GRAVEN: a database of teaching method that applies gestures to represent the neurosurgical approach's blood vessels and nerves.

BACKGROUND: In this era of rapid technological development, medical schools have had to use modern technology to enhance traditional teaching. Online teaching was preferred by many medical schools. However due to the complexity of intracranial anatomy, it was challenging for the students to study this part online, and the students were likely to be tired of neurosurgery, which is disadvantageous to the development of neurosurgery. Therefore, we developed this database to help students learn better neuroanatomy. MAIN BODY: The data were sourced from Rhoton's Cranial Anatomy and Surgical Approaches and Neurosurgery Tricks of the Trade in this database. Then we designed many hand gesture figures connected with the atlas of anatomy. Our database was divided into three parts: intracranial arteries, intracranial veins, and neurosurgery approaches. Each section below contains an atlas of anatomy, and gestures represent vessels and nerves. Pictures of hand gestures and atlas of anatomy are available to view on GRAVEN ( www.graven.cn ) without restrictions for all teachers and students. We recruited 50 undergraduate students and randomly divided them into two groups: using traditional teaching methods or GRAVEN database combined with above traditional teaching methods. Results revealed a significant improvement in academic performance in using GRAVEN database combined with traditional teaching methods compared to the traditional teaching methods. CONCLUSION: This database was vital to help students learn about intracranial anatomy and neurosurgical approaches. Gesture teaching can effectively simulate the relationship between human organs and tissues through the flexibility of hands and fingers, improving anatomy interest and education.

Neurosurgical Practice, Training, and Research Capacity Assessment in Nigeria: A Methodological Approach.

OBJECTIVE: There has been a progressive growth of neurosurgery in Nigeria over the past 6 nulldecades. This study aims to comprehensively evaluate the state of neurosurgical practice, training, and research in the country. METHODS: We used a mixed-methods approach that combined a survey of neurosurgery providers and a systematic review of the neurosurgical literature in Nigeria. The 83-question online survey had 3 core sections for assessing capacity, training, and gender issues. The systematic review involved a search of 4 global databases and gray literature over a 60-year period. RESULTS: One hundred and forty-nine respondents (95% male) completed the survey (65.4%). Their age ranged from 20 to 68 years, with a mean of 41.8 (±6.9) years. Majority were from institutions in the nation's South-West region; 82 (55.0%) had completed neurosurgery residency training, with 76 (51%) employed as consultants; 64 (43%) identified as residents in training, 56 (37.6%) being senior residents, and 15 (10.1%) each held academic appointments as lecturers or senior lecturers. The literature review involved 1,023 peer-reviewed journal publications: 254 articles yielding data on 45,763 neurotrauma patients, 196 on 12,295 pediatric neurosurgery patients, and 127 on 8,425 spinal neurosurgery patients. Additionally, 147 papers provided data on 5,760 neuro-oncology patients, and 56 on 3,203 patients with neuro-vascular lesions. CONCLUSIONS: Our mixed-methods approach provided significant insights into the historical, contemporary, and future trends of neurosurgery in Nigeria. The results could form the foundation for policy improvement; health-system strengthening; better resource-planning, prioritization, and allocation; and more purposive collaborative engagement in Nigeria and other low- and middle-income countries.

A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050.

OBJECTIVE: There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050. METHODS: An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050. RESULTS: Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes. CONCLUSIONS: Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

Toward an optimal cadaveric brain model for neurosurgical education: assessment of preservation, parenchyma, vascular injection, and imaging.

OBJECTIVE: We assessed types of cadaveric head and brain tissue specimen preparations that are used in a high throughput neurosurgical research laboratory to determine optimal preparation methods for neurosurgical anatomical research, education, and training. METHODS: Cadaveric specimens (N = 112) prepared using different preservation and vascular injection methods were imaged, dissected, and graded by 11 neurosurgeons using a 21-point scale. We assessed the quality of tissue and preservation in both the anterior and posterior circulations. Tissue quality was evaluated using a 9-point magnetic resonance imaging (MRI) scale. RESULTS: Formalin-fixed specimens yielded the highest scores for assessment (mean ± SD [17.0 ± 2.8]) vs. formalin-flushed (17.0 ± 3.6) and MRI (6.9 ± 2.0). Cadaver assessment and MRI scores were positively correlated (P < 0.001, R2 0.60). Analysis showed significant associations between cadaver assessment scores and specific variables: nonformalin fixation (ß = -3.3), preservation within ≤72 h of death (ß = 1.8), and MRI quality score (ß = 0.7). Formalin-fixed specimens exhibited greater hardness than formalin-flushed and nonformalin-fixed specimens (P ≤ 0.006). Neurosurgeons preferred formalin-flushed specimens injected with colored latex. CONCLUSION: For better-quality specimens for neurosurgical education and training, formalin preservation within ≤72 h of death was preferable, as was injection with colored latex. Formalin-flushed specimens more closely resembled live brain parenchyma. Assessment scores were lower for preparation techniques performed > 72 h postmortem and for nonformalin preservation solutions. The positive correlation between cadaver assessment scores and our novel MRI score indicates that donation organizations and institutional buyers should incorporate MRI as a screening tool for the selection of high-quality specimens.

The Accreditation Council for Graduate Medical Education 20-Year Trends in Diversity, Equity, and Inclusion in the United States: How Does Neurological Surgery Compare?

BACKGROUND: Within the current medical workforce, diversity is limited among surgical specialties. However, diversity allows physicians to provide culturally competent care. This paper discusses the trends in racial, ethnic, and gender representation within different surgical subspecialties with an emphasis on neurosurgery over a 20-year time frame. METHODS: A retrospective review of data collected by the Accreditation Council for Graduate Medical Education over the past twenty years, as reported in Journal of the American Medical Association, was conducted. Residents from 5 surgical specialties were evaluated based on gender, race, and ethnic identifications from 2002 to 2022. One-way analysis of variance was performed to compare the levels and retention rates of racial, ethnic, and gender diversity within these specialties. RESULTS: Analysis of resident demographics of the 5 surgical specialties reveals an overall trend of increasing diversity over the study period. Over the past 20 years, neurosurgery had an overall increase in Asian (+5.1%), Hispanic (+3.0%), and female (+11.4%) residents, with a decrease in White residents by 2.1% and Black residents by 1.1%. Among the surgical specialties analyzed, otolaryngology had the greatest overall increase in minority residents. Notably, there has been an overall increase in female residents across all 5 surgical specialties, with the highest in otolaryngology (+20.3%) which was significantly more than neurosurgery (P < 0.001). CONCLUSIONS: This chronological analysis spanning 20 years demonstrates that neurosurgery, like other specialties, has seen a growth in several racial and ethnic categories. Relative differences are notable in neurosurgery, including Black, Asian, Hispanic, and White ethnic categories, with growth in females, but at a significantly lesser pace than seen in otolaryngology and plastic surgery.

Factors Affecting Turkish Medical Students' Pursuit of a Career in Neurosurgery: A Single Center Survey Study.

BACKGROUND: Statistics show that over the past 2 decades, even in high-income countries, fewer and fewer students have listed neurosurgery as their top career option. Literature on medical students' pursuit of neurosurgical careers in middle- and low-income countries are scarce. The aim of this research, conducted in Turkey with a middle-income economy, was to contribute insights relevant to medical education and neurosurgery across the world. METHODS: A survey was conducted with a target sample of fourth-year (167 students), fifth-year (169 students), and sixth-year (140 students) medical students (476 in total) from the Medical School at Istanbul Medeniyet University in Turkey. The response rates of the fourth-, fifth-, and sixth-year students were 62% (104/167), 53% (90/169), and 50% (70/140), respectively (in total, 266, including 147 female and 119 male). RESULTS: In terms of the genuine intention, only 2.5% of men and 2.7% of women were committed to specializing in neurosurgery. This study further revealed that possible reasons for these students' low motivation to specialize in neurosurgery were their beliefs that in neurosurgery, the physical and psychological demands were high, and the night shifts were intense, meaning they would not have a social life or spare time for their hobbies; that morbidity/mortality were high; and that financial incentives were insufficient, especially in public institutions. CONCLUSION: Turkish medical students did not rank neurosurgery at the top of their career choices. Possible reasons for this are socioeconomic factors and the inadequate introduction of neurosurgery to medical students.

Perception and Representation of LGBTQ+ Individuals in U.S. Neurosurgical Training.

OBJECTIVE: The aim of this study is to gauge the current social climate in neurosurgical residency training and attitudes regarding sexual orientation and gender identity. METHODS: We conducted a cross-sectional study through a 35-question questionnaire distributed to roughly 1700 residents at all U.S. neurosurgical residency programs. RESULTS: A total of 107 responses were obtained. Seventeen residents (16%) identified as being an LGBTQ+ individual. The majority (76%) of LGBTQ+ residents were concerned about how their sexual orientation would be perceived while applying to programs, and 47% endorsed purposefully concealing sexual orientation at work for fear of rejection or reprisal. More than half (56%) of those surveyed have witnessed homophobic/transphobic remarks by patients. While at work, 29% of LGBTQ+ individuals stated they are uncomfortable being open with their sexual orientation, and 3 LGBTQ+ individuals admitted being the target of direct homophobic/transphobic comments. CONCLUSIONS: This is the first study to our knowledge that has been conducted assessing the presence, perception, and treatment of LGBTQ+ trainees in neurosurgical residency. Our study outlines the challenges LGBTQ+ individuals face when applying to neurosurgical programs, which involves the perception of their sexual orientation, their witnessed instances of homophobic and transphobic comments by coworkers and patients, and their hesitation with discussing their social lives compared with their non-LGBTQ+ peers at work for fear of judgment or reprisal. Ongoing research is needed to address these issues to obtain workplace respect and fairness in this population and thus create an accepting atmosphere and achieve social justice in neurosurgery training.

A Quantitative Assessment of ChatGPT as a Neurosurgical Triaging Tool.

BACKGROUND AND OBJECTIVES: ChatGPT is a natural language processing chatbot with increasing applicability to the medical workflow. Although ChatGPT has been shown to be capable of passing the American Board of Neurological Surgery board examination, there has never been an evaluation of the chatbot in triaging and diagnosing novel neurosurgical scenarios without defined answer choices. In this study, we assess ChatGPT's capability to determine the emergent nature of neurosurgical scenarios and make diagnoses based on information one would find in a neurosurgical consult. METHODS: Thirty clinical scenarios were given to 3 attendings, 4 residents, 2 physician assistants, and 2 subinterns. Participants were asked to determine if the scenario constituted an urgent neurosurgical consultation and what the most likely diagnosis was. Attending responses provided a consensus to use as the answer key. Generative pretraining transformer (GPT) 3.5 and GPT 4 were given the same questions, and their responses were compared with the other participants. RESULTS: GPT 4 was 100% accurate in both diagnosis and triage of the scenarios. GPT 3.5 had an accuracy of 92.59%, slightly below that of a PGY1 (96.3%), an 88.24% sensitivity, 100% specificity, 100% positive predictive value, and 83.3% negative predicative value in triaging each situation. When making a diagnosis, GPT 3.5 had an accuracy of 92.59%, which was higher than the subinterns and similar to resident responders. CONCLUSION: GPT 4 is able to diagnose and triage neurosurgical scenarios at the level of a senior neurosurgical resident. There has been a clear improvement between GPT 3.5 and 4. It is likely that the recent updates in internet access and directing the functionality of ChatGPT will further improve its utility in neurosurgical triage.

Training in Skull Base Endonasal Endoscopic Surgery: Development and Validation of a Novel Low-Cost Simulation with Animal Cadaveric Model.

BACKGROUND: Endoscopic skull base surgery is constantly evolving and its scope has expanded. The acquisition of surgical skills involves a long learning curve with significant risks for the patient. Therefore, training in the laboratory has become essential to achieve appropriate proficiency and reduce the morbidity and mortality associated with these procedures. The objective of our work is to develop and validate a cost-effective and easily replicable simulator for endonasal endoscopy training using a swine cadaveric model. METHODS: We used fresh Pietrain swine heads. Training exercises of increasing complexity were performed. A Specific Technical Skills and Knowledge Scale was created considering the objectives to be assessed in each task. After the simulation, the trainees were required to answer a satisfaction survey. RESULTS: Ten participants were recruited (5 neurosurgery residents and 5 neurosurgeons). The simulator assessment showed statistically significant differences between groups. Performance was better among the group with endoscopic surgery experience. Face validity was assessed through a postsimulation questionnaire showing an overall mean score of 28.7 out of 30, indicating a highly positive overall assessment of the simulator. Furthermore, 100% of the trainees believe that including endoscopy training in their education would be beneficial. CONCLUSIONS: The endonasal endoscopy training simulator using a swine cadaveric model is a useful and accessible tool for enhancing surgical skills in this field. It provides an opportunity for training outside the operating room, reducing the potential risks associated with patient practice, and improving the training of residents.

Women in Neurosurgery: Trends in the United States.

OBJECTIVE: We sought to identify trends in the number of female neurosurgeons across each state and identify state characteristics that affect such values. METHODS: The Physician Compare National Downloadable File was queried from the Center for Medicare & Medicaid Services for 2017 and 2023. Physicians indicating "neurosurgery" as their primary specialty were extracted and duplicates were removed. States were ranked based on the number of female neurosurgeons. The percent growth in the number of female neurosurgeons from 2017 to 2023 was calculated for each state. Univariable and multivariable regressions were used to identify the association between state characteristics and the number of female neurosurgeons. RESULTS: The number of female neurosurgeons was higher in urban states while rural states saw a greater increase compared to five years ago. Univariable regression showed significant differences in the number of neurosurgery residency programs, neurosurgery hospitals ranked in U.S. News & World Report, paid parental leave law, number and percentage of female physicians, and diversity index score (P < 0.05). The diversity index score independently affected the number of female neurosurgeons (P < 0.05). CONCLUSIONS: States with more training programs, female physicians, and paid parental leave policies saw a large number of female neurosurgeons. Diversity in the general population is also crucial to improving the equity in gender representation of neurosurgeons in each state. The increase in female neurosurgery representation in rural states shows that the shortage of neurosurgeons in underserved areas is creating a unique niche for female neurosurgeons to excel.

The Evolving Role of Postgraduate Year 7 in Neurological Surgery Residency.

BACKGROUND AND OBJECTIVES: In 2013, all neurosurgery programs were mandated to adopt a 7-year structure. We sought to characterize how programs use the seventh year of training (postgraduate year 7 [PGY7]). METHODS: We surveyed all accredited neurosurgery programs in the United States regarding the PGY7 residents' primary role and the availability of enfolded fellowships. We compiled responses from different individuals in each program: chair, program director, program coordinator, and current chiefs. RESULTS: Of 120 accredited neurological surgery residency programs within the United States, 91 (76%) submitted responses. At these programs, the primary roles of the PGY7 were chief of service (COS, 71%), enfolded fellowships (EFF, 18%), transition to practice (10%), and elective time (1%). Most residencies have been 7-year programs for >10 years (52, 57%). Sixty-seven programs stated that they offer some form of EFF (73.6%). The most common EFFs were endovascular (57, 62.6%), spine (49, 53.9%), critical care (41, 45.1%), and functional (37, 40.7%). These were also the most common specialties listed as Committee on Advanced Subspecialty Training accredited by survey respondents. Spine and endovascular EFFs were most likely to be restricted to PGY7 (24.2% and 23.1%, respectively), followed by neuro-oncology (12, 13.2%). The most common EFFs reported as Committee on Advanced Subspecialty Training accredited but not restricted to PGY7 were endovascular (24, 26.4%) and critical care (23, 25.3%). CONCLUSION: Most accredited neurological surgery training programs use the COS as the primary PGY7 role. Programs younger in their PGY7 structure seem to maintain the traditional COS role. Those more established seem to be experimenting with various roles the PGY7 year can fill, including enfolded fellowships and transition-to-practice years, predominantly. Most programs offer some form of enfolded fellowship. This serves as a basis for characterization of how neurological surgery training may develop in years to come.

Global Neurosurgery: A Retrospective Cohort Study to Compare the Effectiveness of Two Training Methods in Resource-Poor Settings.

BACKGROUND AND OBJECTIVES: Many low- and middle-income countries are experiencing profound health care workforce shortages. Surgical subspecialists generally practice in large urban centers but are in high demand in rural areas. These subspecialists must be trained through sustainable programs to address this disparity. We quantitatively compared the relative effectiveness of 2 unique training models to advance neurosurgical skills in resource-poor settings where formally trained neurosurgeons are unavailable. METHODS: Neurosurgical procedure data were collected from 2 hospitals in Tanzania (Haydom Lutheran Hospital [HLH] and Bugando Medical Centre [BMC]), where 2 distinct training models ("Train Forward" and "Back-to-Back," respectively) were incorporated between 2005 and 2012. RESULTS: The most common procedures performed were ventriculoperitoneal shunt (BMC: 559, HLH: 72), spina bifida repair (BMC: 187, HLH: 54), craniotomy (BMC: 61, HLH: 19), bone elevation (BMC: 42, HLH: 32), and craniotomy and evacuation (BMC: 18, HLH: 34). The number of annual procedures at BMC increased from 148 in 2008 to 357 in 2012; at HLH, they increased from 18 in 2005 to 80 in 2010. Postoperative complications over time decreased or did not significantly change at both sites as the diversity of procedures increased. CONCLUSION: The Train Forward and Back-to-Back training models were associated with increased surgical volume and complexity without increased complications. However, only the Train Forward model resulted in local, autonomous training of surgical subspecialists after completion of the initial training period. Incorporating the Train Forward method into existing training programs in low- and middle-income countries may provide unique benefits over historic training practices.

The role of limited access to students from more diverse nonfeeder medical schools in creating diversity inequities in neurosurgical residency.

OBJECTIVE: Improving racial/ethnic diversity in neurosurgery is a long-standing issue that needs to be addressed. The positive correlation between medical students with home neurosurgery programs and successful matriculation into neurosurgical residency is well documented. In this article, the authors explored the relationship between decreased racial/ethnic diversity in neurosurgery residency programs and racial/ethnic diversity in feeder medical schools. METHODS: The authors conducted a standardized review of the literature to evaluate potential causes for decreased racial/ethnic diversity within neurosurgery. Additionally, they calculated the average enrollment of Black/African American medical students at the top 5 neurosurgery feeder medical schools (determined by Antar et al. following the 2014-2020 match cycles) during the 2021-2022 school year and compared that with the enrollment at US allopathic medical schools with the highest enrollment of Black/African American students. They also compared these two groups in terms of how many students they sent into neurosurgery residency programs from 2014 to 2020. For each of these comparisons, the authors conducted a two-sample t-test to evaluate correlation between these two variables. RESULTS: There was significantly lower average enrollment of Black/African American students at the top 5 feeder medical programs into neurosurgery residency (80.6 ± 8.32) compared with the top 5 medical schools with Black/African American enrollment in the 2021-2022 school year (279 ± 122.00, p < 0.05). The authors also found a significant increase in the number of students entering neurosurgery residency programs between the top 5 feeder medical programs into neurosurgery residency (30.8 ± 6.06) and the top 5 medical programs for Black/African American enrollment (6 ± 6.16, p < 0.0001). CONCLUSIONS: In this paper, the authors examined, through a Black/African American lens, the role of racial/ethnic diversity in medical schools that historically send many students to neurosurgery residency. This study sought to provide insight into this problem and examine how Black/African American students from nonfeeder medical schools are disproportionately affected. The authors' findings suggest that the lack of Black/African American representation in neurosurgery is strongly correlated with the diversity efforts of medical schools. Lastly, the authors highlight the University of Miami's Summer Research Scholarship in Neurosurgery for Medical Students and other programs as potential solutions to combat the lack of racial/ethnic diversity in neurosurgery.

Analysis of the Caribbean Neurosurgery Workforce: Scope of Practice, Challenges, and Ways Forward.

BACKGROUND: The neurosurgical workforce in the Caribbean and surrounding countries is largely unknown due to the diversity in cultural, linguistic, political, financial disparities, and colonial history between the countries. About 45 neurosurgeons serve 16 million people in the Caribbean Community and Common Market, a trade alliance including most Caribbean nations. We aimed to understand the current scope of neurosurgical workforce in this region while highlighting any system challenges and potential solutions for upscaling the workforce. METHODS: We surveyed neurosurgeons within Caribbean countries and surrounding countries online using qualitative and quantitative methods via Qualtrics. RESULTS: Of the 38 countries within the Caribbean and surrounding countries, 26 (68%) were surveyed and of which 18 (69%) replied. In total, 172 regional neurosurgeons were identified, of which 61 (35%) replied-with a majority of general neurosurgeons (56%). Remarkably, the majority of countries failed to meet the threshold workforce density for safe health care-either expressed by full-time equivalent neurosurgeons or neurosurgical centers (see table). Most neurosurgical practices confirmed receiving or sending medical referrals. If so, most referrals took longer than 8 hours without significant difference regarding the destination. Lastly, challenges confronting neurosurgical advancement were found in the following: technology and equipment (40%), trained personnel (31%), hospital or medical center infrastructure (14%), neurosurgical education, and training (44%). CONCLUSIONS: To our knowledge, this is the first qualitative and quantitative study exploring the current status of the neurosurgical workforce within the Caribbean and surrounding countries. Identifying resources and challenges can contribute to improving regionalized neurosurgical care.

Emerging Subspecialties in Neurology: Interventional Neurology: A Starter Guide for Neurology Residents.

Interventional neurology is a subspecialty at the cross-section of neurology, neurosurgery, and neuroradiology that uses image-guided endovascular catheter techniques to diagnose and treat neurovascular disorders. Although interventional neurology techniques have existed for decades, recent landmark trials in stroke thrombectomy have catalyzed dramatic changes to the interventional neurology field, and there is rising neurology interest and representation. Unlike other neurology subspecialties, however, interventional neurology training and fellowship applications are not standardized. Thus, it can be difficult for neurology trainees to navigate this rapidly changing and multidisciplinary field. This article seeks to provide neurology residents and residency program directors with a brief overview of the modern interventional neurology field, the current fellowship application process, and tips on how neurologists can best prepare for a career in interventional neurology. To this end, we conducted a nationwide survey of interventional neurology fellowship program directors regarding training neurologists. We distill survey responses into concrete, actionable items for neurology trainees.

Assessing the Impact of Shifting Enfolded Neurosurgery Fellowships to Follow the Chief Resident Experience: National Survey of Program and Fellowship Directors.

OBJECTIVE: The neurosurgery chief resident year is traditionally completed during the final residency year; however, a recent directive decried that enfolded fellowships should be undertaken following completion of the chief experience for most fellowships. METHODS: A national survey was distributed to U.S.-based neurosurgery residency/fellowship directors regarding these changes. RESULTS: We received 135 completed surveys (37% response rate). Respondents tended to feel the new post-chief enfolded fellowship mandate represented positive effects on residency training (58%) and chief experiences (54%)-overall, 47% agreed the changes are net positive, 17% neutral, and 36% negative. In addition, 66% respondents thought the enfolded fellowship was enhanced due to previous completion of the chief year. Most did not feel the directives had a negative impact on resident case minimums completion, total case volumes, or overall case mix during residency; but 64% felt it would reduce post-graduate training. Of those who said the mandate would reduce post-graduate training, 45% thought this would be positive. Throughout all questions, most respondents tended to feel strongly, although with little overall consensus across many of these questions. One area of relative agreement was a 60% preference to allow program discretion for chief/enfolded fellowship training timing-with 41% strongly supporting versus 15% strongly rejecting reversion to program-directed administration. CONCLUSIONS: Fervent bimodal opinions exist among residency program and fellowship directors regarding the directives for enfolded fellowships to follow successful completion of the chief resident experience. However, there was broad support for allowing greater program discretion for directing certain enfolded fellowship timing and structure.

An asynchronous web-based intervention for neurosurgery residents to improve education on cost-effective care.

OBJECTIVE: To gauge resident knowledge in the socioeconomic aspects of neurosurgery and assess the efficacy of an asynchronous, longitudinal, web-based, socioeconomics educational program tailored for neurosurgery residents. METHODS: Trainees completed a 20-question pre- and post-intervention knowledge examination including four educational categories: billing/coding, procedure-specific concepts, material costs, and operating room protocols. Structured data from 12 index cranial neurosurgical operations were organized into 5 online, case-based modules sent to residents within a single training program via weekly e-mail. Content from each educational category was integrated into the weekly modules for resident review. RESULTS: Twenty-seven neurosurgical residents completed the survey. Overall, there was no statistically significant difference between pre- vs post-intervention resident knowledge of billing/coding (79.2 % vs 88.2 %, p = 0.33), procedure-specific concepts (34.3 % vs 39.2 %, p = 0.11), material costs (31.7 % vs 21.6 %, p = 0.75), or operating room protocols (51.7 % vs 35.3 %, p = 0.61). However, respondents' accuracy increased significantly by 40.8 % on questions containing content presented more than 3 times during the 5-week study period, compared to an increased accuracy of only 2.2 % on questions containing content presented less often during the same time period (p = 0.05). CONCLUSIONS: Baseline resident knowledge in socioeconomic aspects of neurosurgery is relatively lacking outside of billing/coding. Our socioeconomic educational intervention demonstrates some promise in improving socioeconomic knowledge among neurosurgery trainees, particularly when content is presented frequently. This decentralized, web-based approach to resident education may serve as a future model for self-driven learning initiatives among neurosurgical residents with minimal disruption to existing workflows.