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Spine surgery core curriculum : a review of competencies in subspecialty Fellowship Training Paquette, Scott Jan 29, 2010

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Spine Surgery Core Curriculum: A Review of Competencies in Subspecialty FellowshipTraining ^ , :;-Scott Paquette(Adult Education)Approved by:Dr Dan PrattSupervisorDr John Collins Second ReaderJan 29, 2010Date ApprovedSpineSunrgyCoclmC: To evaluate fellowship trainee and supervisor perceptions on the relative importance of core cognitive and procedural competencies in spine subspecialty fellowship training.iARRvwf ts pvobawtAFh Tvcv: At present, there is no formalized curriculum for spine fellowship training in North America. There have been many recent advances in surgical residency education and similar interest exists in fellowship education. Specifically, there has been a trend towards the standardization and formalization of spine surgery subspecialty training. The purpose of this study was to identify core cognitive and technical competencies required for successful spine fellowship training in order to facilitate the future development of a standardized curriculum for spine surgery.^Cc,th;: A questionnaire was designed through synthesis and amalgamation of two standardized surveys designed previously by other authors. This questionnaire was reviewed for content by spine surgery experts (Canadian Spine Society Education Committee). The questionnaire was administered (online and paper) to fellow trainees and supervisors across Canada and data was collected over a 3-month period. It consisted of 40 MCQ items grouped into 13 broad cognitive skills categories, as well as 29 technical/procedural items. Data was analyzed using quantitative and descriptive statistics (e.g. average mean scores, standard deviations, t-tests).eC;A-c;: The response rate was 91%, with 15 of 17 fellow trainees and 47 of 51 supervisors completing the survey. Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of 29 spine surgery technical skill items. Specifically, additional training was believed to be required for intradural procedures (e.g. syringomyelia, intradural neoplasms) and other less common, technically demanding, procedures (e.g. transoral odontoidectomy, anterior thoracic discectomy). Significant differences (p<0.05) existed in perceptions of importance for specific cognitive and technical skills based on previous residencytraining (orthopaedic or neurosurgical). No such differences were found when comparing responses of the fellow trainees and their supervisors.utFo-A;ltF;: This study demonstrates that fellowship trainees and supervisors have similar perceptions on the relative importance of specific core cognitive and procedural competencies required in achieving successful spine fellowship training. Furthermore, background specialty training (orthopaedic or neurosurgical) influences the perceptions of both fellow trainees and supervisors regarding the importance of specific cognitive and technical skills deemed necessary for successful training.PCf qtwh;: fellowship training, core curriculum, competencies, spine surgerypSuP(erdETCurrently, there is no standardized curriculum for spine surgery fellowship training across North America. In fact, only 17 of 78 programs participating in the SF matching system for spine fellowship training are ACGME accredited.1 Furthermore, spine surgery is currently practiced by specialists with surgical residency training, either in neurosurgery or orthopaedic surgery, with or without fellowship training in spine surgery.However, fellowship training has become an integral part in the education of future surgeons as more and more residents are pursuing fellowships. From 1993 to 2005, data taken from postgraduate year level-5 residents showed an increase in the percentage of those choosing to pursue fellowships from 67% to 77%.2 Guidelines have been developed and published in major spine journals for spinal surgery training. Some have suggested five competencies on which to evaluate trainees: core knowledge, clinical evaluation, non-operative management, operative management, and postoperative care and rehabilitation.3 Further, they suggest that prospective fellows should evaluate both orthopaedic and neurosurgical spine fellowship training programs based on five integral components including: hospital resources, teaching staff, educational program, research activity, and evaluation process.3Other authors have noted an unprecedented surge in new techniques in spine surgery (an example being minimally invasive surgery) and that spinal surgery is a dynamic and growing subspecialty.4 They have therefore concluded that the future spine surgeon should take the best elements of both the orthopaedic and neurosurgical communities into their practice. They state that a substantial proportion of neurosurgical trainees are currently not provided with the necessary skills in terms of operative stabilization of the spine for certain conditions and suggested that orthopaedic and neurosurgical colleagues join hands in developing more integrated, and formal, subspecialty training programs in order to provide future spine surgeons with the capability to deal with the entire spectrum of spinal conditions.4 Indeed, fellowship training has been shown to improve patient care and outcomes.5'11There is a growing movement towards standardization and formalization of spine surgery subspecialty training. There also seems to be a trend towards an amalgamation between orthopaedic surgery and neurosurgery in the training of their fellows to create a combined and comprehensive training program. The primary objective of this study is to evaluate fellow trainee and supervisor (academic spine surgeon) perceptions on the relative importance of specific cognitive and technical competencies required to achieve successful spine fellowship training.We would also like to determine if background residency training in orthopaedics or neurosurgery affects these perceptions. Our hypothesis is that both trainees and supervisors have similar perceptions about the relative importance of specific cognitive and technical competencies required for fellowship training. Furthermore, we hypothesize that, despite differences in training, orthopaedic surgeons and neurosurgeons will have similar such perceptions.^Sn)eDSJi SET ^)n2rTiAn eleven paged Spine Fellowship Training questionnaire was developed by the authors (Appendix A). The questionnaire consisted of three main components: background/demographical questions, cognitive skills questions, and surgical/technical procedures. The background questions were constructed in order to identify respondents as either fellow trainees or supervisors (academic spine surgeons) and as having either previous orthopaedic or neurosurgical residency training. The second and third components of the questionnaire were a synthesis and amalgamation of two standardized questionnaires that have been devised by other authors.The cognitive skills component was constructed using questions from a standardized questionnaire originally developed by Wadey12. The original Wadey questionnaire contained 281 items regarding the various aspects of musculoskeletal education and training objectives that residents/fellows are expected to achieve. It was divided into three sections: a validated international core curriculum for MSK health, specialty objectives of the Royal College of Physicians and Surgeons of Canada (RCPSC) pertaining to orthopaedic surgery, and a complete procedure list based on code books across Canada. Of the 281 items, 12 items are specifically related to spine specific cognitive skills and these items were used for our Spine FellowshipTraining questionnaire. In addition to these 12 spine related items, 27 other items from the original Wadey questionnaire were also added to our Spine Fellowship Training questionnaire because they pertain to general knowledge that is also relevant to spine fellowship education. Each of the 39 items was structured in a similar fashion to the question below:Example: Upon completion of a fellowship training program, please indicate the importance of the ability to be able to take a full and thorough history for the various chief complaints (pain, limitation of activities, neurological symptoms etc.) relevant to the spine.The choices for response of each item are: 1-unable to assess, 2-not important, 3-probably not important, 4-probably important, and 5-important.The third component of our Spine Fellowship Training questionnaire was devised from a previous questionnaire developed by Dvorak13 and includes 29 specific surgical procedures that are performed by spine surgeons. Of these 29 items, 11 are cervical spine procedures, 14 are thoracolumbar spine procedures, and the last 4 are miscellaneous procedures that do not fit into the other two subheadings. For each item there are four parts to the question. The first part asks whether the fellow/resident is competent to perform the specific procedure on completion of their training. There are four response choices: 1-not at all; 2-a little; 3-somewhat competent; and 4- very competent. The second part to the question asks whether, on completion of training, how much additional training the fellow/resident requires in order to perform the specific operative procedure. Once again there are four choices: 1-no further training required; 2-a little training required; 3-some training required; and 4-significant training required. The third part to the question asks how many such procedures the fellow would have participated in on completion of their fellowship training. Lastly, the fourth part of the question asks how important it is for the fellow trainee to be able to perform the specific operative procedure. There are five choices: 1 - unable to assess; 2-not important; 3-probably not important; 4- probably important; and 5- important.Overall, the Spine Fellowship Training questionnaire is a survey containing 69 competency items related to spine surgery fellowship training, as well as background demographic data. This survey instrument was presented to the Canadian Spine Society (CSS) Executive Board throughthe auspices of the Chair of Education of the Canadian Spine Society. The CSS executive board consists of 10 academic spine surgeons and includes both neurosurgeons and orthopaedic surgeons from across Canada. Their review of the questionnaire served as a content review in order to ensure content validity. Any changes to the questionnaire were made based on the recommendations of the content review.The questionnaire was administered in English to academic spine surgeons and the current fellows-in-training in all 11 of the spine fellowship training programs across Canada. Respondents completed either a paper/pencil or online questionnaire. Respondents had the option to choose either option (paper or online). This was done by mailing hard copies of the surveys to each of the participants for them to fill out and return along with information regarding the howJo access the online version. Respondents were provided an envelope within which to seal their completed surveys ensuring confidentiality of responses. The survey was circulated between May and June 2009. This was done to catch all of the fellow trainees during the end of their respective fellowships. An email reminder encouraging all respondents to complete the survey was sent by the Chair of the Canadian Spine Society.Tvcv SFv-f;C;9 The responses for the cognitive skills competency questions were coded 1 to 5 (1-unable to assess to 5-important). The surgical/technical skills questions for confidence and need for additional training were coded 1 to 4 (Confidence: 1-not at all to 4-very competent; Additional Training: 1-none required to 4-significant additional training required). The surgical skills questions for importance of each specific skill were coded 1 to 5 (1-unable to assess to 5- important). Scores were recorded as absolute values.Raw data was entered directly into an Excel database, then crosschecked and verified. Responses were then categorized according to trainee versus supervisor and orthopaedic versus neurosurgical. Descriptive summaries and statistical testing was performed by a senior statistician using SAS software (SAS Inc., Cary, NC) for descriptive summaries, tests of differences between fellow trainee and supervisor responses, and tests of differences between background orthopaedic and neurosurgical residency training.e)idJni:Questionnaire ResponsesA total 17 fellow trainees and 51 academic spine surgeons were identified from the 11 Canadian subspecialty spine fellowship training programs. The questionnaires were mailed out to all 68 of the potential respondents. A total of 62 correctly completed questionnaires were received, either mailed back by the respondent or completed online. This yields an overall response rate of 91%. Fifteen of the respondents were fellow trainees and 47 were supervisors (academic spine surgeons). Including both fellow trainees and supervisors, the orthopaedic and neurosurgical response rates were 96% and 78% respectively (Table 1). For fellow trainees, the mean months of fellowship completed was 11.5 suggesting that the fellows were near the end of their fellowship when the questionnaire was completed.Cognitive Skills CompetenciesThe 39 cognitive skills related questions on the survey were grouped into 13 broad categories (Figure 1). The grouping of questions into these categories was also examined during the content review of the survey. When the questionnaires were distributed to the respondents and available online, the respondents were blinded to grouping of questions. The purpose of grouping was to better compare the wide range of cognitive skills that may be considered important for successful spine fellowship training.All of the 12 questions related to the spine-specific cognitive skills category were rated greater than 4.5, indicating they are considered to be important skills to obtain by the completion of fellowship training. Similar results were obtained for other categories: history and physical examination skills, ordering appropriate investigations, problem-based management skills, treatment of infections, continuity of care, personal and professional skills, involvement in research and teaching, and peri-operative management skills.The four remaining cognitive skills categories had overall mean scores between 3.5 and 4.5. These are: management of chronic inflammatory conditions (i.e. rheumatoid arthritis, spondyloarthropathies), management of chronic pain, understanding medical-legal aspects of practice, and understanding the roles of rehabilitation/physiotherapy for spine conditions. These cognitive skills categories are considered to be ‘probably important’ competencies to achieve by the end of fellowship training. Of these four categories, management of chronic pain had the lowest overall mean score (3.9) and is considered to be the least important skill required.Comparing fellow trainee and supervisor responses for the cognitive skill competencies, there were no significant differences for any of these items in the questionnaire.When comparing responses based on previous orthopaedic or neurosurgical residency training some differences in perceptions of importance were found. Eight of the 39 cognitive skills competency items had significant such differences (p<0.05). These 8 items were distributed across 6 of the 13 categories: treatment of chronic inflammatory conditions, chronic pain management, medical-legal aspects of practice, understanding the role of rehabilitation/physiotherapy, personal and professional skills, and involvement in research and teaching (Table 2). In all of these questions, the mean scores for respondents with an orthopaedic surgery background were higher than those with a neurosurgical background. Four categories showed significant differences in all of their associated survey questions: management of chronic inflammatory conditions, management of chronic pain, understanding medical-legal aspects of practice, and personal and professional skills. These four cognitive skill competencies were rated as being more important for successful spine fellowship training by respondents with an orthopaedic residency training background. It is important to note that, while respondents with a neurosurgical background may have rated these competencies as being less important, all but one of the overall mean scores for the different categories fall in the range of being ‘probably important’ (3.5 to 4.5). The only category considered to be ‘probably not important’ by respondents with a neurosurgical background was management of chronic pain (mean score of 3.45).Surgical/Technical CompetenciesWhen asked how many of each of the 29 surgical procedures trainees participated in on completion of their fellowship training, respondents indicated that trainees had participated in high numbers of the relatively common cases such as: primary lumbar discectomy, two level lumbar laminectomy, or posterior pedicle screw fixation (Figure 2). Also, as expected, trainees seemed to have participated in small numbers of the more uncommon procedures such as: trans-oral odontoidectomy, surgery for syringomyelia, or release of a tethered cord.Surgical Confidence:All together, respondents indicated that fellow trainees are very comfortable performing 14 of the 29 surgical procedures with mean scores greater than 3.5 (Table 3). With respect to comfort level, 11 other surgical procedures had mean scores between 2.5 and 3.5 indicating that fellow trainees are somewhat comfortable performing these procedures by the end of their fellowship. The other 4 surgical procedural skills had mean scores between 1.5 and 2.5 suggesting that fellow trainees had little comfort performing these skills upon completion of fellowship. When comparing responses of fellow trainees to academic spine surgeons, there were no significant differences in perceptions of how comfortable fellows and academic spine surgeons are in performing each surgical procedure. Respondents with a neurosurgical residency background were more comfortable performing a trans-oral odontoidectomy (p=0.026) and release of a tethered cord (p=0.001) than their orthopaedic counterparts.Need for Additional Training:Of the 29 surgical procedures, 12 had overall mean scores of less than 1.5 indicating respondents felt that fellow trainees did not require additional training in these specific procedures (Table 3). Another 13 surgical procedures were rated with mean scores between 1.5 and 2.5, indicating that fellows required ‘a little more’ training in order to perform these procedurescomfortably. Four surgical procedures were rated between 2.5 and 3.5 and respondents felt that fellows required at least ‘some more’ additional training on completion of their fellowship in order to be able to comfortably perform these procedures. Fellow trainees felt that they needed more training in performing posterior C1-2 fusion with screws (p=0.032), trans-oral odontoidectomy (p=0.050), and surgery for thoracic fracture with spinal cord injury (p=0.048) compared to their supervisors. Compared to their neurosurgery colleagues, respondents with an orthopaedic residency background reported requiring more training in order to be able to perform a posterior cervical laminectomy (p=0.034), surgery for syringomyelia (p=0.005), release of a tethered cord (p=0.004), and surgery for an intradural neoplasm (p=0.001).Importance of Surgical Procedure:Of the 29 surgical procedures listed, 20 had mean scores greater than 4.5 and are characterized as being ‘important’ procedures to be able to perform by completion of fellowship training (Table 3). Another 7 surgical procedures had mean scores between 3.5 and 4.5 from all respondents indicating that they are considered to be ‘probably important’ procedures to be able to perform on completion of a spine fellowship. Two procedures, surgery for syringomyelia and release of a tethered cord, are considered to be ‘probably not important’ to be able perform with mean scores between 2.5 and 3.5. There were no significant differences between the mean fellow trainee score and the mean supervisor score with respect to their perceptions of relative importance of each surgical procedural skill. Respondents with neurosurgical residency training indicated that it was more important to be able to perform surgery for syringomyelia (p=0.001), release of a tethered cord (p=0.002), and surgery for an intradural neoplasm (p=0.001) compared to respondents with an orthopaedic background.TDiudiiDrE:Spine surgery is currently practiced by specialists with surgical residency training, either in neurosurgery or orthopaedic surgery, with or without fellowship training in spine surgery.However, more surgeons today have completed fellowships than in the past, and most trainees today complete at least one year of additional training beyond residency before entering practice.2 Given this current trend, more interest has been generated about the education of future surgeons. The debate regarding the type of educational exposure that both residents and fellows should experience is ongoing.14'18Competence can be defined as “the demonstrated ability to safely care for patients in a thoughtful and knowledgeable manner while maintaining acceptable standards of professional behavior.”19 Actual competence can be measured using written and oral proficiency examinations or by directly observing and evaluating specific surgical skills in a controlled environment.20In this study, we sought to measure perceived competencies through the self-reporting by respondents. Therefore, we failed to directly observe actual competencies through measurement of technical skill acquisition, cognitive abilities, and professionalism.20This study has shown that, while there are many cognitive skills that a fellow trainee must master in order to achieve successful completion of a spine surgery fellowship, some specific skills are consistently rated as being more important than others. Specifically, cognitive skills regarding management of chronic inflammatory conditions, management of chronic pain, understanding the medical-legal aspects of spine practice, and understanding rehabilitation/physiotherapy are not considered to be as important as some of the other competencies. However, this is not to say that these skills are not important; in fact they all were generally considered to be ‘probably important’ to attain in order to achieve successful spine fellowship training.In terms of technical/procedural skills, our study shows that fellows seem to be comfortable performing the more common surgical procedures (i.e. lumbar discectomy, posteriorlumbar pedicle screw fixation) and they tend to perform more of these procedures during their fellowship. Fellows are not as comfortable performing the more uncommon procedures (i.e. cervical wiring fusion, surgery for intradural pathology) and the more complex procedures (i.e. anterior thoracic discectomy). Both fellows and their supervisors perceive that the fellows would require additional training in order to become more comfortable performing these uncommon or complex surgical procedures. However, it is important to note that many of these relatively uncommon or more complex procedures are not perceived to be as important to have mastered in order to have successfully completed fellowship training. This suggests that a fellow does not necessarily need to be comfortable dealing with the entire realm of spinal pathology in order to be considered a successful spine surgeon. Perhaps more than one spine fellowship would be required in order to be able to manage the most complex spine surgical cases, and a fellow may need to pursue additional training at the larger academic spine centers in order to be exposed to these cases.There were very few differences between perceptions of fellow trainees and their supervising surgeons regarding the cognitive and technical competencies required for successful fellowship training. This is encouraging because it shows that fellows and supervisors have similar expectations for spine fellowship training.This study also showed that some differences exist regarding perceptions of competencies based on previous residency training (orthopaedic or neurosurgical). Specifically, neurosurgeons consider understanding management of chronic pain as probably not being important for successful fellowship training. Perhaps this is due to orthopaedic surgeons being exposed to patients with work-related injuries and chronic pain issues more often during their residencies than their neurosurgery counterparts. Also, neurosurgeons tend to be more comfortable with, and require less additional training in, surgically managing intradural pathology. This is most likely due to the fact that they are more likely to be exposed to such pathology during their residency training.There are several limitations to this study; specifically that: 1) we are unable to objectively measure competence and are instead recording perceived competence; 2) as this was a cross- sectional study catching trainees at the end of their fellowship, we failed to measure any changes in perceptions that may occur from the beginning of a fellowship to its end; 3) we did not include any private- practice community surgeons and they may have different opinions than the ones we received regarding the relative importance of specific competencies; and 4) there are relatively low numbers of spine fellows in Canada at a given time. Finally, there may be substantial differences between the Canadian spine fellowship experience and that in other countries. However, it would be imprudent to dismiss the Canadian experience without any evidence that these issues affecting fellowship training are not relevant to other countries.urEuJdiDrE:Creating a standardized educational program for spine fellowship training begins with a core curriculum. By completing a nationwide comprehensive study regarding the expectations of spine surgical training, we have provided a platform to develop a consensus regarding all of the surgical and educational competencies required for a successful spine surgical subspecialty program. All together, this will facilitate the training of future spine surgeons armed with the capabilities required to treat the entire spectrum of spinal conditions.e)0)e)Eu)i:1. <SF Match Spine Program Listing> http://www.sfmatch.org/fellowship/f_spn/index.htm2. Borman KR, Vick LR, Biester TW, et al. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg 2008;206(5):782-8.3. Herkowitz HN, Connolly PJ, Gundry CR, et al. Resident and fellowship guidelines: educational guidelines for resident training in spinal surgery. Spine 2000;25:2703-7.4. Boszczyk B, Timothy J, Peul W, et al. Editorial: Neurosurgical training and the spine. Acta Neurochir (Wien) 2007;149;339.5. Amundsen S, Skjaerven R, Trippestad A, et al. Abdominal aortic aneurysms. Is there an association between surgical volume, surgical experience, hospital type and operative mortality? Members of the Norwegian Abdominal Aortic Aneurysm Trial. Acta Chir Scand 1990; 156:323-8.6. Ouriel K, Geary K, Green RM, et al. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient. J Vase Surg 1990;11:493-6.7. Wen SW, Simunovic M, Williams Jl, et al. Hospital volume, calendar age, and short term outcomes in patients undergoing repair of abdominal aortic aneurysms -  the Ontario experience. J Epidemiol Community Health 1996;50:207-13.8. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized: the empirical relationship between surgical volume and mortality. N EngJ Med 1979;301(25):1364-9.9. Zdanowski Z, Daneilsson G, Jonung T, et al. Outcome of treatment of ruptured abdominal aortic aneurysms depending on the type of hospital. EurJ Surg 2002;168(2):96-100.10. Kelly JV, Hellinger FJ. Physician and hospital factors associated with mortality of surgical patients. Med Care 1986; 24(9):785-800.11. Pearce WH, Parker MA, Feinglass J, Ujiki M, and Manheim LM. The importance of surgeon volume and training outcomes for vascular surgery procedures. J Vase Surg1999;29:68-7.12. Wadey VMR, Halpern J, Bouchard J, et al. Orthopaedic surgery core curriculum: the spine. Postgraduate Medical Journal 2007;83:268-272.13. Dvorak MF, Collins JB, Murnaghan L, et al. Confidence in spine training among senior neurosurgical and orthopedic residents. Spine 2006;31 (7): 831-7.14. Garfin SR. Editorial on residencies and fellowships. Spine 2000;25:2700-2.15. Eismont FJ. The education, training, and evaluation of a spine surgeon. Spine 1996;21 (18):2059-2063.16. Matheny JM, Brinker MR, Elliot MN, et al. Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop 2000;29:945- 52.17. Grauer JN, Vaccaro AR, Beiner JM, et al. Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice. Spine 2004;29:685-96.18. Dailey SW, Brinker MR, Elliot MN. Orthopaedic residents’ perceptions of the content and adequacy of their residency training. Am J Orthop 1998;27:563-70.19. Hall JC, Crebbin W, Ellison A. Towards a hybrid philosophy of surgical education. Aust NZJ Surg 2004;74:908-11.20. DeLisa JA. Evaluation of clinical competency. Am J Phys Med Rehabil 2000;79:474-7.nvg-C 19 eC;.tF;C evcC; pv;Ch tF eC;lhCFof i.Colv-cf zrwc,t.vChlo tw ECAwt;Awalov-NResidency Completed EligibleRespondentsCompletedSurveys% RespondingOrthopaedics 50 48 96Neurosurgery 18 14 78Total 62 62 91nvg-C x9 TlssCwCFoC; lF ^CvF eC.twcCh DR.twcvFoC ts utaFlclmC ibl--; DcCR; pv;Ch tFeC;lhCFof pvobawtAFhCognitive Skill Category (question #/total # questions for each skill)AllRespondentsOrthopaedicRespondentsNeurosurgeryRespondentsSignificance(P-value)Management of Inflammatory Conditions (1/1)4.4 4.5 3.9 0.010Management of Chronic Pain (1/2)3.6 3.7 3.2 0.039Management of Chronic Pain (2/2)4.2 4.3 3.7 0.017Understanding Medical-Legal Aspects of Practice (1/1)4.1 4.2 3.5 0.010Rehabilitation and Physiotherapy (2/3)4.4 4.6 4.0 0.002Personal and Professional Skills (1/2)4.6 4.7 4.2 0.035Personal and Professional Skills (2/2)4.8 4.9 4.6 0.045Research and Teaching (1/2)4.8 4.9 4.5 0.012Numerical scores are means on scales of 1 to 5, where for importance: 1=unable to assess, 2=not important, 3-probably not important, 4-probably important, 5-important.nvg-C 39 nCo,Flov-I4wtoChAwv- utR.CcCFolC;: ^CvF utRstwc JCmC-M ECCh stw ShhlcltFv- nwvlFlFaM vFh eC-vclmC DR.twcvFoC stw S-- eC;.tFhCFc;Technical/Procedural Skill Comfort Level Need for Importance ofAdditional Skill____________ Training________________3.8 1.3 4.9Application of tongs and cervical closed reductionPosterior cervical laminectomy Posterior C1-2 fusion with screws Posterior cervical wiring fusion Posterior C3-7 screw/plate/or rod fusion Occipito-cervical fusion with rods/screws/plates Trans-oral odontoidectomy Anterior cervical discectomy +/- fusion without plating (1 level)Anterior cervical plating (1 level)Anterior cervical corpectomy and reconstructionSurgery for cervical burst fracture with cord injuryPrimary lumbar discectomy Discectomy for recurrent disc Two level lumbar laminectomy Lumbar posterior non-instrumented fusion Posterior pedicle screw fixation (T8-S1)Upper thoracic (C6-T8) pedicle screw fixationPostero-lateral thoracic discectomyAnterior thoracic discectomyAnterior L1 corpectomy and reconstructionSurgery for thoracic fracture with spinal cordcompressionSurgery for High Grade spondylolisthesis Right thoracic Idiopathic Scoliosis 60 degree Degenerative Lumbar Scoliosis with StenosisOsteotomy for Lumbar Flat-backSurgery for syringomyeliaRelease of a tethered cordSurgery for an intradural neoplasmSurgery for spinal metastases____________3.8 1.3 4.93.4 1.8 4.82.7 1.8 3.83.9 1.2 5.03.3 1.7 4.81.7 3.1 3.73.6 1.3 4.54.0 1.2 4.93.7 1.4 5.03.6 1.6 4.93.9 1.2 5.03.6 1.5 4.94.0 1.2 5.03.4 1.2 4.23.9 1.2 5.03.7 1.4 4.93.2 1.9 4.72.8 2.2 4.63.0 2.1 4.83.6 1.5 4.93.2 2.0 4.72.9 2.2 4.33.3 2.0 4.72.9 2.3 4.52.0 2.7 3.51.9 2.7 3.52.2 2.5 3.73.8 1.4 4.8Numerical scores are means on scales of: 1 to 4 for Comfort Level (1 -not at all, 2-a little, 3-somewhat, 4-highly); 1 to 4 for Need for Additional Training (1-none, 2-a little more, 3-some more, 4-significant additional); and 1 to 5 for Importance of Skill (1-unable to assess, 2-not important, 3-probably not important, 4-probably important, 5-important).Figure 1. Relative Importance of 13 Distinct Cognitive Skill Competency CategoriesLEGEND: CATEGORY1-Diagnosis & Management Skills-Spine Specific2-History & Physical Examination Skills3-Investigations4-Problem-Based Management Skills5-Treatment of Infections6-Continuity of Care7-Management of Chronic Inflammatory Conditions8-Management of Chronic Pain9-Medical/Legal Aspects of Practice10-Rehabilitation/Physiotherapy11-Personal & Professional Skills12-Involvement in Research & Teaching13-Peri-operative ManagementCognitive SkillsFigure 2. Mean Number of Cases Completed During FellowshipApplication of Tongs & Cervical Closed Reduction Posterior Cervical Laminectomy Posterior C l-2 fusion with screws Posterior cervical wiring fusion Posterior C3-7 screw/plate/rod fixation Ocdpito-cervical fusion with rods/screws/plates Trans*oraJ odontoidectomy Anterior cerivical discectomy ♦/- fusion without plating Anterior cervical plating (1 level) Anterior cervical corpectomy and reconstruction Surgery for cervical burst fracture with cord injury Primary lumbar discectomy Discectomy for recurrent disc Two level lumbar laminectomy Lumbar posterior non-instrumented fusion Posterior pedide screw fixation (T8-S1) Upper thoracic pedide screw fixation (C6-T8) Postero-lateral thoracic discectomy Anterior thoracic discectomy Anterior L1 corpectomy and reconstruction Surgery for thoracic fracture with spinal cord compression Surgery for high grade spondylolisthesis Right thoracic Idiopathic Scoliosis 60 degree degenerative lumbar scoliosis with stenosis Osteotomy for lumbar flat-back Surgery for syringomyelia Release of a tethered cord Surgery for an intradural neoplasm Surgery for spinal metastasesTECHNICAL/PROCEDURAL SKILLS0 15 30S..CFhlQ 19 i.lFC 0C--tk;,l. nwvlFlFa /AC;cltFFvlwCRespondent is: FELLOW TRAINEE or PRACTICING SPINE SURGEONFellowship Discipline: ORTHOPAEDIC or NEUROSURGERY or COMBINED FELLOWSHIPor NONEPrevious Residency Training: ORTHOPAEDIC SURGERY or NEUROSURGERYNumber:Date of Participation:Name of Hospital(s) of training:Gender: M FAge:0re 0)JJrqi rEJ%:4wtyCocCh 0AcAwC uvwCCw 4vc,: ur^^dEDn% ide()rE tw SuST)^Duide()rEJCFac, ts 0C--tk;,l. nwvlFlFa zRtFc,;N: 5 tw 1x tw 17 tw x8 tw <x82tk svw v-tFa lF ftAw cwvlFlFaG zRtFc,;N:DFcwthAocltF:Thank you very much for agreeing to participate with this research initiative. This survey will consist of two main themes, spine related musculoskeletal medicine based on the WHO’2002 directive and procedures specific to the practice of spine surgeons. You will be asked to indicate the importance of a particular topic or subject matter and the choices for response will be:1 Unable to Assess2 Not Important -  “do not need to know as an spine surgeon”3 Probably not important -  “not likely necessary to know as an spine surgeon”4 Probably important and -  “nice to know as an spine surgeon”5 Important -  “must know as an spine surgeon”Your opinion regarding these questions will be very important even though the answers may seem very obvious. I would request that you provide a response, which bests represents, your opinion with respect to your discipline of spine surgery. If you determine that the entire section would be important to know then just indicate that it is all important to know.Finally, I would request that you complete the entire questionnaire without discussion. Should you have any questions regarding a particular item during the interview then please “flag it” and we will discuss upon completion of the questionnaire.S9 i4)uD0Du i4DE) ur(EDnDH) iPDJJi:1. Please indicate the importance of the ability to construct an appropriate differential diagnosis and plan of patient enquiry, investigation, and assessment for a patient presenting with back pain:dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2  3 42. Please indicate the importance of the ability to demonstrate knowledge, the ability to diagnose, initially manage and to know when to immediately refer a patient with cauda equina syndrome:dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5Please indicate the importance of the ability to diagnose and manage back pain relating to:3. spondylolisthesis and spondylolysis.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 54. spinal cord or root entrapment (e.g. herniated lumbar disc).dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 55. vertebral fractures of traumatic origin.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 56. vertebral fractures of osteoporotic origin.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 57. inflammatory back pain such as ankylosing spondylitis.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 58. spinal deformity such as scoliosis.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc1 2  3 4DR.twcvFc59. destructive lesions of the spine presenting with back pain which may be of infectious or tumor origin such as tuberculosis, metastasis and/or malignancydFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5Please indicate the importance of the ability diagnose and manage a patient with:10. low back pain and sciatica.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 511. neck pain.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 512. Please indicate the importance of the ability to appropriately diagnose and manage a patient with an acute spinal injury.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5p9 ()E)eSJD6)T ur(EDnDH) iPDJJi:HISTORY &PHYSICAL EXAMINATION SKILLS13. Please indicate the importance of being able to take a full and thorough history for the various chief complaints (pain, limitation of activities, neurological symptoms etc.) relevant to the spine.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 514. Please indicate the importance of the ability to understand the impact of a chronic spine condition on the patient in terms of impairment of function and limitations/restrictions of activities.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 515. Please indicate the importance of the ability to perform a screening and focused history and physical examination of the spine in a trauma situation.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5INVESTIGATIONS16. Please indicate the importance of the ability to order and understand interpretation of appropriate diagnostic investigations relevant to the spine (CT, MRI, U/S, EMG etc.):dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5PROBLEM-BASED MANAGEMENT SKILLSPlease indicate the importance of the ability to diagnose and manage a patient presenting with:17. regional pain or stiffness.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 518. generalised pain or stiffness.dFvg-C nt EtcS;;C;; DR.twcvFc1 24wtgvg-f Etc 4wtgvg-f  DR.twcvFc DR.twcvFc DR.twcvFc3 4 519. decrease or loss of motion or weakness.20. altered sensation.21. deformity.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 522. a mass.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5TREATMENT OF INFECTIONSPlease indicate the importance of the ability to demonstrate knowledge, the ability to diagnose, initially manage and to know when to immediately refer a patient with:23. a spinal soft tissue infectiondFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 524. a spinal bone infection.dFvg-C nt EtcS;;C;; DR.twcvFc1 24wtgvg-f Etc 4wtgvg-f  DR.twcvFc DR.twcvFc DR.twcvFc3 4 5CONTINUITY OF CARE25. Please indicate the importance of the need to obtain clinical experience managing patients during the various stages of spine-related injury and healing. (For example: obtaining clinical experience from the emergency room or outpatient clinic through to the rehabilitation clinic.)dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5Please indicate the importance of the ability to appropriately diagnose and manage patients with: MANAGEMENT OF CHRONIC INFLAMMATORY CONDITIONS:26. Chronic inflammatory arthritis such as rheumatoid arthritis, or any of thespondyloarthropathies.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5MANAGEMENT OF CHRONIC PAIN27. Fibromyalgia or chronic generalized pain.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5Please indicate the importance of the ability to understand and manage:28. EtFjtwavFlo .vlF vFh o,wtFlo .vlF that may be pertinent to spinal conditions.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5MEDICAL-LEGAL ASPECTS OF PRACTICExO9 Patients requiring RChlov-I-Cav- vFh hl;vgl-lcf assessment and the pertinent issues that may be associated with the management of these patients such as: demands made by insurance companies, the Worker’s Compensation Board and employers.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 x 3 8 'REHABILITATION/PHYSIOTHERAPY:Please indicate the importance of the ability to:3W9 Assess wCcAwF ct ktwb or wCcAwF ct play/activitydFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 x 3 8 '31. Know and understand the specifics associated with wC,vgl-lcvcltF of a spinal injury or disorder.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 x 3 8 '3x9 Understand the various complementary and alternative forms of medical therapies available for the management of spinal injuries or disordersdFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 x 3 8 'PERSONAL AND PROFESSIONAL SKILLS33. Know and understand l;;AC; wC-vclFa ct K wCv- -lsCU such as: how to start a practice; dealing with time management and finances both in personal and business life and; proper balance between work and personal lifedFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 534. Work cooperatively with other medical and paramedical personneldFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5RESEARCH & TEACHING35. Upon completion of a fellowship training program in Canada please indicate the importance of the ability to be able to develop effective teaching and communication skills by means of: teaching colleagues and students, conference presentations, clinical and scientific reports and patient education.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 536. Upon completion of a fellowship training program in Canada please indicate the importance of the ability to be able to develop, demonstrate or appreciate critical appraisal skills of literature, be involved with clinical/basic science research projects and/or participate in journal clubs as they may pertain to the area of musculoskeletal health/conditions.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 5PERIOPERATIVE MANAGEMENT SKILLS37. Please indicate the importance of the ability to know and demonstrate understanding of the indications/contraindications associated with surgical procedures.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-fS;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 538. Please indicate the importance of the ability to know and demonstrate understanding of the principles of management of peri-operative,post-operative and long-term complications of surgical procedures.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 539. Please indicate the importance of the ability to demonstrate the principles of recognizing and managing intra-operative complications during surgical procedures.dFvg-C nt Etc 4wtgvg-f Etc 4wtgvg-f  S;;C;; DR.twcvFc DR.twcvFc DR.twcvFc DR.twcvFc1 2 3 4 540. Please list three clinical conditions you are likely to encounter, but which your fellowship has not equipped you to manage confidently. (Or list three clinical conditions that you expect trainees to encounter that your fellowship program has not adequately equipped them to manage.)n,C cCo,Flov-I.wtoChAwv- .twcltF ts c,C LAC;cltFFvlwC l; vmvl-vg-C tF-lFC c,wtAa, iAwmCf ^tFbCf:http://www.survevmonkev.eom/s/DKCSDSC or in original web format:http://www.surveymonkey.eom/s. aspx?sm=q9vpvl_7C_2fewGQKRo1J8gxA_3d_3d

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