Neurosurgery makes pain management curricular breakthroughs

Troy Parks
Staff Writer
AMA Wire
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Leaders in neurosurgery have taken a hands-on approach to training residents with an eye toward filling knowledge and skill gaps—one such gap is pain management. Learn how they’re making strides in preparing residents for the board exam and more effective patient care.

Neurosurgery “boot camps” were created in 2009 to help fill in some of the knowledge gaps in resident training. Neurosurgeons in training attend one boot camp at the start of internship and another before becoming a junior resident.

“The boot camps … use extensive simulation labs with ICU crises where you have a mannequin on a table with an ICU monitor,” said Christopher Winfree, MD, an assistant professor of neurological surgery at the Columbia University College of Physicians and Surgeons in New York City. “They go through all kinds of scenarios. The important thing is to have the residents trained across all of the topics they need to know.”

The Neurological Surgery Milestone Project, developed in 2013, was created to further formalize the content of residency training. The content addresses areas such as procedural skills, professionalism and interpersonal relations with colleagues and patients. The Milestones also facilitate resident assessment to make sure residents are making appropriate progress as they go through their training.

Training neurosurgical residents in pain management

Six years ago, Dr. Winfree became president of the pain section of the two major neurosurgery groups, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The executive committees asked him to make pain management in neurosurgery more prominent.

Dr. Winfree developed a module for the resident boot camp that includes everything residents need to know about pain management in neurosurgery. Topics covered include different types of pain, neuropathic pain medications, how opioids work, treatment ladders, chronic and acute pain management, caring for patients with opioid dependence or substance use disorder, and buprenorphine treatment.

“I thought that would be an excellent opportunity to teach pain management at a boot camp level so the interns and junior residents are not only getting comprehensive neurosurgical training but also a focus—at least in one module—on pain,” he said.

Making sure the knowledge sticks

“Everybody likes to think that when you institute a new curriculum, it’s going to be great,” Dr. Winfree said. “But we had no data to prove that. Further, we had neurosurgery residents and attendings not doing so well in the pain sections on their board exams.”

“People weren’t really getting it and weren’t really learning what they needed to learn,” he said. “We tried to address that with the boot camp [and] the milestones, and that was a good start, but we were still making little progress on board exam performance.”

As a member of the editorial board of the Self-Assessment Neurological Surgery (SANS), which writes the board exam questions, Dr. Winfree wrote 150-200 questions, vetted by the Board, for a rotating practice exam, which includes a different set of 100 questions each year. Using the results from these tests, they can now see how the residents are doing on the sections regarding pain.

Some of these pain questions are used at the boot camp sessions. The residents study the material and take a test before they arrive and then are tested again at the end of the course.

In Dr. Winfree’s pain lecture, he talks about pain management for neurosurgery, including craniotomy, spine surgery, post-operative pain management, use of non-opioid medications, the treatment ladder, management of specific chronic pain conditions and much more.

“We’re trying to get away from passive learning, because how many times have we all sat in lectures and retained probably 10 percent,” he said. “When you have somebody study ahead of time and test them on it ahead of time, then show it to them in person, where they can sit one-on-one with faculty members in these sessions, and then you test them on it again, they have this stuff for life.”

“This isn’t just stuff that the residents blow off,” he said. “They study [it]. They’re professionals, and we treat them like professionals. But we test them also. We make sure that they know the material.”

“Every question has an explanation at the end,” he said. “It’s self-assessment, but it’s not just yes, no, you got it right or wrong. The residents get an explanation as to why the answer is right or wrong.”

Changing the curriculum at Columbia

Dr. Winfree is also changing how he teaches neurosurgical residents at Columbia University Medical Center. “I would give talks on the material,” he said, “and randomly call the residents after and quiz them about the lecture—and the results were terrible. It was almost like the residents did not attend the lecture.”

“The whole passive, didactic learning thing is 20th century,” he said. “What we’ve been actively trying to do is get things to the 21st century. Now, instead of just giving a random talk on neuro for pain, I designed a curriculum that directly follows the milestones.”

Every week, residents training with Dr. Winfree present a case, and the group addresses the topic. Instead of a long lecture, the residents’ case study lasts 15 minutes, with Dr. Winfree moderating. “Studies have shown that an educated person’s attention span for a talk is 18 minutes,” he said. “That’s why TED Talks are 18 minutes and contain stories, because a story represents a cognitive hook that allows a person to pay attention more.”

“It’s not a lot of PowerPoint and bullet presentations,” he said. “It’s images that reinforce the stories that are being told … so it captivates the residents’ attention. It’s active learning, not passive learning.”

So how have the residents responded? They like it, a lot.

“Nobody wants to sit through an hour lecture,” Dr. Winfree said. “We’ve been doing these boot camp courses every year now, and every time we do it, we survey the residents. Every resident says, ‘Get rid of the didactic lectures, we’re falling asleep, [and] we’re not learning anything.’”

“What does work is a shorter, case-based set of scenarios,” he said, commenting on survey results and exam performance data. “We’re not having hour-long lectures, we’re doing 15 minute small group sessions to go over all of those things, and the residents are responding.”

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Comments

Where's the data to support the effectiveness of this training program? Where are examples of the program?
Congratulations. It is high time that neurosurgery engage in the evaluation & management of pain, which is after all a neurological disorder. My hope is that the program will focus not only on neurosurgical intervention (ablation or neuromodulation) but also on the complex core concepts of the nature, prevention, evaluation & management (surgical & other) of pain in all of its manifestations. As to pedagogic techniques it remains to be seen whether this new concept of 15 minute segments, to keep the fellows awake, is sound. It needs to vetted in the crucible of time. Not everything new is necessarily better. Whatever the technique, it must be include intellectual as well as psychomotor constructs. Every neurosurgeon knows that afferent input is necessary to inform a desirable efferent response.
Show Comments (2)
Apr 21, 2017
Recent studies reveal that physicians’ gestures, language and level of warmth can have an impact that exceeds patients’ subjective experience of care.