key: cord-0776153-sa0eyzq7
authors: Ramos-Fresnedo, Andres; Domingo, Ricardo A.; ReFaey, Karim; Gassie, Kelly; Clifton, William; Grewal, Sanjeet S.; Chen, Selby G.; Chaichana, Kaisorn L.; Quiñones-Hinojosa, Alfredo
title: Neurosurgical Interactive Teaching Series: A Multidisciplinary Educational Approach
date: 2020-09-18
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.09.074
sha: 5796ceb93546f19171df861c032bf4de507ca1a2
doc_id: 776153
cord_uid: sa0eyzq7

Objective The goal of this manuscript is to investigate the effects of a multidisciplinary multinational web-based teaching conference on trainee education, research and patient care. Methods We present the structure, case selection and presentation of our educational lectures. We retrospectively reviewed our database to gather data on the number of presentations, type of presentation, and the pathology diagnosis from November 11, 2016 until February 28, 2020. To investigate attendee satisfaction, we analyzed our yearly CME evaluation survey results to report the impact that this series may have had on our attendees. We assigned a numeric value to the answers and the mean overall scores where compared through an ANOVA. Further analysis on specific questions was performed with a Fisher’s exact test. Results We have hosted 150 lectures, in which we have presented 208 neurosurgical cases corresponding to 133 general session, 59 pituitary, and 16 spine cases, as well as 28 distinct lectures by guest speakers from institutions across the globe. We received 61 responses to our yearly CME evaluations over the course of three years. On these evaluations, we have maintained an excellent overall rating from 2017-2019 (two-sided p>0.05) and received significantly less suggestions to improve the series comparing 2017 with 2019 (two-sided, p=0.04). Conclusion As the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript.

the impact that this series may have had on our attendees. We assigned a numeric value to the 8 answers and the mean overall scores where compared through an ANOVA. Further analysis on 9 specific questions was performed with a Fisher's exact test. 10 Results: We have hosted 150 lectures, in which we have presented 208 neurosurgical cases 11 corresponding to 133 general session, 59 pituitary, and 16 spine cases, as well as 28 distinct 12 lectures by guest speakers from institutions across the globe. We received 61 responses to our 13 yearly CME evaluations over the course of three years. On these evaluations, we have 14 maintained an excellent overall rating from 2017-2019 (two-sided p>0.05) and received 15 significantly less suggestions to improve the series comparing 2017 with 2019 (two-sided, 16 p=0.04). 17

Conclusion: As the world of medicine is constantly changing, we are in need of developing new 18 tools to enhance our ability to relay knowledge through accredited and validated methods onto 19 physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based 20 lectures as presented in this manuscript. 21

In 1919, Alfred W. Adson founded the neurosurgery department at the Mayo Clinic. However, 2 his expertise was mostly related to general surgery. Despite being appointed to treat 3 neurosurgical patients, he is noted to describe neurosurgery as a "hopeless field" due to the high 4 mortality and morbidity associated with these procedures at that time. 1 Just a few years prior to 5 the work of Dr. Adson, (1904) , Harvey Cushing was establishing neurosurgery as its own 6 separate discipline. 2-6 Neurosurgery has since evolved from general surgeons taking care of 7 neurosurgical patients, to a completely separate entity with multiple sub-specializations; 8 including vascular, functional, spine, pediatrics, and skull-base. 7 As we advance medical 9 knowledge, we strive towards the need to process an impressive amount of information limited 10 to a single topic, leading to a sub-specialization across all medical fields, including 11 neurosurgery. 7-9 12 13 Furthermore, certain pathological entities require multiple medical sub-specialties to achieve the 14 best patient care possible. It has been repeatedly shown that multidisciplinary approach to 15 patient care maximizes patient outcomes in multiple disciplines, and this holds true for neuro-16 oncology as well. [10] [11] [12] Similarly, in skull-base surgery, resection of these tumors is an essential 17 component of treatment, but a multispecialty team, including neurosurgery, radiation oncology, 18 neuro-oncology, neuro-pathology and neuro-radiology is needed to appropriately manage these 19 patients. 12 20 21

Institutions have established weekly multidisciplinary meetings where complex cases are 22 discussed to reach a consensus on how that specific case should be approached. 13, 14 Based on 23 the multidisciplinary approach, we created a separate weekly lecture format, that is broadcast 24 internationally, where trainees are encouraged to critically prepare (with the help of multiple 25 experts) and review surgical cases for educational purposes. In this multimedia format, the 26 trainee is encouraged to use intraoperative videos to be able to tell a story where multiple groups 27 get to comment and learn from, including the junior and senior colleagues. 28 29 Technological advances over the recent years has had an impact on the way physicians are 30 trained, shifting from practicing directly on the patient towards the use of indirect and simulated 31 experiences to avoid harming the patient during their learning. [15] [16] [17] In this manuscript we present 32 the structure of a new integrative, interactive, international, and multidisciplinary educational 33 approach to neurosurgical cases (Accredited by the Accreditation Council for Continuing 34

Medical Education (ACCME)) 18 of patients who underwent care in our institution, as well as 35 data from our experience since the series was established in November of 2016. 36

The neurosurgical teaching series lecture is held on a weekly basis. It is scheduled to last one 40 hour, where two interactive cases are presented. The cases are led by our neurosurgery resident 41 physicians, fellows, and trainees, who present at least once a month. The lecture is structured in 42 a way that the presenter talks about the case as if he was the lead physician, promoting third 43 order thinking skills. The physicians and surgeons who are involved in the care of the case are 44 present for guidance and surgical rationale. The physicians who were not involved in the care of 45 the presented case are also in the audience for questions and discussions. 46

To develop a multidisciplinary approach, members from the following specialties are present to 47 enrich our discussion from different perspectives: neurosurgery, neurology, medical neuro-48 oncology, radiation-oncology, neuroradiology, neuropathology, otorhinolaryngology, 49 neuropsychology, and endocrinology. 50

After the cases are presented, the audience engages in a discussion on the rationale that will be 52 beneficial in the education of trainees. This is a real-time peer-reviewed discussion using 53 scientific evidence from the literature, as well as experience from our institution. 54 55

The structure of the case presentations is based on recommendations by the American Board of 57

Neurological Surgery (ABNS) for case studies. 19 Cases are selected with two weeks in advance, 58 so the presenter can properly prepare the case, have a thorough understanding, and review the 59 presentation with the corresponding neurosurgery supervisor, and all other physicians involved 60 in care. Additionally, the neuro-pathology team prepares representative images of the histology 61 studies performed on the tissue, and the neuro-radiology team selects representative images from 62 the diagnostic workup to make a comment on how the diagnosis was guided. These cases are 63 selected to either have a high complexity or include surgical pearls and nuances to maintain our 64 trainees up to date. 65

The presentations begin with the history of present illness and chief complaint, including the 67 evolution of the disease and symptomatology. Initial workup is then presented including 68 laboratory values, imaging studies (e.g. Magnetic Resonance Imaging (MRI), Computerized 69 J o u r n a l P r e -p r o o f Tomography (CT) scans, and conventional angiography) that are representative of the decision-70 making process during surgical assessment based on case-specific characteristics. Presenters are 71 encouraged to recognize important anatomical landmarks in these images. After the history, 72 symptomatology, and diagnostic workup is presented, differential diagnoses are discussed with 73 the audience, enlisting the most probable to the least probable. The final diagnosis is not 74 disclosed with the audience to encourage third order thinking. To enhance surgical education, a 75 brief operative procedural video is presented. This video is three to five minutes long, and 76 includes: positioning, surgical approach, surgical pearls, reconstruction, and closure. Post-77 operative hospital care and evolution is presented to evaluate acute complications related to the 78 procedure. Post-operative follow-up with relevant laboratory values and imaging studies is also 79 presented. This is followed by conclusions, where the presenter is encouraged to engage in 80 critical thinking and comment on the obstacles that had to be overcome during patient care. To 81 finalize the case, a brief review of the literature with the latest data is presented. The audience 82 and the presenter are then encouraged to engage in an active discussion about the nuances of the 83 case ( Fig. 1) . 84 85

Every four weeks our multidisciplinary neuro-oncology team holds a special pituitary section 87

where the endocrinology team leads the discussion about complex pituitary cases. These are co-88 presented by both endocrinology and neurosurgery to provide a more thorough understanding of 89 the hypothalamic-pituitary-end organ axes disrupted by these lesions. 20 90 J o u r n a l P r e -p r o o f Although rare, spinal and medullary tumors arise and also need a multidisciplinary approach to 91 their care. 21, 22 Every eight weeks, we hold a special spine section to discuss two challenging 92 cases on spinal oncology. 93

We retrospectively analyzed our records of the multidisciplinary teaching series, including the 95 yearly report done to comply with the regulations for Continuing Medical Education (CME). 96

We analyzed previous presentations to review their diagnosis, which are presented in this paper. 97

Presentations that were not available for retrospective review were not included in the analysis. 98

To ensure patient confidentiality, the presentations are stored in a password protected and 99 encrypted drive for educational and research purposes, within the Mayo Clinic server. Informed 100 consent for research and education was obtained for each case prior to presentation. No patient 101 information, identity or identifiers are disclosed during the presentations. 102

After the end of every calendar year, our group surveys our audience members from the different 105 disciplines to provide feedback about this academic activity. To obtain objective suggestions 106 these responses are anonymized. We reviewed the feedback reports for the years 2017, 2018, 107 and 2019. 108

To assess whether there has been a change overall in the survey results over the course of our 110 series, a one-way ANOVA with Tukey's multiple comparisons was performed. To obtain the 111 mean score of the survey we assigned a numerical value to the answers of every question as 112 follows: Answers to questions 1, 5, and 6 included: Very deficient, deficient, good, very good, 113 and excellent; and values from 0-4 were assigned, respectively. Answers to questions 2, 3, and 4 114 included: Unmet, partially met, and met; and values from 0-2 were signed, respectively. 115

Answers to questions 7, 8, 9, and 10 included: No or yes; and values from 0-1 were assigned, 116 respectively. For question 11, we assigned a value of 2 for the answer "no changes needed" and 117 no score for any other answer. 118

To evaluate the changes for each specific question, a Fisher's exact test was performed. Only 119 questions 1 and 11 were analyzed as they were the only questions with variation of the 120 responses. 121 122 Statistical analysis was carried our using GraphPad Prism (Version 8 for Mac, GraphPad 123

Software, San Diego, California USA, www.graphpad.com). The questions and answers to the 124 close-end questions are summarized in Table 1 . 125 126 RESULTS 127

We analyzed our records from November 11, 2016 to February 28, 2020 . Over this period, we 129 have hosted a total of 150 meetings. There has been a total of 208 cases presented; out of which 130 133 were general session cases, 59 were pituitary cases, and 16 were spine cases. We have also 131 Over 86.9% of the total survey answers for question 1 rated the lectures overall as "excellent" 154 (maximum rating) while the rest 13.1% rated it as "very good"; no answers were recorded for the 155 rest of the categories (good, bad, very bad). Objectives 1 and 2 were recorded as "met" on the 156 100% of the survey results; while 96% recorded objective 3 as "met" with only one response as 157 J o u r n a l P r e -p r o o f "partially met"; no responses were recorded as "unmet". For presenter skills in 2018, 73.1% of 158 the responses recorded them as "excellent" while the rest classified them as "very good"; in 2019 159

we saw an increase in this ratings to a recorded 83.3% rating them as "excellent"; we had no 160 year 2018 (two-sided, 54.5% and 45.5% vs. 69.2% and 30.8%, p=0.37) or year 2018 to year 177 2019 (two-sided, 69.2% and 30.8% vs. 87.5% and 12.5%, p=0.27) (Fig. 4) . Even though the topics discussed in the lectures are focused on neurosurgical topics, the format 181 of the presentations allows for any healthcare professional, ranging from technicians to fully 182 trained faculty. This is due to the recurring specific structure that can be applied to any medical 183 field or specialty, allowing any-level health professional to develop an ordered rationale and 184 third order thinking. By directing to any type of health worker, we allow the lectures to have a 185 larger audience. There have been results on the variability of attention span in humans, and its relationship with 209 different types of stimulus. 41 Our group has tried to account for these factors by including 210 multimedia elements, such as imaging and short surgical videos into the presentations; as well as 211 frequent interaction between attendees. In this manuscript we present a CME accredited, 212 recurring and international lecture series for medical trainees from all levels of education that has 213 been shown to have a direct impact in patientcare. 214 215 A multidisciplinary approach towards patient care is essential to achieve optimal outcomes in 216 neuro-oncologic patients. 10, 11, [42] [43] [44] [45] Many institutions, including our own, have implement a 217 weekly multidisciplinary conference, commonly known as a multidisciplinary tumor board 218 (MTB), where complex cases from the practice are discussed to reach an integrative approach 219 towards treatment. 13, 14, 46 Recent studies have surged about the importance and benefits of these 220 multidisciplinary meetings, further highlighting the importance of this approach to patient 221 care. [47] [48] [49] Due to the growing evidence, our group decided to establish a weekly educational 222 series for our young surgeons. We believe that a multidisciplinary form of care must be 223 integrated to the education of every surgical trainee, as early understanding of its benefits will be 224 beneficial to the care delivered by them. To the best of our knowledge, this is the first manuscript to describe an established 228 multidisciplinary interactive lecture series, organized and presented by medical trainees that is 229 held on a weekly basis. We present how a structured meeting can be effectively held in the 230 benefit of residents and attendings. We also present data on the type of lesions that are chosen 231 for presentation, which are mostly skull base tumors. This is probably due to the tenacity of the 232 cases that are chosen for presentation as they require a multispecialty team. [10] [11] [12] We believe that 233 this educational tool will have a positive impact in the career of our young residents, and as such 234

we are enthusiastic to share our methods with other training programs. The overall satisfaction level has been maintained as "excellent" throughout the past three years 244 as reflected in our analysis. Even though in the year 2019 we obtained less "excellent" responses 245 than the previous two years, the difference was non-significant. We believe that this is possibly 246 due to the responses consistently falling within the maximal values throughout the study period, 247 therefore any small variation within the responses will not affect the significance. The decrease 248 in these responses may be due to the variability of the attendees answering the survey as they 249 may be different between the years, as well as a minimal difference in the definition between 250 "very good" and excellent". Moreover, on analysis of question 11 we see a significant 251 improvement in the feedback, with a significant increasing number of answers recommending no 252 further changes to the format, suggesting that our attendees are satisfied with how the meeting is 253 carried out. 254 255 By creating a case review within a multidisciplinary setting, like the one we present in this paper, 256

we take medical education one step further by allowing our trainees to develop a framework of 257 how to critically think through complex cases, and receive real time feedback from international 258 experts as they present. 259

This is a study representing the data that we have collected from our weekly multidisciplinary 262 lecture series. It was done at a single institution with a single multidisciplinary team within a 263 single residency program. Studies within our institution, as well as multicenter studies are 264 needed to validate our data, as well as the efficacy and impact that these meetings have in the 265 education of young physicians. 266

There are inherited limitations in this study as it is retrospective and survey-based in nature. 268

These include sampling error and recall bias. As the survey results are anonymous and blinded, it 269

gives us the opportunity for future feedback. Even though this study has its strengths and 270 limitations, it can provide a baseline for future manuscripts in order to improve medical 271 education. 272

As the world of neurosurgery is constantly changing, we are in need of developing new tools to 275 enhance our ability to relay knowledge through accredited and validated methods onto 276 physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based 277 lectures as presented in this manuscript. We encourage the community to share their experience 278 institution. This process is based on the recommendations by the ABNS for case studies. 463

Following these steps allows for a structured format that can be replicated on a weekly basis. N/A -Data was unavailable for this section. The answers that were not recorded in the survey results were not included in the summarized table. Answers to questions 1,5, and 6 included: Excellent, very good, good, bad, very bad. Answers to questions 2, 3, and 4 included: Met,

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