The Royal College of Physicians and Surgeons of Canada (RCPSC) is the governing body responsible for the accreditation of residency training programs in Canada. Although the core principles of neurosurgical residency training in Canada are similar to the United States, the pathway to RCPSC certification has distinct differences from the American Board of Neurological Surgeons (ABNS). Furthermore, although the formal initiation of the competency-by-design (CBD) curriculum for neurosurgical residency programs across Canada aligns certain aspects of the Canadian training program with its American counterpart, notable differences remain. Considering the ABNS ineligibility of Canadian neurosurgery graduates, a comprehensive comparison of the current state of the Canadian training program is warranted.
Residency Training
Neurosurgery residency training in Canada is six years in total, comprised of five years of clinical service and one year of research or clinical electives – often during the 4th year of residency. At some centers, the trainee has the option of extending this one-year period for post-graduate research training – often in the form of a PhD or MSc, thus extending the total residency time beyond six years. Although the American curriculum is overall longer (seven years), the clinical and research/elective time is more standard at five and two years, respectively.
In-training Evaluations
Prior to the implementation of the CBD curriculum, Canadian neurosurgery residents were evaluated at the conclusion of each rotation by In-Training Evaluation Reports (ITERs). A final ITER (FITER) is also generated by the program director at the conclusion of residency. The CBD curriculum seeks to formalize and standardize these evaluations.
For all surgical subspecialties, a parallel surgical foundations curriculum has also been developed. Resident trainees are eligible to take the Surgical Foundations exam 12-15 months into their training. While a passing score on this exam is not a requirement for progressing through training, it is a necessity for eligibility for the final subspecialty examination and certification. While American neurosurgery residents complete a neurosurgery-specific written examination during residency, Canadian trainees only complete the Surgical Foundations written exam during residency.
Pathway to Board Certification – ABNS vs. FRCSC
Unlike the ABNS, the RCPSC Board certification – also known as the Fellowship of the Royal College of Surgeons of Canada, FRCSC – of Canadian neurosurgical trainees takes place at the conclusion of the final year of the residency program. This examination is comprised of a two-day written component, followed by a one-day oral component. FRCSC certification is a pre-requisite for an independent neurosurgical practice in Canada. In contrast, ABNS certification in the United States is a voluntary process and not required for independent practice. The written examination can be taken during residency and a passing score is required for eligibility for the oral examination, should one choose to become board-certified. The American neurosurgical graduate must keep track of a minimum of 125 cases for which they have had primary responsibility; the content of the ABNS oral examination is based on these logged cases. Based on RCPSC statistics (2015-2017), the passing rate for the neurosurgical FRCSC examination is 94.7% (http://www.royalcollege.ca/rcsite/credentials-exams/writing-exams/results/exam-pass-rate-percentages-e), while the ABNS examination passing rate is 81% (https://www.abns.org/frequently-asked-questions/). These statistics are likely affected by the smaller sample size of trainees in Canada. The standardized nature of the FRCSC exam, however, likely has a positive impact on the higher pass rate for Canadian graduates. For additional details regarding the ABNS certification process, the reader is encouraged to visit this article by Dr. Jeremiah Johnson.
Transition to CBD Curriculum in Canada
The RCPSC has been working toward the full-scale launch of the CBD curriculum across all training programs. The goals of this initiative are to address evolving patient and societal needs, ensure an evolving competency across the education continuum from residency to retirement while striving for excellence and enabling physicians to recognize areas in need of improvement while shifting away from the culture of “failure to fail”. This curriculum was launched in 2017 with select programs, applied to the surgical foundations curriculum in 2018 and is now fully launched across neurosurgical programs as of July 1, 2019.
Similar to the American Council of Graduate Medical Education (ACGME), the CBD is also comprised of milestones. In both applications, these milestones provide a framework for evaluation based on direct observation. However, within the Canadian CBD context, an additional layer constituted by Entrustable Professional Activities (EPAs) has also been devised, for which milestones are the building blocks. An EPA is defined as an essential task within a discipline that an individual trainee can be trusted to perform independently. Thus, while milestones are seen as an individual’s abilities, EPAs are tasks that must be successfully accomplished. The totality of specific EPAs define each sub-specialty.
Attainment of each EPA is contingent on the successful completion of a predetermined number of assessments for each stage of training; the number of successful assessments varies across EPAs. Upon the completion of five years of clinical training, a neurosurgery resident in Canada is expected to have completed 61 neurosurgical EPAs along with 20 EPAs from surgical foundations. This amounts to 220 successful assessments over this period. This is in addition to the ITERs that are completed at the end of each rotation.
Evaluating the Current CBD Framework
The current CBD framework formalizes trainee assessments in an outcome-based manner (i.e. case-based observation of a consultation on a complex posterior fossa brain tumor or endoscopic resection of a pituitary adenoma). This increases transparency and is practical. Furthermore, training stage-specific assessments empower the resident trainee to identify areas in need of improvement in order to further focus in his/her training. However, as with any newly-implemented system, ongoing evaluation and modification of this framework is necessary.
As noted above, one of the goals of the CBD curriculum is to shift toward failure being seen as an opportunity to improve. Thus, with a conservative estimate of requiring two attempts to successfully pass each assessment, a total of 440 assessments are needed for each resident over five clinical years. For faculty, this amounts to seven assessments per resident, per month. This is onerous with no incentives for those participating. Furthermore, in light of the focus on duty hours restrictions, this amount of additional non-clinical work can have an impact on the resident training experience as well. Recognizing the need for ongoing evaluations of the Canadian CBD framework, each national committee is scheduled to meet once every six months to gather feedback and implement necessary changes.
Future Directions
The upcoming changes to the Canadian neurosurgery curriculum promise to bring a more formal structure and standardization. This also potentially enables more objective evaluation of graduating trainees across board certification governing bodies (e.g. the RCPSC and the ABNS). This is critical, as currently Canadian graduates who are board-certified in Canada (FRCSC) are not eligible to apply for ABNS certification. Despite this restriction, many Canadian graduates are employed at top-rated academic institutions in America, even though they will not be board-certified in the foreseeable future. While the rationale for this restriction is multi-factorial, the increased structure of the Canadian training program may offer more objective data to prospective employers and neurosurgery chairs considering hiring Canadian graduates. Regardless, the evolution of the CBD curriculum, along with its impact on neurosurgical training and beyond, is exciting.
Seyed Alireza Mansouri, MD
Geisinger