The seven-year Residency program includes:
- 12 months, Neurosurgery Internship
- 24 months, Junior Residency
- 12 months, Senior Residency
- 18 months, Protected Research time
- 6 months, International Elective in Ireland
- 12 months, Chief Residency
Beginning with the PGY-2 level, the neurosurgery residents spend 36 months on clinical neurosurgery (adult and pediatric), three months on neurology (adult and pediatric), and a one-month rotation is spent on neuropathology/microsurgical anatomy and technique. The pediatric neurosurgery rotation is a six-month block, and the call schedule for the pediatric and adult services is separate. On the adult service, there are usually four or five neurosurgery residents and one or two surgical interns who share call. Four to six months are spent in Dublin, Ireland, for an elective clinical rotation. The remaining 15-18 months are devoted to research training and review of basic neuroscience principles. Residents preparing for an academic career may elect to spend one or two additional years of research training with an opportunity to work towards a PhD in neurobiology or related disciplines. Residents are required to take the written examination of the American Board of Neurological Surgery for self-assessment and credit during their training and must pass the examination in order to complete residency training.
Residency Educational Program
Residents at the PGY-1 level spend nine months on the general surgical service and three months completing their neurology requirements for the ABNS. The neurology time is spent in the Neurology and Neurosurgery Intensive Care Unit, which is an excellent introduction to neuro critical care issues for the incoming resident. The general surgical experience consists of approximately two months of clinical neurosurgery and seven months of general surgery and surgical subspecialties.
PGY-1 residents are expected to be able to perform a history and physical exam, order medication and diagnostic tests, collect and analyze test results and communicate these results to the members of the team and faculty. The PGY-1 resident is also expected to learn to obtain informed consent, assist in the operating room and perform invasive procedures such as central line placement, Swan Ganz catheter placement, chest tube placement, ICP monitor and ventriculostomy placement under the supervision of the faculty or senior residents at the discretion of the responsible faculty member.
PGY-1 residents are expected to begin their didactic studies in neurosurgery emphasizing patient care, but also start to read from the textbooks provided by the department (Yeomann’s Textbook of Neurosurgery) as well as critical articles and references recommended by senior residents and staff. At the completion of the PGY-1 year, the resident should understand enough of the basics of neurosurgery to be able to begin seeing consults and managing patients as a junior resident at the beginning of the PGY-2 residency year.
Residents at the PGY-2 level are considered “junior residents” on the neurosurgical service. They cover the four adult services (Dacey/Dowling/Zipfel/Hawasli, Chicoine/Rich, Ray/Kim/Osbun, Wright/Santiago, and Dorward/Dunn/Leuthardt), and they cover three months of “night float.” Residents focus on vascular neurosurgery, neuro-oncology, complex spine surgery, functional neurosurgery, epilepsy, and endovascular neurosurgery. Residents will also learn the fundamentals of frame-based and frameless stereotaxis, gamma Knife neurosurgery during this first year of neurosurgical training. Extensive experience is gained taking care of critically ill neurosurgical patients. When covering the “night float” rotation, junior residents work from 6 p.m. to 6 a.m., six nights per week, seeing consultations in the Emergency Department and the hospital, and managing the entire inpatient service. Residents operate as first assist to faculty as well as under the supervision of the neurosurgical chief residents and senior residents during this year.
At the completion of the PGY-2 year, he or she should be able to perform a comprehensive neurological history and examination, formulate a meaningful differential diagnosis, order and interpret appropriate diagnostic tests, and present this information in an organized and articulate manner. He or she should be adept at performing lumbar puncture, ventriculostomy, ICP monitor insertion and skeletal traction. This basic understanding of neurosurgical principles is emphasized on a weekly basis during a teaching conference, and two hours are spent each Wednesday focusing on didactic education in neurosurgery.
In the operating room, the junior-level resident should master patient positioning and frame placement for stereotactic procedures. He or she should be able to plan an approach and incision for surgery. He or she should be able to handle tissue appropriately, stop simple bleeding, take direction well, anticipate surgical maneuvers, and perform as a team member. He should be able to master shunts, burr holes, craniotomy for trauma, carpal tunnel release, and simple spine procedures.
During the PGY-3 neurosurgical year, residents are considered “junior residents.” Residents spend six months rotating on each the three chief-led services at Barnes-Jewish Hospital, four months at St. Louis Children’s Hospital under the supervision of a senior resident, and two months rotating on the neuropathology and neuroradiology services. The resident works under the direct supervision of the chief resident, but he or she is given increasing autonomy in patient care as well as in the operating room.
It is expected that the intermediate resident be adept in the use of the literature and routinely demonstrate the ability to search selected topics and present these to the surgical team. The intermediate resident should be able to discuss and explain nonoperative and operative treatment options for common neurosurgical problems, as well as the expected benefits, risks and alternatives. This knowledge base is emphasized at departmental conferences, where the senior level residents are prepared on a weekly basis for oral discussion of common and more complicated neurosurgical problems.
Read more: A Year in Perspective from a PGY-3
Residents at the PGY-4 level are considered “senior residents.” As seniors, the residents spend six months at St. Louis Children’s Hospital where they are responsible for their own service and six months at Barnes-Jewish Hospital on a chief-led service. The senior residents are expected to function as first assistants in the operating room with their attending surgeons.
At St. Louis Children’s Hospital, the senior resident is responsible for managing the pediatric neurosurgical service. The resident works in concert with a pediatric neurosurgery fellow and a team of nurse practitioners and physician assistants to see patients on the ward and in the clinics and maintain a busy operative schedule.
The senior-level resident is expected to supervise and teach the junior residents. He or she is able to perform progressively more complex surgical procedures under the direct supervision of the faculty. Expected surgical competencies include stopping more serious bleeding problems, proficiency in stereotactic biopsy and craniotomy, incision planning, opening craniotomies and suboccipital craniectomies, removal of intra-axial neoplasms, exposure of the spine, anterior cervical discectomy, simple cervical instrumentation, lumbar laminectomies, lumbar disc removal and simple lumbar instrumentation.
The senior-level resident is also expected to continue his or her didactic education in neurosurgery independently. He or she is expected to begin to develop clinical and research interests, with projects initiated with various members of the departmental staff. He or she is expected to prepare research for presentation at national meetings and to begin to plan for his or her time in the laboratory beginning in the PGY 5 year.
Read more: A Year in Perspective from a PGY-4
Joint Neurosurgery and Otolaryngology Skull Base Course.
PGY-5 and PGY-6:
The PGY-5 and -6 years are spent in the research laboratory. The experiences available to residents are many and varied. While spending time in the laboratory, the resident is expected to continue his or her didactic education. The resident is a frequent participator in neurosurgical conferences, further augmenting his or her academic development.
During the research years, six months of time are spent as a senior registrar on the neurosurgical service at Beaumont Hospital in Dublin, Ireland. This experience is an excellent precursor to the resident’s chief residency experience.
Chief Residency Year (PGY-7):
During the chief residency year, the PGY-7 resident functions as the primary physician responsible for the management of the adult neurosurgical services. Each chief resident covers a team that consists of one junior-level resident. While the senior-level residents are responsible for their own services, the chief resident is available for guidance and support.
The chief resident should have mastered the information contained in standard texts and be facile in using the literature to solve specific problems. The chief resident is expected to have passed the primary ABNS examination before beginning his or her final academic year in neurosurgery.
The chief resident should be able to perform most complex and high-risk procedures expected of a neurosurgeon independently or with the assistance of the attending surgeon. These procedures include complex spinal instrumentation, aneurysm clipping, removal of intra- and extra-axial neoplasms, temporal lobectomy and carotid endarterectomy. The chief resident should be able to manage the neurosurgical patient from the clinic or the emergency department, with an understanding of the differential diagnosis and treatment plan for even the most complex neurosurgical and neurological problems. He or she functions under the direct supervision of the neurosurgery faculty, but by the completion of the chief residency year, the PGY-7 resident should begin to feel comfortable practicing and operating independently, transitioning to either a subspecialty fellowship training environment or to independent practice.
During this final year of training, the resident has the opportunity to demonstrate the mature ethical, judgmental and clinical skills needed for independent practice of neurosurgery. The chief resident assumes a leadership role in teaching on the surgical service. The morals and values of the profession – including the expected selfless dedication to patient care – should be highly developed. Over the course of the neurosurgical residency, the chief resident will have established habits of a lifelong study and a commitment to continuous improvement of self and to the practice of neurosurgery.
Read more: A Year in Perspective from a PGY-7