On resident duty hour restrictions and neurosurgical training: review of the literature

The introduction of a 42 + 4 h work week for surgical residents in Switzerland - a stakeholder analysis

BACKGROUND

The Swiss national union of residents and attendings (VSAO) has voiced its desire for a transition from the current 48 h work week to a 42 + 4 h work week, in which 42 h be focused on patient care with the remaining 4 h be dedicated solely to training purposes. This could potentially result in a significant decrease in surgical education time. The current study seeks to address the issues involved in its implementation as well as possible compensatory mechanisms.

METHODS

This mixed methods study seeks to clearly underline the challenges associated with the implementation of a 42 + 4 h work week. First, the major stakeholders were identified and analysed via umbrella review. Thereafter, a classic stakeholder analysis was performed. Via morphological matrix, possible models for the implementation of a 42 + 4 h work week were developed and evaluated. Finally, representatives from the identified stakeholder groups were interviewed and given the opportunity to provide feedback.

RESULTS

A total of 26 articles were identified by the literature search and were used to identify the major stakeholders and issues involved in the implementation of the desired work hour regulation. Overall, these showed conflicting results with regard to the effect decreased working hours would have on surgical training and patient outcomes. In the end, the morphological matrix produced three feasible and desirable models for the implementation of a 42 + 4 h work week. Each included compensatory mechanisms like auxiliary staff, reduction in administrative tasks, and a switch to EPAs. In their interviews, the stakeholders generally supported these solutions.

CONCLUSION

Given the increasing emphasis on the importance of a positive work-life balance, it seems inevitable that the next few years will see the introduction of a 42 + 4 h work week in Switzerland. However, it is imperative that every effort be made to preserve the quality of training and patient care for the next generations. This will require the cooperation of all stakeholders in order to find workable solutions.

Automated and Optimized Neurosurgery Scheduling System Improves Resident Satisfaction

BACKGROUND AND OBJECTIVES

Neurosurgery residency involves a complex structure with multiple hospitals, services, and clinic days, leading to challenges in creating equitable call schedules. Manually prepared scheduling systems are prone to biases, error, and perceived unfairness. To address these issues, we developed an automated scheduling system (Automated Optimization of Neurosurgery Scheduling System [AONSS]) to reduce biases, accommodate resident requests, and optimize call variation, ultimately enhancing the educational experience by promoting diverse junior-senior-attending relationships.

METHODS

AONSS was developed and tailored to the University of Florida program, with inaugural use in 2021-2022 and mandatory implementation in the 2022-2023 academic year. 2019-2021 academic years were used as control. Residents were surveyed using Google Forms before and after implementation to assess its impact. Outcome measures included call and pairing variations, duty hours, as well as subjective factors such as satisfaction, fairness, and perceived biases.

RESULTS

Twenty-six residents (28%-39% female/year) were included in the study. AONSS was used for 6/13 blocks during the 2021-2022 academic year and 13/13 blocks for the 2022-2023 academic year. Overall call variation reduced by 70%. All other objective secondary measures have improved with AONSS. Weekly and monthly duty hours were reduced and less varied. Satisfaction scores improved from 21% reporting being somewhat satisfied or very satisfied to 90%. Fairness scores improved from 43% reporting being somewhat fair or very fair to 95%. Perception of gender bias decreased from 29% to 0%. No resident felt there was racial bias in either system.

CONCLUSION

Our newly developed automated scheduling system effectively reduces variation among calls in a complex neurosurgery residency, which, in return, was found to increase residents' satisfaction with their schedule, improve their perception of fairness with the schedule, and has completely removed the perception of sexual bias in a program that has a large percentage of females. In addition, it was found to be associated with decreased duty hours.

The "STARS" study: advanced preoperative rehearsal and intraoperative navigation in neurosurgical oncology

BACKGROUND

Neurosurgical 3D visualizers and simulators are innovative devices capable of defining a surgical strategy in advance and possibly making neurosurgery safer by rehearsing the phases of the operation beforehand. The aim of this study is to evaluate Surgical Theater™ (Surgical Theater LLC, Mayfield, OH, USA), a new 3D neurosurgical planning, simulation, and navigation system, and qualitatively assess its use in the operating room.

METHODS

Clinical data were collected from 30 patients harboring various types of brain tumors; Surgical Theater™ was used for the preoperative planning and intraoperative 3D navigation. Preoperative and postoperative questionnaires were completed by first and second operators to get qualitative feedback on the system's functionality. Furthermore, we measured and compared the impact of this technology on surgery duration.

RESULTS

Neurosurgeons were overall satisfied when using this rehearsal and navigation tool and found it efficient and easy to use; interestingly, residents considered this device more useful as compared to their more senior colleagues (with significantly higher scores, P<0.05), possibly because of their limited anatomical experience and spatial/surgical rehearsal ability. The length of the surgical procedure was not affected by this technology (P>0.05).

CONCLUSIONS

Surgical Theater™ system was found to be clinically useful in improving anatomical understanding, surgical planning, and intraoperative navigation, especially for younger and less experienced neurosurgeons.

High fidelity simulation of the endoscopic transsphenoidal approach: Validation of the UpSurgeOn TNS Box

Objective

Endoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa.

Methods

Novice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system.

Results

Fifteen participants were recruited of which n = 10 (66.6%) were novices and n = 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (n = 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14-16.75) for novices and 29/30 (IQR 27-29) for intermediate and experts (p < 0.001, Mann-Whitney U). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25-13) for novices and 18/20 (IQR 17.75-19) for intermediate and experts (p < 0.001, Mann-Whitney U). Interrater reliability was 0.949 (CI 0.983-0.853) for OSATS and 0.945 (CI 0.981-0.842) for Task-Specific Technical Skills. Suggested improvements for the model included the addition of neuro-vascular anatomy and arachnoid mater to simulate bleeding vessels and CSF leak, respectively, as well as improvement in materials to reproduce the consistency closer to that of human tissue and bone.

Conclusion

The TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality).

Overwork among resident physicians: national questionnaire survey results

BACKGROUND

Residents experience the longest working hours among physicians. Thus, it would be beneficial to perform a nationwide survey in Japan on residents' long work hours and the background factors promoting upper limits on working hours of Japanese residents. The aim of this study was to study or assess the state of physicians' excessive work hours and its background factors using a questionnaire survey.

METHODS

The survey was sent to 924 hospitals. The physicians' general attributes, work hours and conditions, and employers' foundational entities were explored. Multiple logistic regression analysis was performed to elucidate the background factors for long work hours.

RESULTS

Of the 4306 resident physicians who responded, 67% had ≥ 60 in-hospital hours/week and 27% had ≥ 80 h/week; 51% were on-call ≥ four times/month. Many of them hoped for increased remuneration. Additionally, female (reference: male, OR: 0.65, 95% CI: 0.55-0.76), 35-40 years old (reference: 25-30 years old, OR: 1.83, 95% CI: 1.32-2.54), childlessness (reference: child, OR: 1.41, 95% CI: 1.12-1.75), surgical specialization (reference: internal medicine, OR: 2.51, 95% CI: 1.96-3.23), neurosurgical specialization (reference: internal medicine, OR: 4.38, 95% CI: 2.92-6.59) and hospitals with 200-400 physicians (reference: <100 physicians, OR: 1.82, 95% CI: 1.12-2.96) exhibited significant correlations with ≥ 80 in-hospital hours/week.

CONCLUSION

Understanding the factors that increase the likelihood of residents working very long hours could aid in making targeted changes to address the specific concerns. Moreover, reducing working hours to a reasonable limit can improve resident physicians' health and the quality of care they provide in their community.

Thoracic Pedicle Screw Placement Utilizing Hands-On Training Session on Three-Dimensional Models

The utilization of three-dimensional (3D) models has been an important element of medical education. We demonstrate a three-dimensionally-printed (3DP) thoracic spine model for use in the teaching of freehand pedicle screw placement. Neurosurgical residents with varying years of experience practiced screw placement on these models. Residents were timed, and models were evaluated for medial and lateral breaches. Overall, this technical report describes the utility of 3D spine models in the training of thoracic pedicle screw placement. The tactile feedback from the 3D models was designed to represent both cortical and cancellous bones.

Evaluation of simulation models in neurosurgical training according to face, content, and construct validity: a systematic review

BACKGROUND

Neurosurgical training has been traditionally based on an apprenticeship model. However, restrictions on clinical exposure reduce trainees' operative experience. Simulation models may allow for a more efficient, feasible, and time-effective acquisition of skills. Our objectives were to use face, content, and construct validity to review the use of simulation models in neurosurgical education.

METHODS

PubMed, Web of Science, and Scopus were queried for eligible studies. After excluding duplicates, 1204 studies were screened. Eighteen studies were included in the final review.

RESULTS

Neurosurgical skills assessed included aneurysm clipping (n = 6), craniotomy and burr hole drilling (n = 2), tumour resection (n = 4), and vessel suturing (n = 3). All studies assessed face validity, 11 assessed content, and 6 assessed construct validity. Animal models (n = 5), synthetic models (n = 7), and VR models (n = 6) were assessed. In face validation, all studies rated visual realism favourably, but haptic realism was key limitation. The synthetic models ranked a high median tactile realism (4 out of 5) compared to other models. Assessment of content validity showed positive findings for anatomical and procedural education, but the models provided more benefit to the novice than the experienced group. The cadaver models were perceived to be the most anatomically realistic by study participants. Construct validity showed a statistically significant proficiency increase among the junior group compared to the senior group across all modalities.

CONCLUSION

Our review highlights evidence on the feasibility of implementing simulation models in neurosurgical training. Studies should include predictive validity to assess future skill on an individual on whom the same procedure will be administered. This study shows that future neurosurgical training systems call for surgical simulation and objectively validated models.

Data-Driven Residency Training: A Scoping Review of Educational Interventions for Neurosurgery Residency Programs

BACKGROUND

Neurosurgery residency programs are tasked with imparting large volumes of both clinical knowledge and technical skill to trainees in limited time. Many investigators have described local practices, which may offer evidence-based interventions in neurosurgical residency education, but this literature has not been systematically reviewed.

OBJECTIVE

To perform a scoping review of educational practices in neurosurgery, which are supported by quantitative, peer-reviewed research.

METHODS

A scoping review of the literature was performed. PubMed, Embase, and Web of Science databases were queried for articles describing educational interventions for neurosurgery residents, which included a quantitative assessment of the effect on resident performance.

RESULTS

From an initial set of 1785 unique articles, 29 studies were ultimately screened and included. Studies were into the following 6 topics: (1) didactics and curricula (n = 13), (2) nontechnical skills (n = 6), (3) wellness and burnout (n = 4), (4) assessment and feedback (n = 2), (5) mentorship and career development (n = 2), and (6) research (n = 2). Individual study results were described.

CONCLUSION

Several educational interventions in neurosurgical training are supported by quantitative evidence. Methodological shortcomings are prevalent among studies of education, particularly in the selection of meaningful outcome measures. A summary of evidence-based considerations is provided for current and future program directors.

Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations

The purpose of this report is to chronicle a 2-decade period of educational innovation and improvement, as well as governance reform, across the specialty of neurological surgery. Neurological surgery educational and professional governance systems have evolved substantially over the past 2 decades with the goal of improving training outcomes, patient safety, and the quality of US neurosurgical care. Innovations during this period have included the following: creating a consensus national curriculum; standardizing the length and structure of neurosurgical training; introducing educational outcomes milestones and required case minimums; establishing national skills, safety, and professionalism courses; systematically accrediting subspecialty fellowships; expanding professional development for educators; promoting training in research; and coordinating policy and strategy through the cooperation of national stakeholder organizations. A series of education summits held between 2007 and 2009 restructured some aspects of neurosurgical residency training. Since 2010, ongoing meetings of the One Neurosurgery Summit have provided strategic coordination for specialty definition, neurosurgical education, public policy, and governance. The Summit now includes leadership representatives from the Society of Neurological Surgeons, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the American Board of Neurological Surgery, the Review Committee for Neurological Surgery of the Accreditation Council for Graduate Medical Education, the American Academy of Neurological Surgery, and the AANS/CNS Joint Washington Committee. Together, these organizations have increased the effectiveness and efficiency of the specialty of neurosurgery in advancing educational best practices, aligning policymaking, and coordinating strategic planning in order to meet the highest standards of professionalism and promote public health.

NIH funding trends for neurosurgeon-scientists from 1993-2017: Biomedical workforce implications for neurooncology

INTRODUCTION

Neurosurgeons represent 0.5% of all physicians and currently face a high burden of disease. Physician-scientists are essential to advance the mission of National Academies of Science (NAS) and National Institutes of Health (NIH) through discovery and bench to bedside translation. We investigated trends in NIH neurosurgeon-scientist funding over time as an indicator of physician-scientist workforce training.

METHODS

We used NIH Research Portfolio Online Reporting Tools (RePORTER) to extract grants to neurosurgery departments and neurosurgeons from 1993 to 2017. Manual extraction of each individual grant awardee was conducted.

RESULTS

After adjusting for U.S. inflation (base year: 1993), NIH funding to neurosurgery departments increased yearly (P < 0.00001). However, neurosurgeon-scientists received significantly less NIH funding compared to scientists (including basic scientists and research only neurosurgeons) (P = 0.09). The ratio of neurosurgeon-scientists to scientists receiving grants was significantly reduced (P = 0.002). Interestingly, the percentage of oncology-related neurosurgery grants significantly increased throughout the study period (P = 0.002). The average number of grants per neurosurgeon-scientists showed an upward trend (P < 0.001); however, the average number of grants for early-career neurosurgeon-scientists, showed a significant downward trend (P = 0.05).

CONCLUSION

Over the past 23 years, despite the overall increasing trends in the number of NIH grants awarded to neurosurgery departments overall, the proportion of neurosurgeon-scientists that were awarded NIH grants compared to scientists demonstrates a declining trend. This observed shift is disproportionate in the number of NIH grants awarded to senior level compared to early-career neurosurgeon-scientists, with more funding allocated towards neurosurgical-oncology-related grants.

The Effects of 24-Hour Neurosurgical Call on Fine Motor Dexterity, Cognition, and Mood

Background: Concerns regarding the effects of fatigue on physician performance and quality of life lead to the implementation of duty hour restrictions for residents by the Accreditation Council for Graduate Medical Education (ACGME). These restrictions have been met by strong criticism from the neurosurgical community. This is partly due to a lack of objective evidence that fatigue results in decrements in professional function in neurological surgeons. There is also concern that the restrictions have diminished clinical and operative experience as well as the development of professional responsibility in residency.

Objective: To evaluate whether 24-hour neurosurgical call has an objective impact on fine motor dexterity, cognitive thinking skills, and mental well-being.

Methods: Subjects were tested before and after taking 24 hours of neurosurgical call. We evaluated fine motor dexterity using the Vienna Test System Motor Performance Series, cognitive thinking abilities using a battery of paper-pencil neuropsychological tests, and mental well-being using the Profile of Mood States. 

Results: A total of 27 subjects were included in this study, 12 seasoned to neurosurgical call and 15 naive to neurosurgical call. The seasoned subjects demonstrated no statistically significant change in performance after call on any of the tests for fine motor dexterity or cognitive thinking abilities. The nonseasoned subjects demonstrated multiple decrements in fine motor dexterity and cognitive thinking abilities after taking call. In the Motor Performance Series, they had a statistically significant decrease in the speed of untargeted movements in the nondominant hand during the tapping test (p = 0.002), and a decline in the precision of fine motor movements and information processing as evidenced by an increase in the number of errors of the dominant hand in the line tracking test (p = 0.014). There was a statistically significant decline in their immediate memory during Hopkins Verbal Learning Test (p = 0.025), and complex attention, mental flexibility, and visual-motor speed in the Trail Making Test (p = 0.03). The Profile of Mood States found no difference in feelings of anger (p = 0.54), tension (p = 0.358), or depression (p = 0.65). There were increased feelings of confusion (p < 0.001) and decreased feelings of vigor (p < 0.001) and friendliness (p = 0.001). Nonseasoned subjects had an increase in total mood disturbance (p = 0.012) but seasoned subjects did not (p = 0.083). 

Conclusion: Our results suggest that fatigue-induced decrements in professional function can be ameliorated by experience with prolonged duty hours. In contrast to nonseasoned subjects, those who were conditioned to 24-hour neurosurgical call demonstrated resilience in fine motor dexterity and cognitive thinking skills, and exhibited no change in total mood disturbance. An argument can be made that we are turning the neurosurgical training paradigm upside down with the current ACGME duty hour restrictions. 

An Analysis of the On-Call Clinical Experience of a Junior Neurosurgical Resident

The process of transforming a medical student to a competent neurosurgeon is becoming increasingly scrutinized and formalized. However, there are few data on resident workload.

We sought to quantify the workload and educational experience of a junior resident while “on-call.”

A single resident's on-call log was reviewed from the period of July 1, 2014 to June 30, 2016, corresponding to that resident's postgraduate years 2 and 3. For each patient encounter (ie, consult or admission), information pertaining to the patient's demographics, disease or reason for consult, date/time/location of consult, and need for any neurosurgical intervention within the first 24 hours was collected.

In total, 1929 patients were seen in consultation. The majority of patients were male (62%) with a median age of 50 years (range, day of life 0-102 years) and had traumatic diagnoses (52%). The number of consults received during the 16:00 to 17:00 and 17:00 to 18:00 hours was +1.6 and +2.5 standard deviations above the mean, respectively. The busiest and slowest months were May and January, respectively. Neurosurgical intervention performed within the first 24 hours of consultation occurred in 330 (17.1%) patients: 221 (11.4%) major operations, 69 (3.6%) external ventricular drains, and 40 (2.1%) intracranial pressure monitors.

This is the first study to quantify the workload and educational experience of a typical neurosurgical junior resident while “on-call” (ie, carrying the pager) for 2 consecutive years. It is our hope that these findings are considered by neurosurgical educators when refining resident education.

Burr hole trepanation for chronic subdural hematomas: is surgical education safe?

BACKGROUND

There is a paucity of data concerning the safety and efficacy of surgical education for neurosurgical residents in the evacuation of chronic subdural hematomas (cSDH) by burr hole trepanation.

METHODS

This is a retrospective analysis of prospectively collected data on consecutive patients receiving burr hole trepanation for uni- or bilateral cSDH. Patients operated by a supervised neurosurgery resident (teaching cases) were compared to patients operated by a board-certified faculty neurosurgeon (BCFN; non-teaching cases). The primary endpoint was surgical revision for any reason until the last follow-up. The secondary endpoint was occurrence of any complication until the last follow-up. Clinical status, type of complications, mortality, length of surgery (LOS), and hospitalization (LOH) were tertiary endpoints.

RESULTS

A total of n = 253 cases were analyzed, of which n = 217 (85.8%) were teaching and n = 36 (14.2%) non-teaching cases. The study groups were balanced in terms of age, sex, surgical risk (ASA score), and preoperative status (Karnofsky Performance Scale (KPS), modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS)). The cohort was followed for a mean of 242 days (standard deviation 302). In multivariate analysis, teaching cases were as likely as non-teaching cases to require revision surgery (OR 0.65, 95% CI 0.27-1.59; p = 0.348) as well as to experience any complication until the last follow-up (OR 0.79, 95% CI 0.37-1.67; p = 0.532). Mean LOS was about 10 min longer in teaching cases (53.0 ± 26.1 min vs. 43.5 ± 17.8 min; p = 0.036), but LOH was similar. There were no group differences in clinical status, mortality and type of complication at discharge, and the last follow-up.

CONCLUSIONS

Burr hole trepanation for cSDH can be safely performed by supervised neurosurgical residents enrolled in a structured training program, without increasing the risk for revision surgery, perioperative complications, or worse outcome.

Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Analysis of Published Viewpoints in Surgery

PURPOSE

Individuals representing various surgical disciplines have expressed concerns with the impact of resident duty hours (RDH) restrictions on resident education and patient outcomes. This thematic review of published viewpoints aimed to describe the effects of these restrictions in surgery.

METHOD

The authors conducted a qualitative systematic review of non-research-based literature published between 2003 and 2015. Articles were included if they focused on the RDH restrictions in surgery and resident wellness, health promotion, resident safety, resident education and/or training, patient safety, medical errors, and/or heterogeneity regarding training or disciplines. A thematic analysis approach guided data extraction. Contextual data were abstracted from the included articles to aid in framing the identified themes.

RESULTS

Of 1,482 identified articles, 214 were included in the review. Most were from authors in the United States (144; 67%) and focused on the 80-hour workweek (164; 77%). The emerging themes were organized into three overarching categories: (1) impact of the RDH restrictions, (2) surgery has its own unique culture, and (3) strategies going forward. Published opinions suggested that RDH restrictions alone are insufficient to achieve the desired outcomes and that careful consideration of the surgical training model is needed to maintain the integrity of educational outcomes.

CONCLUSIONS

Opinions from the surgical community highlight the complexity of issues surrounding the RDH restrictions and suggest that recent changes are not achieving all the desired outcomes and have resulted in unintended outcomes. From the perceptions of the various stakeholders in surgical education studied, areas for new policies were identified.

Microsurgical Performance After Sleep Interruption: A NeuroTouch Simulator Study

OBJECTIVE

In times of the ubiquitous debate about doctors' working hour restrictions, it is still questionable if the physician's performance is impaired by high work load and long shifts. In this study, we evaluated the impact of sleep interruption on neurosurgical performance.

METHODS

Ten medical students and 10 neurosurgical residents were tested on the virtual-reality simulator NeuroTouch by performing an identical microsurgical task, well rested (baseline test), and after sleep interruption at night (stress test). Deviation of total score, timing, and excessive force on tissue were evaluated. In addition, vital parameters and self-assessment were analyzed.

RESULTS

After sleep interruption, total performance score increased significantly (45.1 vs. 48.7, baseline vs. stress test, P = 0.048) while timing remained stable (10.1 vs. 10.4 minutes for baseline vs. stress test, P > 0.05) for both students and residents. Excessive force decreased in both groups during the stress test for the nondominant hand (P = 0.05). For the dominant hand, an increase of excessive force was encountered in the group of residents (P = 0.05). In contrast to their results, participants of both groups assessed their performance worse during the stress test.

CONCLUSIONS

In our study, we found an increase of neurosurgical simulator performance in neurosurgical residents and medical students under simulated night shift conditions. Further, microsurgical dexterity remained unchanged. Based on our results and the data in the available literature, we cannot confirm that working hour restrictions will have a positive effect on neurosurgical performance.

The 2016 AANS Presidential Address: Leading the way

This AANS presidential address focuses on enduring values of the neurosurgical profession that transcend the current political climate. The address was delivered by Dr. Batjer during a US presidential election year, but the authors have intentionally avoided discussing the current chaos of the American health care system in the knowledge that many pressing issues will change depending on the outcome of the 2016 elections. Instead, they have chosen to focus on clarifying what neurosurgeons, and the American Association of Neurological Surgeons, in particular, stand for; identifying important challenges to these fundamental principles and values; and proposing specific actions to address these challenges. The authors cite "de-professionalism" and commoditization of medicine as foremost among the threats that confront medicine and surgery today and suggest concrete action that can be taken to reverse these trends as well as steps that can be taken to address other significant challenges. They emphasize the importance of embracing exceptionalism and never compromising the standards that have characterized the profession of neurosurgery since its inception.