Neurosurgery Curriculum

3 Programme of Learning

This section covers the expected learning outcomes, learning methods, breadth of experience and levels of performance at critical progression points in the training programme and the levels of performance expected of those completing training.

The practice of Neurosurgery requires generic and Neurosurgery knowledge, clinical and technical skills and behaviours to manage patients presenting with a wide range of central and peripheral nervous system disorders. It involves development of competence in diagnostic reasoning, managing uncertainty, dealing with co-morbidities, and recognising when another opinion or care is required (as well as developing technical skills in the areas and to the level described in the syllabus as shown in appendix 2). The main areas for learning are described by the CiPs, which are the high-level learning outcomes for training in Neurosurgery described below and shown in full in appendix 1.

Training is designed to produce a person capable of safely and effectively performing the role of a first day consultant surgeon. The role of a consultant curgeon can be thought of as a sum of all the various tasks that need to be performed through a working week. These tasks are the high-level outcomes of the curriculum and grouping these together describes the role of a consultant surgeon. To perform a high-level clinical task as a consultant surgeon requires trainees to be able to integrate areas of learning from all parts of the syllabus, including knowledge, clinical skills, professional skills and technical skills. In addition, a consultant surgeon will need to have acquired the generic skills, behaviours and values shared by all doctors in order to perform this task safely and well. A capability is a set of skills that can be developed through training from novice to expert and, therefore, these high-level clinical outcomes are known as Capabilities in Practice. They are common across all surgical specialties and are delivered within the context of the GPCs and the Neurosurgery syllabus.

The are five CiPs which are shared between all surgical specialties:

  1. Manages an out-patient clinic
  2. Manages the unselected emergency take
  3. Manages ward rounds and the on-going care of in-patients
  4. Manages an operating list
  5. Manages multi-disciplinary working

The generic knowledge, skills, behaviours and values shared by all doctors are described in the GPC framework. The GPCs are essential components and have equal weight to the CiPs in the training and assessment of clinical capabilities and responsibilities in the training programme.

The GPC framework has nine domains:

Domain 1: Professional values and behaviours

Domain 2: Professional skills

Practical skills
Communication and interpersonal skills
Dealing with complexity and uncertainty
Clinical skills

Domain 3: Professional knowledge

Professional requirements
National legislative requirements
The health service and healthcare system in the four countries#

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and team working

Domain 6: Capabilities in patient safety and quality improvement

Patient safety
Quality improvement

Domain 7: Capabilities in safeguarding vulnerable groups

Domain 8: Capabilities in education and training

Domain 9: Capabilities in research and scholarship

Simply put, the CiPs and GPCs are the constituent parts of the role of a consultant neurosurgeon. Each part is as important as the next and doctors are required to be capable in all parts of the role in order to be able to practice independently. In order to complete training and be recommended to the GMC for certification and entry to the specialist register, the doctor must demonstrate that they are capable of unsupervised practice in all CiPs and GPCs. For example, managing an unselected emergency take (CiP 2) requires the integration of knowledge, clinical and diagnostic skills, and technical skills described in the syllabus as well as communication and interpersonal skills, time management skills and many other generic skills described in the GPCs in order to be delivered safely, professionally and effectively. This will be assessed using the Multiple Consultant Report (MCR) as described below. The full content of the five CiPs can be found in appendix 1.

The Interrelationship between GPCs, CiPs and MCRS

Figure 2 - The interrelationship of the GPCs, the syllabus, the CiPs and their descriptors to the role of a consultant surgeon. Items from the syllabus are combined with items taken from the GPC Framework to form the small tasks that are the CiP descriptors. When the small tasks of the descriptors are integrated they comprise the constituent parts of the role of a consultant surgeon (the CiPs). When the CiPs are taken together, along with the GPCs, the role of a consultant surgeon (the overall outcome of the curriculum), is described. Each of these CiPs will be developed through training until the level required of a day-one consultant is reached. Assessment in an outcomes-based curriculum through the MCR examines the trainee from the perspective of the outcome (a consultant surgeon), and compares performance in each CiP and in the GPCs to that level. If the outcome level is not reached, then targeted feedback and development plans can be made with reference to the CiP descriptors and beyond to the syllabus items and GPC items that combine to form the descriptors.

The five CiPs taken together describe the role of a consultant neurosurgeon but more detail is needed to help trainees develop that capability through training via detailed feedback and focused development goals.

We can break the CiPs down into smaller tasks. Each of these smaller tasks is a CiP descriptor. For example, managing the unselected emergency take (CiP 2), includes the need to promptly assess acutely unwell and deteriorating patients and deliver resuscitative treatment and initial management and ensure sepsis is recognised and treated in compliance with protocol (see appendix 1). If a trainee has not yet reached the level required of a new consultant in a CiP then the descriptors can be used to describe in standard language what needs to be improved through learning and training to allow the trainee to get closer towards the outcome of training. By describing the component parts of a CiP, descriptors also aid decisions on assessment of the level of supervision required by a trainee at the time of that assessment, providing prompts for feedback of performance by allowing identification of areas of excellence or specific detail on areas for development, including in behavioural and professional domains. Descriptors can, therefore, help trainees identify where to focus their efforts to become competent and safe independent practitioners. More detail about assessment and feedback is given in section 5, Programme of Assessment.

Each CiP is judged against a scale that describes the level of supervision required to perform the CiP to the standard of certification. The level of supervision changes in line with the trainee’s progression, consistent with safe and effective care for the patient. Typically, there should be a gradual reduction in the level of supervision required and an increase in the complexity of cases managed until the level of competence for independent practice is acquired. In the early years, therefore, it would be normal for trainees to achieve a lower supervision level and progress as experience is gained.

The supervision levels are:

Level I: Able to observe only

Level II: Able and trusted to act with direct supervision:

a) Supervisor present throughout
b) Supervisor present for part

Level III: Able and trusted to act with indirect supervision

Level IV: Able and trusted to act at the level expected of a day-one consultant

Level V: Able and trusted to act at a level beyond that expected of a day-one consultant

At the end of phase 1 there is a critical progression point for phase 2 entry, assessed at the ARCP, where trainees will demonstrate competencies in knowledge, clinical skills and professional behaviours commensurate with the CiPs and defined syllabus. The MRCS examination will be achieved by this point in the training programme.

An indicative point is placed at the end of phase 2 which describes the level of competence that the majority of trainees will have developed within this indicative five years. This point allows penultimate year identification of trainees developing more slowly than the indicative trajectory and for appropriate support to be given through targeted or extended training. The ISB examination in Neurosurgery will normally be achieved by this point in the training programme.

At the end of phase 3 there is a critical progression point for entry into the specialty register. Trainees are required to reach level IV in all the CiPs and in addition to acquiring all the skills described in the GPC framework (and the other certification requirements shown in section 5.4), and will be able to demonstrate the surgical skills of a day-one consultant. Supervision levels are shown for the end of phases 1, 2 and 3 in table 1.

Excellence will be recognised by:

a) Exceeding the supervision level expected for the end of phase 1, 2 or 3
b) Achievement of a supervision level at an earlier phase than would normally be expected
c) Achievement of level V in any of the CiPs
d) Recognition of particularly good performance in any of the descriptors within a CiP.

Table 1: Supervision levels to be achieved by the end of each phase of training
Capabilities in Practice Supervision Level
(end of phase 1)		 Indicative Supervision Level (end of phase 2) Supervision Level (end of phase 3 and certification)
Manages an out-patient clinic Level IIa Level III Level IV
Manages the unselected emergency take Level IIa Level III Level IV
Manages ward rounds and the on-going care of in-patients Level IIb Level III Level IV
Manages the operating list Level I Level III Level IV
Manages multi-disciplinary working Level I Level III Level IV

The curriculum requires trainees to accrue a rich experience that promotes deep learning of knowledge, clinical skills, technical skills, professional behaviour, leadership and all other generic professional skills that are considered necessary to ensure patient safety throughout the training process and specifically at the end of training. The scope of practice of a day-one consultant in Neurosurgery is described in the syllabus. In addition, there are certain skills and conditions within the syllabus that are of such central and fundamental importance to the safe practice of Neurosurgery that they are highlighted as critical conditions and index procedures.

3.5.1 The syllabus

The syllabus, shown in appendix 2, provides a detailed description of the Neurosurgery-specific knowledge, clinical and technical skills required for each phase of training and for certification in Neurosurgery. The syllabus is organised by topics which are the presenting conditions of patients in relation to Neurosurgery. Trainees are expected to have exposure to all topics in phase 2 of training.

3.5.2 Critical conditions

From the syllabus, a list of critical conditions has been identified which are of significant importance for patient safety and demonstration of a safe breadth of practice. Across surgery, these are defined as any condition where a misdiagnosis could be associated with devastating consequences for life or limb. These critical conditions are assessed individually by means of the Case Based Discussion (CBD) and Clinical Evaluation Exercise (CEX), which both include an assessment of clinical judgment and decision-making. An indicative three or more CBDs or CEXs must be achieved at the specified level to progress between phases of training. Phase 1 CBD or CEX assessments may be performed by phase 2 or 3 trainees or by a consultant. Phase 2 and 3 CBD or CEX assessments must be performed by a consultant. They provide formative feedback to the trainee and feed into the summative assessment of the Assigned Educational Supervisor (AES) via the AES report for the ARCP. A list of critical conditions for Neurosurgery is given in appendix 3 and is included in the certification requirements in this curriculum. These critical conditions were decided following wide consultation with clinicians and trainers in Neurosurgery.

3.5.3 Index procedures

In addition to the critical conditions, a list of index procedures has been identified. Index procedures are common but important operations central to the practice of Neurosurgery, competence in which is essential to the delivery of safe patient care. Taken together they form a representative sample of the breadth of operative procedures in the specialty. Learning in the index procedures is indicative of learning in the broad range of technical procedures in the syllabus and surgical logbook and are, therefore of significant importance for patient safety and demonstration of a safe breadth of practice. Each of these index procedures are assessed individually by means of the Procedure Based Assessment (PBA) which provides formative feedback to the trainee and feeds into the summative AES report for the ARCP. An indicative three or more PBAs must be achieved at the specified level to progress between phases of training.  The paediatric surgery index cases require only one PBA at the specified level.  Phase 1 PBAs may be performed by phase 2 or 3 trainees or by a consultant. Phase 2 and 3 PBAs must be performed by a consultant. A list of index procedures and the indicative numbers expected for neurosurgical practice is included in the certification requirements (section 5.4) and appendix 4. The indicative numbers of cases before certification are necessary as trainees would not normally be expected to have achieved sufficient experience to be able to manage the range of pathology they encounter unless these numbers were met. It is recognised that competence could be achieved with fewer cases, if supported by evidence from other assessments. Meeting the numbers does not, in itself, imply competence. These index procedures and indicative numbers were decided following wide consultation with clinicians and trainers in the specialty.

3.5.4 Special Interest training

Special Interest training is required by employers and high fidelity transferable operative skills can be obtained in a variety of special interest areas pre-certification. In the table below, for each special interest we have described the area of practice that would be expected to be learned by all trainees and the areas that would be expected to be mastered by only those developing this area as a special interest. All aspects of training in trauma, infection, acute hydrocephalus, intracranial haemorrhage and acute tumour cases are required by all trainees at completion of phase 3.

Table 2: Skills that need to be learned during training. Also defined are skills that are not required by a day-one consultant in Neurosurgery with that special interest, which may be developed by professional development in post or placement in a fellowship following certification.
Neurosurgery All trainees by certification Transferable microsurgical skills acquired during phase 3 Post certification
Hydrocephalus All aspects including Endoscopic third ventriculostomy Advanced endoscopic techniques  
Neuro-Oncology Biopsy and resection of intracranial tumours and extramedullary spinal tumours Resection of pineal, thalamic, insular and brainstem lesions. Resection of intramedullary spinal cord tumours. Stereotactic Radiosurgery
Skull Base and Pituitary Surgery Management of majority of cases, including acquisition of transferrable microsurgical skills Resection of pituitary tumours. Resection of difficult skull base tumours (e.g. vestibular schwannoma).

 

 
Neurovascular Management of all patients with acute presentations of neurovascular conditions including subarachnoid haemorrhage, intraparenchymal haemorrhage, intraventricular haemorrhage, massive cerebral or cerebellar infarction Clipping of intracranial aneurysms, resection of AVMs Interventional radiology skills. Bypass surgery
Pain, Epilepsy and Functional Management of complications of procedures including infected or malfunctioning implants Stereotactic electrode placement or lesioning. Insertion of neuromodulation devices and pharmacological pump delivery systems. Surgical procedures used in the treatment of epilepsy.  
Spine Management of patients with acute and elective presentations of cervical and lumbar spinal degenerative disease requiring operative intervention (e.g. disc prolapse causing radiculopathy, cauda equina syndrome or myelopathy). Emergency and surgical management of infection, oncological disease and trauma including anterior and posterior subaxial cervical spine fusion. Thoracolumbar spine stabilisation techniques that may be used in the management of degenerative deformity, metastatic disease and trauma.
Surgical fusion techniques at the Atlantoaxial junction.
Advanced spinal microsurgical procedures such as resection of intramedullary spinal cord tumours and vascular malformations.		 Advanced skills including deformity correction
Paediatrics Emergency management of children with raised intracranial pressure, including operative management where delay due to transfer time will cause harm to the patient. Possible causes include traumatic brain swelling, intracranial haemorrhage (trauma or spontaneous), brain tumours, hydrocephalus. Elective management of hydrocephalus. Management of planned surgery in all other subspeciality areas. Advanced Paediatric Neurosurgery skills including syndromic craniofacial surgery
Peripheral Nerve Surgery Ability to diagnose and refer or manage all surgical and medical peripheral nerve pathologies   Surgery for peripheral nerve tumours, brachial plexus injuries and cervical ribs

The certification requirements, shown in section 5.4, summarise the experience trainees need to achieve by the end of the training programme.