimally invasive and noninvasive techniques, I thought it would be an interesting point of discussion. I wonder if I would get the same responses in a Neurology thread (imagine I would for the most part!)

You're welcome. The "neurosurgical pathology" referred more to aneurysmal SAH and AVMs than the movement disorders treated by DBS. Neurologists certainly do play an important role in DBS surgeries (verifying targeting, programming, etc.) and in the long-term follow-up of DBS patients. That said, despite the lead size, DBS is pretty invasive and will remain so for the foreseeable future

 

[mmmcdowe]

The issue comes down to logistics. Yes someone could theoretically learn to do dbs in 2 years including removal of hardware and even craniotomy for hematoma. Two years of doing nothing but that would make you adequately skilled. It comes down to you never get to do just that. First you would need enormous volume in order to occupy your time completely. Second you would have to find a hospital that would find a fellow who just does that and maybe the patient care around them worth the cost versus near infinite resident work funded by the government. Third you would need an accrediting body that would recognize you, test you, and provide you with board certification. Neurosurgery board won't and neurology board probably can't even of they wanted to. Its the same argument as to why cant i just do a aneurysm/brain tumor/spine residency only. Theoretically you could if the above conditions were met but the current medical structure values broader education parameters and the consolidation of resources.

 

[Neurointerventionalist]

Agree with mmmcdowe, but think that in the future this may change and, like in IR/NIR or GK, many specialists will work together depending on clinical and procedural skills instead of specialty.

The problem of managing complications is of course impossible to solve in modern medicine: EVERY doctor needs MANY other doctors to manage his/her complications; otherwise every cardiologists should also be a vascular surgeon, and every neurosurgeon also a neurologist and neurorad, and so on. And I know many interventional neurorads and neurologists who can manage aneurysm complications way better than neurosurgeons who only did spine surgery for many years.

Also the idea (very common among neurosurgeons, actually) of a single "superdoctor" who can manage diagnosis, imaging, surgery, endovascular intervention, radiosurgery and ICU is totally against the best current practice.

Finally, a neurologist should actually be trained in general surgery (at least in europe) and able to suture and to learn craniotomy in 2years.Tthe only real obstacle is turf protection by neurosurgeons; and like in neurointerventions (where everyhody is welcome but hopefully to work in a NIR unit), I also hope that if neurologists will learn the procedure will always work in neurosurgical units and not on their own.

 

[kitsunepixie]

Finally, a neurologist should actually be trained in general surgery (at least in europe) and able to suture and to learn craniotomy in 2years.Tthe only real obstacle is turf protection by neurosurgeons; and like in neurointerventions (where everyhody is welcome but hopefully to work in a NIR unit), I also hope that if neurologists will learn the procedure will always work in neurosurgical units and not on their own.

Yeah...and then they can help us deal with shunts in the middle of the night.

 

[Little Green Mensch]

... I also hope that if neurologists will learn the procedure will always work in neurosurgical units and not on their own.

If they're adequately trained, why would it matter if there are neurosurgeons around to back them up?

Also, as mmmcdowe mentioned, the population required to support a one-trick pony DBS doc would be huge (unless bariatric and psychiatric DBS take off, which I think is unlikely to happen soon).

As for it being best practice to foist your complications onto other doctors, I'd disagree. Fixing common complications should be within the scope of practice of every procedural specialty. On the flip side, operators certainly do need to be cognizant of the limitations of their experience and training, and consult experts when appropriate.

 

[Neurointerventionalist]

If they're adequately trained, why would it matter if there are neurosurgeons around to back them up?

It is not to back them up, but to make teamwork and share knowledge. For complex procedures, solitary practice is definitely a bad practice.
I worry about a "functional invasive neurology" community parallel to that of functional neurosurgeons (with its own society, congress and so on).

Also, as mmmcdowe mentioned, the population required to support a one-trick pony DBS doc would be huge (unless bariatric and psychiatric DBS take off, which I think is unlikely to happen soon).

Why should he only perform DBS...? Do functional neurosurgeons only perform DBS? As a neurologist he can follow the patients treated, or partecipate to emergency on-call rotations.

As for it being best practice to foist your complications onto other doctors, I'd disagree. Fixing common complications should be within the scope of practice of every procedural specialty.

Agree with you here, probably I did not explain well. Of course minor complications should be managed, but will rely on colleagues in many occasions anyway.

 

[Neuro-OPS]

This has been a great conversation, thanks to all for chiming in with their thoughts.