NEUROSURGICAL

  FOCUS Neurosurg Focus 49 (1):E12, 2020

Neurosurgical Forum
LETTERS TO THE EDITOR

Surgical logbooks in neurosurgery: a
simple way to enhance training
TO THE EDITOR: I have read the article by Deora
et al.1 on neurosurgery training in lower-middle-income
countries (Deora H, Garg K, Tripathi M, et al. Residency
perception survey among neurosurgery residents in low-
er-middle-income countries: grassroots evaluation of neu-
rosurgery education. Neurosurg Focus. 2020;48[3]:E11). I
want to congratulate the authors on their effort to gather
trainee feedback internationally. The authors have ana-
lyzed teaching patterns, subspecialty exposure, examina-
tion patterns, work hours, surgical training, and medium
of learning in their article.
The authors noted that despite working long hours, res-
idents were dissatisfied with their operative training and
hands-on exposure. As a surgical resident, one of the most
important aspects of training is the surgical skills they de-
velop through the period. The authors in their study state
that more than 60% of the respondents felt the need for
better hands-on exposure during the training. This is a
concern with regard to the competence of graduating resi-
dents safely performing independent procedures.
In the United Kingdom (UK), the accreditation board
proposes the candidate should have completed 1200 cases
with 50 index cases across specialties.2 Following suc-
cessful completion of an examination, registration to the
specialist register should satisfy criteria in clinical and op-
erative experience, competence, research, quality improve-
ment, medical education, training, management, leader-
ship, and participation in conferences.3 This sets high
standards in surgical competency and expertise, improving
patient safety and outcome.
A surgical logbook that is maintained and validated by
trainers will enable us to ensure a higher quality of train-

FIG. 1. Comprehensive report of procedures. EVD = external ventricular drain; VP = ventriculoperitoneal; AVM = arteriovenous
malformation; ICH = intracerebral hemorrhage; A = assisted; S-TS = supervised-trainer scrubbed; S-TU = supervised-trainer
unscrubbed but in theatre; P = performed; T = training a trainee; S-S = supervised (scrubbed); S-U = supervised (in theatre); S-H
= supervised (in hospital); UC = under my care; O = observed; U = undefined; PCC = performed with consultant colleague; PPT =
performed in part by trainee; PAT = performed: assisted by trainee.

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Neurosurgical forum
ing in surgical specialties, especially neurosurgery. Moni-
toring of the type of case is considered one way to ensure
a general level of experience and competence before be-
ginning postresidency practice. It provides an objective
record of residents and medical schools, and evidence that
the level of operative participation is significant in techni-
cal skills development.4 The E-Logbook (www.elogbook.
org) is an initiative by the Royal Colleges in the UK to
record and monitor the training of its residents and build
a surgical portfolio helping them through appraisals, re-
validations, and recertifications. It is a free resource that
can be used by practicing surgeons across the globe. Each
procedure is tagged with the level of involvement of the
trainee, and also breaks down each step of the surgery to
record participation in operative stages. A comprehen-
sive report at the end of residency can help evaluate one’s
strengths and weakness and guide further improvement
(Fig. 1).
The need of the hour in training centers is to inculcate
the western concept of “surgical minimums” or a com-
pulsory operative log for each level of resident training,
enabling a finishing surgical resident to be “competent” at
a minimum and preferably “proficient” in essential proce-
dures.5 This would ensure that each trainee has performed
a basic requisite of essential procedures both under super-
vision and with reasonable independence.6
To conclude, as rightly pointed out by the authors, post-
graduate surgical training in these countries, although
grueling and tiresome, needs quantitative and qualitative
enhancement. Implementing a surgical logbook is a good
step to begin with. It will help us provide the society with
competent neurosurgeons trained to perform basic proce-
dures with reasonable confidence, expertise, and minimal
complications in an independent setting.
Ajay Hegde, MCh, FRCSEd
Institute of Neurological Sciences, Glasgow, United Kingdom
References
  1. Deora H, Garg K, Tripathi M, et al. Residency perception
survey among neurosurgery residents in lower-middle-
income countries: grassroots evaluation of neurosurgery
education. Neurosurg Focus. 2020;48(3):E11.
  2. Intercollegiate Surgical Curriculum Programme. The
Intercollegiate Surgical Curriculum. Educating the surgeons
of the future. Accessed May 20, 2020. https://www.iscp.
ac.uk/static/public/syllabus/syllabus_ns_2015.pdf
  3. Joint Committee on Surgical Training. Certification
Guidelines and Checklists. Accessed May 20, 2020. https://
www.jcst.org/-/media/files/jcst/certification-guidelines-and-
checklists/certification-guidelines--ns-2017-final.pdf
  4. Harrington CM, Kavanagh DO, Ryan D, et al. Objective
scoring of an electronic surgical logbook: Analysis of impact
and observations within a surgical training body. Am J Surg.
2017;214(5):962–968.
  5. Bell RH Jr. Why Johnny cannot operate. Surgery.
2009;146(4):533–542.
  6. Vilanilam GC, Easwer HV, Menon G, Vikram K. “Magister
neurochirurgiae”: A 3-year ‘crash course’ or a 5-year ‘punc-
tilious pedagogy’? Neurol India. 2017;65(2):434–437.
Disclosures
The author reports no conflict of interest.
2 Neurosurg Focus  Volume 49 • July 2020
Correspondence
Ajay Hegde: dr.ajayhegde@gmail.com.
INCLUDE WHEN CITING 
DOI: 10.3171/2020.3.FOCUS20207.
Response
We thank Dr. Hegde for the interest he has shown in our
article. He has pointed out that in our survey, most of the
respondents expressed a desire for more hands-on train-
ing despite evidently working long hours. He has rightly
suggested that maintaining a logbook detailing the types
of procedures performed and the level of involvement of
the trainee in each procedure would be helpful in objec-
tively evaluating the training experience, so that a certain
minimum standard in technical ability of the trainees can
be ensured at the conclusion of the residency. This is the
practice that is being followed in the UK and has stood the
test of time.
However, it is important to acknowledge that the work-
ing conditions in developed countries like the UK are sub-
stantially different from those that our survey addressed.
It is easier to ensure uniformity of training experience in
a small nation with a common language and plentiful re-
sources, where certification to residency programs will
only be granted once they satisfy certain minimum statu-
tory requirements. Similar standards are also mandated
by law for residency programs in low-middle-income
countries (LMICs), yet the implementation is not as rigor-
ous, because the interests of providing a clinical service
often override the concerns of a training program.1 Most
of the residents in LMICs must also assume administra-
tive roles and arrange logistics too, due to lack of person-
nel dedicated to these indispensable tasks.2,3 Additionally,
neurotrauma emergencies claim a substantial chunk of the
resident’s time in LMICs due to lack of the requisite num-
ber of specialized trauma centers.
However, with economic progress and increasing avail-
ability of resources, residency training is getting its due
attention, indicated by the growing number of cadaveric
workshops and courses organized solely for the residents.
The importance of these supplemental teaching activities
in crucially enriching the training experience was ac-
knowledged by the respondents in our survey. Regarding
surgical logbooks and detailing documentation of training
experience from a trainee’s perspective, uniformity is still
a long way away.
Fortunately, at least in India, consensus is slowly build-
ing towards establishment of a national accreditation
board that would replace an individual institution’s exam-
ination pattern. It would be an important step toward en-
suring uniformity in training and minimum competency.
We are hopeful that with the increasing penetration of
high-speed internet, the near future would see enthusias-
tic adoption of e-logbooks, which will allow comparative
evaluation of training programs.
Harsh Deora, MCh, DNB
National Institute of Mental Health and Neurosciences, Bangalore,
Karnataka, India
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 Neurosurgical forum

Kanwaljeet Garg, MCh

All India Institute of Medical Sciences, New Delhi, India
Manjul Tripathi, MCh
Postgraduate Institute of Medical Education and Research,
Chandigarh, India
Shashwat Mishra, MCh
All India Institute of Medical Sciences, New Delhi, India
Bipin Chaurasia, MS
Bangladesh State Medical University, Dhaka, Bangladesh

References
  1. Mishra S. The “reverse” evaluation! Neurol India.
2017;65(2):433.
  2. Garg K, Deora H, Mishra S, et al. How is neurosurgical
residency in India? Results of an anonymized national survey
of residents. Neurology India. 2019;67(3):777–782.
  3. Yagnick NS, Deora H, Tripathi M, et al. Letter to the Editor.
Doing more with less and the barebones neurosurgical setup.
J Neurosurg. 131(3):987–988, 2019.

INCLUDE WHEN CITING 

DOI: 10.3171/2020.3.FOCUS20218.
©AANS 2020, except where prohibited by US copyright law

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