Evaluation of the Department of Neurosurgery of the Seoul National University Hospital

Neurosurgical wards

The DNS currently has two regular wards (55W, 45W), of 32 beds each. Patients from all neurosurgical subspecialties are admitted on these wards. The attending neurosurgeons see their own patients, respectively the patients belonging to their own subspecialty, on their daily ward rounds.

Intensive care unit

Technically the DNS has 13 beds on the intensive care unit (ICU), which is led by the Department of Anesthesiology. However, sometimes different departments compete over available ICU beds. Besides some patients, like poly-trauma patients, occupy ICU beds over prolonged periods of time. Both may result in intermittent shortage of ICU capacity. As the DNS does not have own intermediate care beds to buffer this shortage, it may lead to cancellation or postponement of elective neurosurgical procedures.

Pediatric beds

For pediatric patients ten additional beds on regular wards and three ICU beds are available in the children hospital.

Operating rooms

The DNS uses three operating rooms (ORs) in the central OR tract on the second floor of the SNUH main building. Additionally 1.5 ORs in the children hospital are reserved for elective neurosurgical procedures. Neurosurgical subspecialties have fixed time slots for their elective cases during the week.

Outpatient clinic

The outpatient clinic is set up in collaboration with the Department of Neurology at the Neuroscience Center. Each neurosurgical subspecialty offers specific sessions for all kinds of neurosurgical disorders. A neurosurgeon regularly sees more than 50 or even 70 patients per day.

Scheduling of procedures

Quality control

Craniotomy patients routinely undergo postoperative CT control. Postoperative implant positions (pedicle screws etc.) are routinely controlled by 2D X-ray.

During the routine morning conferences, held daily at 7:30 AM, the emergency cases are reported. Together with history and clinical data, selected CT slices or radiographies of the patients are presented. Physicians are requested to attend this conference. However, some residents and fellows are not always present, and some quite regularly leave the conference before it ends.

A mortality and morbidity conference is scheduled monthly. Cases to be presented are suggested by the fellows and finally confirmed by the chairman. Attendance is generally good. Specialists from other subjects are not regularly invited.

Microbiologists, hospital pharmacist or other non-neurosurgical specialists do not routinely round on neurosurgical wards or patient records. Critical incident monitoring is not yet performed routinely.

Patients' identity is regularly checked by the anesthesiologist upon arrival in the OR. Patients do furthermore wear name tags when transported to the OR.

Prior to skin incision a surgical team-time-out is recommended, but not always performed.

Subspecialties and centers

The DNS has a high level of specialization. Faculty, fellows and residents form distinct teams, dedicated to neurosurgical subspecialties. Furthermore five independent centers provide specific complex technologies. Currently 16 neurosurgeons and two physicists form the DNS's faculty2).

Education

The education at DNS is organized strictly following the academic year. Each March the department recruits five new residents. During the following years (1 year internship, 4 years residency) they will rotate through the DNS. After completion of their term, they qualify for neurosurgical board examinations. All residents I interviewed while working at the DNS were very satisfied with the overall quality of their education. All of them were willing to continue their education after board examinations in a fellowship program at DNS or elsewhere.

New fellows, like interns and residents, start their terms in one of the DNS's subspecialties each year at the beginning of March. Both residents and fellows are formally attached to the attending faculty members of their corresponding teams, while these faculty members are responsible for their practical and theoretical education.

The DNS starts each day with a morning conference at 7:30 AM. Following presentation of emergency cases and the OR schedule, residents frequently have to prepare and report interesting cases. This makes these conferences more educative for themselves and their peers. Additionally each Saturday special lectures for residents and fellows are offered by the DNS's faculty.

Research

The staff of the DNS shows an exceptional interest in clinical research, which is most impressively documented by the high volume of publications9,10) (more than 70 annually). The application of PAs for documentation and data collection greatly contributes to the successful generation of clinical data. In Korea composing of a scientific publication is obligatory for qualification for board examinations. Residents and fellows frequently present their manuscripts in the morning conference, discussing the current state of their projects.

The DNS's brain tumor tissue bank was established in 1995. It currently includes more than 6000 specimen. The pediatrics section's brain bank, collecting brain tumor and brain specimen from epilepsy surgery, started the same year. Both offer a good basis for basic research.

Within the DNS five research laboratories are dedicated to basic research, and offer physicians (residents, fellows and faculty) the background to develop their projects and investigate their ideas.

Wards

Nurses education, training and overall competency within the DNS seems appropriate and meets international standards.

The assignment of many organizational and administrative tasks to a team of PAs seems a very effective system.

Other groups of non-medical professionals are not regularly involved in direct patient care at DNS.

German nurses are generally educated for three years, while they need an additional two years specific training if they want to qualify for the ICU or OR.

The work of our admission-manager is comparable to that of the DNS's PAs. Besides we recently employed a clinical hospital pharmacist, optimizing our medical therapy (taking medication history, checking medication in terms of correct dosage, possible interactions, etc.). This has not only improved the overall quality of the medical treatment, but also helped to reduce the residents and nurses workload1).

ICU

While the high volume of procedures the DNS performs anually9,10) impressively documents its general capacity and size, ICU capacity seems to be a bottle neck, restricting further growth. The admission of patients in very critical conditions (like poly-traumas, etc.), or complications that require long term respiration therapy, easily results in cancellation of elective procedures and/or the transfer of other emergency cases to other hospitals.

Besides, the fact that the DNS's ICU is exclusively managed by anesthesiologists has some disadvantages. Anesthesiologists are less experienced in managing specifically neurosurgical conditions, like vasospasm or elevated intracranial pressure.

The NMU has its own ICU. However this is not a nationwide standard, but varies greatly among German hospitals. Nevertheless all neurosurgical residents in Germany have to rotate on an ICU for at least 6 months. This helps anesthesiologists to better manage specifically neurosurgical disorders, while neurosurgeons can learn anesthesiological techniques and prepare themselves for emergencies.

To buffer intermittent shortages in ICU capacity the NMU has set up its own intermediate care unit, which can take of patients who require more intensive care for longer periods.

Time management in the OR

The DNS does not have separate rooms for induction and termination of anesthesia, so both has to be performed in the OR itself. This prolongs the changing times between surgical procedures, which is frequently more than 1.5 hours. Consequently it either restricts the number of procedures performed per day, or results in significant exceeding of the official maximum working hours.

At NMU we likewise lack resources for overlapping induction of anesthesia. In some German centers where it is performed routinely however, it contributes to save significant OR time.

At NMU we are continuously struggling to improve our starting- and changing times, for example by strict documentation and analysis of the times required for each step (transport of the patient to the OR, induction of anesthesia, arrival of residents/neurosurgeons, positioning, etc.).

OR technology

The DNS owns and applies up to date technology for all kind of major neurosurgical procedures, including many minimal invasive techniques. The standard application of electrophysiological monitoring (mostly SSEP and MEP) for all craniotomy patients is an outstanding feature. Frequent application helps to develop a routine and increase the overall quality of the monitoring. Image-guidance, 5-ALA fluorescence guidance and intraoperative ICG angiography are routinely used in some areas, namely neuro-oncology and open vascular neurosurgery.

At NMU we yet apply electrophysiological monitoring only in selected cases (such as surgery close to eloquent brain-areas). Concerning image-guidance and intraoperative imaging, I believe, that its role will further increase within the near future. At NMU we presently use several systems (2 Brainlab Kolibri®, a Siemens ARCADIS Orbic® 3D C-arm and a Mazor robotics Renaissance® robot) for an increasing number of indications. Meanwhile this includes pedicle screws placement5), stereotactic puncture and lysis of ICH13) and even EVD or shunt-catheter placement in selected cases8). While this is not yet international standard, a growing number of articles document the benefits, especially in combination with minimal invasive approaches7).

Outpatient clinic

DNS's faculty members see an extremely high number of patients in their outpatient clinic. This is an astonishing performance.

At NMU we generally see less than half that number of patients per day. As German law strictly demands careful information concerning alternative treatments and possible risks at this early stage of the treatment, we consider 30 min per patient as necessary.

Planning of procedures and management style

Within the DNS team-leaders are comparatively independent in their clinical decisions and, as the SNUH is a public hospital, no economic pressure interferes with their medical judgment. The position of the chairman is that of a primus inter pares (the first among equals). This assignment of responsibilities to team-leaders also applies to administrational issues, like the scheduling of procedures. The administration is thus firmly divided between subspecialties (time slots for surgery are individually assigned and managed by each team etc.). This keeps the effort at a manageable level and allows reliable long term planning (ORs are scheduled days or even weeks in advance).

In contrast to the decentralized management style applied at the DNS, and most anglo-american countries; German institutions, including NMU, are more hierarchically structured. Administrative duties and clinical responsibilities are concentrated in the hand of the director and/or his assistant. He will schedule all operations and assign faculty members, fellows and residents to their respective duties. Thus a single contact person keeps the overview of the whole department and decides on important issues.

Teams/subspecialties

The division of the DNS into distinct teams for each sub-specialty (like vascular, oncology, etc.) allows a high level of specialization, while still offering the complete spectrum of neurosurgery. The incorporation of centers (like the Gamma Knife Center, etc.) offering advanced and complex technologies into the DNS is doubtless a strong feature of the department. The DNS can thus offer multimodal treatment strategies, as for example required in large AVM's or some brain-tumors, out of a single hand. Thus patients do not have to change their contact physician during long and complex treatments, which reduces the risk of loss of time and/or information.

For endovascular interventions the excellent and close cooperation between DNS and the Department of Neuroradiology achieves the same goal.

The strict division of subspecialties also contrasts the situation at NMU. In Mainz, like in most German centers faculty members are generally expected to cope with all kind of neurosurgical disorders. This is of special importance during on-call duties, as at NMU only two faculty members are obliged to be reachable at any time. Our pediatric neurosurgery section presents the only exception from this rule. It is largely independent and its background on-call service is provided by its own faculty.

At NMU most centers providing specialized equipment and techniques are not integrated into the Department of Neurosurgery. Endovascular treatment is performed by the Department of Neuroradiology and stereotactic radiation therapy is lies in the hands of our radio-oncologists.

Quality management

The DNS applies several modern methods to ensure its high quality standards. Mortality and Morbidity conference with open discussions on complicated cases is scheduled each month. Some teams (endovascular) even routinely meet with specialist from other hospitals to discuss important issues, including complications.

Name tags are issued to the patients scheduled for surgery and team-time-out is recommended prior to skin incision in all surgical procedures. It is however important, to regularly remind the employees of these recommendations. This does also apply for measures ensuring personnel's personal safety, such as using protective gloves when dealing with potentially contaminated materials, or to avoid recapping of sharp instruments after use4).

The DNS performs standardized monitoring of postoperative results by clinical examination and imaging studies. Craniotomy patients in the DNS routinely undergo CT imaging, while spinal implants are checked by plain X-ray.

Like the DNS, NMU has introduced name tags and team-time-out in the OR (which might also not be performed very strictly I fear, especially while I myself am abroad). Complications are regularly discussed among faculty and, if considered helpful, neuroradiologists or other specialists. The introduction of critical incident monitoring, which is yet more frequently applied by anesthesiologist11), constituted a further step6). Regular meetings with specialists from other hospitals are not yet standard at NMU.

In Mainz, like at DNS, every craniotomy patient is scheduled for control-CT 4 hours after surgery. At NMU we also perform CT-scans of all spinal implants, as we consider it superior to plain 2D X-ray in ruling out any misplaced implants.

Education

The education at DNS, like the general organization and management style, follows the anglo-american system, which has been adopted by most countries worldwide. In interviews DNS's residents reported several advantages of this system. The strict adherence to academic years and firm attachment to individual teams and their attending faculty, clearly defines the reciprocal responsibilities of residents and faculty. Faculty members furthermore receive a good feedback of their trainee's individual abilities and deficits. In Korea the residents are not performing surgeries themselves. Primarily they take care of the patients outside the OR and develop their surgical skills while assisting fellows and faculty as first or second assistant. Morning conferences and special educative days are useful to help residents to cover the theoretical background of our science.

After finishing their residency, the candidates take board examinations and graduate as neurosurgeons. Korean neurosurgical board examinations reach high levels in international rankings3).

In interviews DNS residents reported, that after taking board examination, in average about 80% of Korean neurosurgeons will continue their formal education by joining a fellowship program. However, among those working at the DNS everyone seems willing to augment his experience by one or several fellowships.

Fellows, like residents, do not frequently perform surgical procedures independently. They do however regularly work as first assistant, performing approaches and closing wounds, etc. for their attending faculty members.

In Germany academic years are of no importance after graduating from medical school. Residents and fellows can start in new positions at any time of the year. This makes the system on one hand more flexible. Residents can choose to work halftime or even pause their education for a certain period, which especially benefits young parents. While on the other hand controlling each resident's individual progress is more difficult. Before qualifying for board examinations German residents have however, to complete a strictly defined number of procedures by themselves (100 spinal operations, 50 craniotomies for intra-cerebral lesions, 50 craniotomies for traumatic head injuries, etc.)12). To achieve this, they largely depend on their superiors, who will have to take the role of assistant during these procedures, while still bearing the full responsibility. Thus depending on the conditions and their personal initiative it can take residents much longer than the minimally required 6 years to finally graduate as neurosurgeons. At NMU it is our policy to encourage young colleagues to take their board examinations as soon as possible.

During morning meetings at NMU the residents routinely present in detail the operative technique of procedures in which they will assist, or which they will be allowed to perform with assistance of a faculty member. This makes morning conferences even more educative and interesting for them. Regular educational sessions are held on Tuesdays prior to the morning conferences and intermittently on other dates.

Following board examination, German neurosurgeons are expected to cope with most neurosurgical emergencies, as well as to manage standard cerebral and spinal disorders by themselves. This comprises basically those procedures which are obligatory for qualification for board examination. Young graduated neurosurgeons will get assistance from their superiors only on demand or in more complex cases. However, such more complex procedures require additional experience, which young German neurosurgeons gather during the following years, while working at different institutions. A formalized fellowship-system, where young neurosurgeons apply for certain subspecialties, is not common.

Research

Using the PAs for collection of clinical data is an excellent way of getting high quality clinical data. Consequently the clinical research at DNS is very good. The high number of tumor specimen collected within the last two decades, proves the DNS's employees high motivation and dedication to science. The Department itself provides several facilities for basic research.

Furthermore the frequent presentation of manuscripts by residents and fellows documents the efficient recruitment and motivation of these young doctors for scientific issues. Besides, during several national scientific meetings I could attend while in being in Korea, an astonishing number of the DNS's alumni presented recent data. This shows that the DNS's successfully inspired its graduates to continue research after leaving the department.

At NMU we have no PAs who help on data collection and physicians unfortunately often lack the time to do it themselves. Tumor specimen (fresh, fixed or in culture) are however, like at DNS, collected during each resection. The NMU has its own neuro-oncology lab and a laboratory for microscopic and minimal invasive techniques, including animal research facilities. Presently we are working on establishing a laboratory for image-guided and computer assisted neurosurgery as well.

In order to graduate for German board examinations, applicants do not need any scientific publication. However, German physicians are required to compose a scientific thesis in order to get the degree of a medical doctor (Dr. med.). Before completion of this thesis they are "physicians" but not "doctors".