Chapter 12: Complex Training for Neurosurgeons
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Description
Dr. Sawaya first sketches the usual educational requirements for a neurosurgical specialization: seven years after medical school, including a year of research, then a period of training for sub specialization. He then explains the one- to two-year Tumor Fellowship begun at MD Anderson in 1990/’91 with one fellow (there are now four). Very few institutions have training in tumor surgery, and MD Anderson’s program is very specialized. Dr. Sawaya describes what it offers to fellows: a large volume of patients, opportunities for constant use of technology; frequent awake craniotomies. Dr. Sawaya notes that MD Anderson fellows are very desirable hires after their training.
Dr. Sawaya then talk about his role as head of the joint program in neurosurgery established in 2005 between MD Anderson and the Baylor College of Medicine. He tells the story of why Baylor was interested in setting up such a program and how he was approached to serve as Chair. (He tells an anecdote about going to John Mendelsohn after the five-year review of the joint program: Dr. Mendelsohn asked him at that meeting if he wanted to submit his name as a candidate for MD Anderson’s president, as Dr. Mendelsohn was leaving.) His contract to serve as Chair was renewed for another five years, and Dr. Sawaya notes that the program hired thirteen faculty in the first three years.
Next Dr. Sawaya explains what neurosurgery residents bring to the Tumor Program and to MD Anderson. He then explains the computer matching process that links residents with institutions whose programs they might enter. He then describes the process of selecting residents and how a residency unfolds, noting that fellows have a different mindset than residents. He talks briefly about employment for neurosurgeons, which is a very small specialty. He briefly compares MD Anderson with Memorial Sloan-Kettering. Dr. Sawaya notes how the diversity of specializations and functions housed in the Department of Neurosurgical Oncology has enabled each to grow stronger.
Identifier
SawayaR_02_20130625_C12
Publication Date
6-25-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The EducatorThe Administrator; The Educator; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Education; Understanding the Institution; Institutional Mission and Values
Transcript
Tacey Ann Rosolowski, PhD:
That’s great. I wondered if we could talk a little bit about training and education in neurosurgery. It’s come up in the conversation a number of times how important education is. So tell me about the training programs and what’s required to go through and learn to use all of this equipment.
Raymond Sawaya, MD:
In neurosurgery or in tumor—?
Tacey Ann Rosolowski, PhD:
How would you like to interpret that?
Raymond Sawaya, MD:
We have two—it’s a two-phase training. I happen to be chairman at Baylor, so we have twenty-one residents in neurosurgery there. So I’m very, very involved in the training of neurosurgeons in general. And that is a seven-year training.
Tacey Ann Rosolowski, PhD:
The program at Baylor?
Raymond Sawaya, MD:
Yes.
Tacey Ann Rosolowski, PhD:
Do you want to talk about that first?
Raymond Sawaya, MD:
I do, because that really builds it up to what we do here.
Tacey Ann Rosolowski, PhD:
So how did that program start—that joint program?
Raymond Sawaya, MD:
Okay. That’s not what I was going to tell you about, but I’m happy to talk about this.
Tacey Ann Rosolowski, PhD:
No, no, do what you want to do then.
Raymond Sawaya, MD:
What I wanted to tell you is to train a neurosurgeon, the neurosurgeon has to spend seven years after medical school to receive a diploma that allows them to practice neurosurgery. And by neurosurgery, I mean A to Z. It could be pediatrics. It could be trauma. It could be spine. It could be brain. It could be vascular aneurysms and so on and so forth. So that is the standard training of a neurosurgeon, including a full year of research. And so we do that. Now once the resident finishes that training, it’s extremely common that they want to now sub-specialize within neurosurgery—very, very common. Now some don’t want to do that. They just go into private practice, and they do general neurosurgery, and that’s fine. There is need for that. But I would say the majority feel that they want to really focus in one area. And so spine, for degenerative disease, is the most common condition that a neurosurgeon sees. So maybe half of neurosurgeons go in that field. The other half, they will sub-specialize in very, very specific areas of the brain or the spine, and one of them is tumor. And so once they finish their residency, they apply for a fellowship. And if they’re interested in the tumor specialty, then they are likely to apply to us here. And so I started that fellowship here, which is either one or two years, depending on whether they want to do research or not. So they do one year of clinical, one year of laboratory research. And we started with one fellow a year here in 1990-’91. And now we have four fellows a year. Because there was need—very few places have training in tumor surgery. And so we get a lot of demand, and we cannot take everybody that applies to us. We probably take half of those who apply to us. So there are a lot of people who want that and end up going other places. There are not too many places in North America that offer that. Now, when they come here, it’s so focused that they develop tremendous skills in just one year, because we do so many operations. So technically—we have all the technology needed, and it’s used every day. It’s not like they have to wait two months to see this kind or that type of surgery. They see it practically every day. We do, for instance, a lot of awake craniotomies. Patients are awake during surgery. There are some residents who go through their entire training program—seven years—and have never seen it. Never seen it, in seven years. So they come here and they see it several times a week. So clearly that’s tremendous learning opportunities for them in training. And by the time they finish their fellowship with us, with the reputation of this place and their capabilities and training, they become very desired. Places would want somebody like this to help them build their own programs. So that’s the focus of our fellowship here in neurosurgical oncology.
Tacey Ann Rosolowski, PhD:
How are the new regulations about hours spent?
Raymond Sawaya, MD:
That affects much less the fellows. It affects the residents a lot. And keep in mind that the residents who sleep in the hospital when they’re on call, that burns a lot of hours. Our fellows here do not need to stay in the hospital. So they may have a long day, but then they go home and those hours don’t count when they’re home or when they’re off. Even if they are on call, they are home, that doesn’t count. The residents who have to stay in the hospital as part of the requirements of covering the service in certain hospitals—like Ben Taub, the trauma hospital, you cannot go home. So all these hours they count against the eighty hours. So that unfortunately means that these residents have to go home the next morning and miss the opportunity to see some really interesting—or participate in some really interesting surgery. So yeah, I mean, we don’t like it. It has some purpose, because also having the residents so fatigued that there are problems of inattention and errors because of the person being less than alert. So we’ve adapted. And I think our residents do well. They are happy. I think they finish their training pretty well prepared, because we have a very large program. They see a lot. They see a lot with a huge number of faculty, a huge number of patients. And like small programs, where a resident may go through the entire residency not seeing an awake craniotomy, that doesn’t happen in this program.
Tacey Ann Rosolowski, PhD:
With the fellows again, do you have—are there plans to grow that program in any way?
Raymond Sawaya, MD:
No, we’ve grown it as big as—there is nothing, nothing like it anywhere in North America, nothing like it. Sloan-Kettering takes two fellows a year. Most places take one fellow a year. We take four, we sometimes take five fellows. What we’re doing now, because of my role at Baylor, is I’ve increased the number of residents who take advantage of the service here. And by doing that, I have cut back on the number of fellows.
Tacey Ann Rosolowski, PhD:
Well, would you like to talk about the Baylor program now, just because it seems really inter-linked?
Raymond Sawaya, MD:
I would be happy to.
Tacey Ann Rosolowski, PhD:
Yes, so tell me how it came about.
Raymond Sawaya, MD:
It came about—you probably know—how are we doing time-wise?
Tacey Ann Rosolowski, PhD:
I have us down until 3:30. Does that work for you?
Raymond Sawaya, MD:
Yeah. That’s good.
Tacey Ann Rosolowski, PhD:
Do you want to stop like five minutes before?
Raymond Sawaya, MD:
No, 3:30 is fine, 3:30 is fine, and we’re happy to get back together. I mean there’s so much to talk about, I guess. And I see you’re still flipping pages. So the quick background was the divorce between Baylor College of Medicine and the Methodist Hospital. You’re familiar with that. And so as a result of that, many departments, especially the surgically based departments, had to make a decision. Do they stay with Baylor or do they stay with Methodist? Neurosurgery chose to stay with the Methodist, and a major reason for that is they need a hospital to practice as a neurosurgeon. So as this was happening in 2004, with the arrival of a new president at Baylor, they anticipated that there would be an issue with neurosurgery, although they tried to convince the chairman at the time to kind of stay with Baylor. So in early 2005, I was approached by the dean of the medical school to see if I would be interested in taking over the position of chair of Neurosurgery at Baylor. I met with the dean, and once I understood what it is that they were looking for, I mentioned that—you know—I would love to do that, because I’m very interested in training and especially in a prestigious institution like Baylor College of Medicine. However, I would find it difficult to give up entirely my position and my role at MD Anderson, having built this department and my passion is in oncology. You know—I didn’t see myself giving that up. So the conclusion of that meeting was that the two presidents will talk to each other and see if they would agree in me doing this dual role, rather than me leaving MD Anderson and taking on the chairmanship there. The two presidents did talk. Dr. Mendelsohn called me, and he told me what they were offering and asked me if I was interested. I told him I was intrigued that he would favor that, because as the president of MD Anderson, why would he lose the—call it the influence or the input of one of his faculty. I mean, it’s going to be a distraction for me. But he viewed it—and as he explained it to me—he viewed it as sending an ambassador to Baylor College of Medicine. And since we all live in the same community, having this supportive interaction is a good thing. So I do think this was a major factor in me being given this opportunity. I can’t help it but think back to this proposal.
Tacey Ann Rosolowski, PhD:
I was just thinking that, too.
Raymond Sawaya, MD:
And say that I think John felt like, “Maybe I owe Ray something.” You know—that may be wishful thinking on my part. But I do suspect he may have by then become much more aware of everything. So I was given that opportunity. It was a five-year contract. So in 2010, I presented a progress report to Dr. Mendelsohn and to the president of Baylor. And Mendelsohn called me in his office. Not only did he commend me on the tremendous accomplishment in five years, he asked me if I would be willing to run for his position as he was stepping down. I said, “Whoa, coming from you having run this place for fourteen years, and knowing me, and if you think that I would be a good person for that job, yeah, absolutely. I’ll be delighted to.” And that’s what encouraged me to apply for that position. Of course, it didn’t get anywhere, but I did apply and John encouraged me to do it. So clearly, he was very impressed. I mean, he did tell me he was extremely impressed by what I had accomplished in those five years. So we renewed the contract for another five years, and now I am three years through that contract. The contract was April 1st, so we’re a little past three years. So I have a little less than two years left in that contract, and I anticipate that as that contract ends, I think I will relinquish my role at Baylor and have them have a full-time permanent chair there, which they deserve. And I think they are certainly over the hump. The risk that they had back in 2005 was of losing their training program because they would not have had a major hospital to support them. Here suddenly I bring MD Anderson as a major training source for their residents in addition to the other couple hospitals that they have. But the main adult private hospital they had at Methodist, they lost. And so I established a new service at St. Luke’s, and we have now a major neurosurgical service at St. Luke’s with all the faculty and all the procedures that residents need to learn that is outside of tumor. The oncology we can cover here, but non-oncology we don’t. We don’t have those patients here. So we couldn’t run a training program in neurosurgery at MD Anderson. We could run a fellowship like we do, because it’s specialized in tumors. But general neurosurgery, degenerative disease, movement disorders, stroke, aneurysms, trauma—none of that we see here. So you could not train neurosurgical residents in a cancer center.
Tacey Ann Rosolowski, PhD:
Now did that program grow? I mean, how was it handed to you? It was an existing program?
Raymond Sawaya, MD:
Yeah, but it was—I hired thirteen faculty in three years. For neurosurgery, that is huge. Thirteen faculty in three years. And for each position, I interviewed on average three people. So just do the math. How many dinners did I have?
Tacey Ann Rosolowski, PhD:
I was going to say, lots of lunches and lots of dinners.
Raymond Sawaya, MD:
But look at—you know—I look at it now, and it’s tremendous.
Tacey Ann Rosolowski, PhD:
It sounds like the institution really committed a lot of resources to that as well.
Raymond Sawaya, MD:
Yeah.
Tacey Ann Rosolowski, PhD:
I mean, that’s what it takes.
Raymond Sawaya, MD:
Of course.
Tacey Ann Rosolowski, PhD:
And in terms of the population of residents, how did that increase?
Raymond Sawaya, MD:
Yeah, we went from fifteen to twenty-one. We are now twenty-one. Actually, this week is for the first time, we have a twenty-one —a complement of twenty-one residents at Baylor in the program. We were eighteen until last year. We became nineteen, and now we’re twenty-one. So we will be that for a little while, and eventually we may go to twenty-eight. It’s so huge a program. It’s one of the largest in the country.
Tacey Ann Rosolowski, PhD:
Now in terms of the relationship that the program has with MD Anderson, it seems the residents obviously get an enormous experience with cancer patients. What do you see them bringing to MD Anderson?
Raymond Sawaya, MD:
They bring their youth. They bring their attention to detail. They are superbly trained doctors. They—a resident is much more committed to their education than a fellow. A fellow feels, I’ve done it all. I’m here to take the crème de la crème. A resident is seeking the basics. So residents are much more attuned to details. They tend to work harder, because they haven’t proven themselves yet. They bring an energy that galvanized the faculty. They are looking for project, and they want to get involved. And so that increases the productivity. And these are smart, smart kids. The residents that we select at Baylor, just to give you an idea—because I do that selection— Last year I received 247 applicants. For how many positions? Three, three positions. I have twenty-one because we are seven years, three every year, times seven is twenty-one. Three. I take three residents a year that match with us. I get 247 applicants. I interview about forty. That means 200 of some of the brightest students. And I assure you they are very bright with superb credentials. Two hundred of these people I turn down to interview. And then of the forty we interview, we rank them, and we take the three that match with us. And usually those end up among the top ten.
Tacey Ann Rosolowski, PhD:
When you say match with us—
Raymond Sawaya, MD:
It’s a computer match. It’s a national match. All neurosurgical programs participate in that match. And all the people you interview and all the other hospitals and universities interview—sometimes the same candidates in many, many—especially the good places will take the best candidates. And then let’s say I like a candidate that I am giving a number one rank on my list. That person may put Johns Hopkins as their number one. And Johns Hopkins may put them number one. So they match at Johns Hopkins. That’s why I don’t get my number one, two, and three, but to get my three among my top ten, when I have received 247 applicants, interviewed forty, and I get my three candidates among the top ten. Then you know they are outstanding. Frequently we joke when we have our faculty meeting—group meeting—to rank, because I have them interview with about twelve people. I’m not the only one that interviews them. It’s very important to get feedback from everybody else. We make our list and we’ll say, “Anyone in the top twenty we would be lucky to get and be extremely happy to get because they are so fantastic.” And sure enough, this year, we just started our three new interns. We had our graduation Saturday night where the chief resident is graduated, and we introduce the new ones, because the lifeline keeps going. So fantastic people—outstanding people. So these residents, when they rotate here—and this year we will have three at a time—three at a time. So every year nine of the twenty-one residents will have spent four months each at MD Anderson. And they will do it as a PGY 2, which is post-graduate year two, PGY 5, and PGY 7, chief resident. So it’s a graduation. At that PGY 2, they have a lot to learn and they look at really, really basic stuff. PGY 5, now they are much more knowledgeable and they can do a lot more and learn a lot more sophisticated stuff. And then when they are chief resident, then they get to do some really complicated, advanced surgery and they have the confidence because they have been here twice before. So they’ve seen it, they’ve learned it. Now they are focusing on more essentials. So that’s the advantage. The fellows are really now looking to practice in a university where they will do what we do here. So they really need that much higher level—then they spend a whole year here. It’s not like four months. So they really get to absorb all the stuff that we do. And when they leave here, they’ve got so much knowledge and so much expertise that they’re very desirable. If a program is needing someone like that—wow, they got a very good person from here. Now unfortunately, there are times when there are not too many job opportunities. Neurosurgery is a small field. There are not a lot of neurosurgeons in this country. There are ninety-nine training programs. That’s not huge.
Tacey Ann Rosolowski, PhD:
So what happens? I mean, are there actually people who aren’t placed? Do they go overseas?
Raymond Sawaya, MD:
No, they go in private practice. There are always jobs in private practice. But after having done all that and gained so many skills, not to be able to apply those skills is kind of unfortunate. We do see that periodically.
Tacey Ann Rosolowski, PhD:
That would be a tough one to deal with.
Raymond Sawaya, MD:
Yeah, so we really work hard, and we love when we get a fellow that’s been offered a job. That fellow comes here knowing that he or she has a job waiting for them at whatever university they’ve come from.
Tacey Ann Rosolowski, PhD:
Now you said that the fellowship program here is really unique. I mean, it both does and doesn’t surprise me. It doesn’t surprise me because it’s MD Anderson. But it does surprise be, because there are other large cancer institutes in the US. So how does the program here compare to the neuro programs at other institutes?
Raymond Sawaya, MD:
Just to give you an idea, we do twice as much as they do at Memorial Sloan-Kettering. Twice as much in neuro. I’m not talking about other cancers, but in neuro we do twice as much, and we have twice as many the number of faculty they have. So clearly there is a difference of scale that is major. And what I was referring to as this being very unusual is to have that kind of volume, to have that many opportunities for fellows to train with us. As I said earlier, most programs that offer fellowship in brain tumors take one fellow a year, because they don’t have the volume. We take four. So clearly we have, therefore, four times the volume that most programs have, and twice the volume that Memorial Sloan-Kettering has. It’s clearly a top, top, top, major cancer center in the United States and in the world. So I think part of it is the tree that I shared with you the other day. Having diversified within the field of neuro-oncology, it has helped develop and strengthen each area—not only brain tumors, but each area of neurosurgical oncology. And that has met the needs of the demands of a complicated sect of diseases and illnesses. And providing that expertise here at such a high level has attracted a lot of patients. That’s why we have grown the way we have. And we keep growing.
Tacey Ann Rosolowski, PhD:
Well we’re almost at 3:30, would you like to close off for today?
Raymond Sawaya, MD:
Yeah. Why don’t we do that? What—
Tacey Ann Rosolowski, PhD:
Let me just say, it is 3:26, and I am turning off the recorder. Thank you very much.
Raymond Sawaya, MD:
My pleasure. (End of Audio 2 Session 2)
Recommended Citation
Sawaya, Raymond MD and Rosolowski, Tacey A. PhD, "Chapter 12: Complex Training for Neurosurgeons" (2013). Interview Chapters. 1548.
https://openworks.mdanderson.org/mchv_interviewchapters/1548
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