Educating Residents in Spine Surgery: Discrepancies in Entrustable Professional Activities Across Neurosurgery and Orthopedic Surgery

Introduction: Patients having spine surgery expect the highest levels of competency from their surgeons, regardless if they are neurosurgeons or orthopedic surgeons. However, the expected standard of competent performance in the setting of competency-based education and Entrustable Professional Activities (EPAs) has not been defined. Parameters of assessment and the standard expected of graduating residents need to be defined.

Methods: Nationwide Canadian survey neurosurgery and orthopedic surgery Faculty.

Results: The recommended number of assessments for spinal procedures was 5 and there was no significant difference between neurosurgery and orthopedic Faculty. The recommended number of assessors based on total responses was 2. Neurosurgery Faculty recommended higher number of assessors (n = 3) than orthopedic surgery Faculty (n = 2) for posterior spinal decompression EPA (PSD) (p = 0.01) and spinal instrumentation EPA (SI) (p = 0.04).
Based on total responses, 83% felt that PSD was appropriate to the general practice, 86.8% considered it not too broad, and 62.3% expected entrustment level E, being able to adapt performance/decisions in response to contextual complexities of the activity and perform activity independently and safely, as a graduation target. The proportions of these consideration were lower in SI at 58.5%, 71.7% and 56.6%, respectively.
Neurosurgery Faculty were more likely to consider these EPAs appropriate for general practice than orthopedic surgery Faculty for PSD (94.7% vs 53.3%, p = 0.0003) and SI (68.4% vs 33.3%, p = 0.02) and had higher expectation of level E as a graduation target for PSD (76.3% vs 26.7%, p = 0.001) and SI (65.8% vs 33.3%, p = 0.03) than orthopedic surgery Faculty.

Conclusion : Differences exist in parameters of assessment and expected standard competence performance of spine procedures among specialties and certifying bodies. This study has important implications for the design of residency and fellowship education in spinal surgery in North America and internationally.