Neurosurgical training in the 1970’s consisted of 1-year of a general surgical internship, followed by 4 years of residency. The tenets of training were that the resident would show up, work hard, read everything and get lots of experience. At the conclusion of training, the resident would be a NEUROSURGEON able to manage all types of neurosurgical problems. No post-graduate subspeciality fellowship was anticipated or required.
In the late 1980’s and early 1990s, primarily stimulated by a threatened loss of spine practice with the growing applications of instrumentation, the need for focused subspecialty training became acutely obvious for the preservation and advancement of neurosurgery as a specialty managing the entire nervous system and its appendages and/or supporting structures. Over time, fellowships became commonplace, and included such subspecialties as pediatrics, cerebrovascular, spine, tumor/neurooncology, trauma/critical care, and pain/functional stereotactic and epilepsy.
In 1999, the Committee for Accreditation of Subspecialty Training (CAST), under the direction of the Society of Neurological Surgeons (SNS), was created and charged with the development of an accreditation system for subspecialty fellowship training programs within neurosurgery. Since that time, CAST has accredited multiple subspecialty neurosurgical fellowships in neurosurgical training programs across North America.
Accreditation was initially limited to the program that met CAST standards, but CAST did not issue any specific documents to individual trainees. At first, CAST considered recognition of both enfolded and post-graduate training experiences as equivalent, but within several years, the term fellowship became reserved only for post-graduate trainees. The ABNS was not prepared to certify individuals completing any of these fellowships, so the individual fellowship training program was responsible for issuing any certificate to the trainee.
Over the next 10+ years, several major changes in the neurosurgical educational environment occurred, including:
- 2002- ACGME competencies & duty hour restrictions
- 2009- Neursurgery manages all aspects of neurosurgical training PGY1-PGY7
- 2010- ACGME/RRC residency requirements changed from institutional data to resident case categories
- 2012- All ACGME programs moved to a standardized training length of 7 years
- 2013- Development of ACGME Milestones for neurosurgery and SNS Matrix curriculum
The Milestones and Matrix projects integrated the educational material and committees working within all neurosurgical organizations, and outlined the details and specifics of core residency training, including base levels of case categories and competencies to be completed by every graduating resident.
At about this time, the UCNS (United Council of Neurology Subspecialty Societies) began to recognize subspecialty certification of individual trainees completing UCNS fellowships outside the confines of the ABMS. Joining with a leading consumer group Leapfrog, this group advocated that “UCNS-certified” individuals provided superior neurocritical care compared to other types of practitioners. As a result, neurosurgeons began to find themselves restricted in the writing of orders on their patients or to serve as experts in neuro-critical care in many intensive care units across the country.
Recognizing the need to maintain neurosurgical expertise in the critical care management of their patients, and to make sure than neurosurgical subspecialty fellowship training in its chosen areas were equal to or superior to those that might be provided by other specialties, a Task Force was appointed by the SNS. The specific charges to the Task Force were:
- the development and clarification of advanced subspeciality training requirements within neurosurgery beyond those of core residency, so that the structure of and training received within a CAST-accrediated neurosurgical subspeciality training fellowships is standard across programs.
- working within the Milestones framework, the determination of the feasibility and details of enfolding fellowships equivalent to post-graduate training.
- in concert with the ABNS, the development of methodology for the certification of individuals participating in these programs.
CAST was thereafter renamed as the Committee on Advanced Subspecialty Training. In carrying out its mission, CAST sought advice from educational subspecialty stakeholders such as the Joint Sections of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS). To further promote and formalize the relationship between CAST and the Sections in this process, CAST formed Fellowship Review Committees (FRC), whose charge is to assist CAST in updating subspecialty fellowship requirements (both programmatic and individual trainee), developing guidelines for an enfolded subspecialty experience, and acting as supplemental reviewers for specific applications of programs and individuals.