Education Research: Evaluation of Epilepsy Surgery Education in Epilepsy and Clinical Neurophysiology Fellowship Programs

Abstract

Background and objectives: To assess the scope of surgical epilepsy exposure and training among fellows in Epilepsy and Clinical Neurophysiology (CNP) fellowship programs in the United States. Characteristics associated with increased fellow involvement in epilepsy surgery were evaluated.

Methods: A 10-question multiple-choice survey was designed to characterize individual fellowship programs, epilepsy surgery programs, trainee involvement, and assessment of trainee performance. The survey was distributed to program directors of adult Epilepsy and CNP-EEG track fellowships between November 2021 and April 2022. Epilepsy surgery procedures included resective approaches, neurostimulation modalities, and palliative interventions approved for drug-resistant epilepsy. Associations between categorical variables were evaluated using the Fisher exact test.

Results: There were 37 responses from a total of 72 survey recipients (51% response rate). The majority (68%) of surgical programs performed >30 surgical procedures per year. The range of procedures was overall similar across programs. At most programs, fellows were personally involved in 1-10 (49%) or 11-30 (46%) surgical procedures per year. Institutions with >50 surgical cases/year were more likely to expose fellows to >10 cases/y compared with institutions with volumes ≤50 per year (77% vs 33%, p = 0.017). Fellows had the greatest involvement in presurgical planning with more variable involvement in perioperative and postoperative activities. Competency in surgical management was primarily investigated through faculty assessments (97%), whereas oral (46%) and written (30%) assessments were less frequently used.

Discussion: High-volume epilepsy surgery centers provide trainees with increased exposure despite also having more fellowship positions. There is variability in surgical epilepsy exposure, trainee involvement, and performance evaluation metrics between institutions. We identify specific areas that programs may focus on to improve fellow competency in the surgical management of epilepsy.

Figure 1. Demographics and Characteristics of Epilepsy Centers Surveyed

(A) Total number of programs surveyed per US region. (B) Response rate of programs surveyed per region. (C) Number of surgical procedures performed per year per region; the Y axis corresponds to the percent of the responding programs. (D) Number of fellows per program by region; the Y axis corresponds to the percent of the responding programs.

Figure 2. Characteristics of Surgical Procedures Performed at Responding Centers

(A) Total number of surgical procedures performed per year per institution. (B) Types of procedures performed. DBS = deep brain stimulation; LITT = laser interstitial thermal therapy; RNS = responsive neurostimulation; SDE = subdural electrode implantation = RFA, radiofrequency ablation; SEEG = stereoelectroencephalography; VNS = vagus nerve stimulation.

Figure 3. Trainee Exposure and Assessments in Epilepsy Surgery

(A) Number of procedures per year in which trainees are personally involved. (B) Types of preoperative, perioperative, and postoperative activities that trainees are involved in. (C) Types of didactic resources used by surveyed programs. (D) Types of assessments used to assess competency in epilepsy surgery management. Imaging coregistration = performing multimodal imaging coregistration for intracranial EEG. iEEG = intracranial EEG recording; stimulation mapping = performing electrical stimulation mapping; iEEG placement = determination of electrode/lead placement; Faculty A = faculty assessments; Oral A = oral assessments; Written A = Written Assessments.