Letter: Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs

To the Editor: We read with great interest the recent article published by Yearly et al1 highlighting the integration of Veterans Affairs (VA) Medical Center rotation into neurosurgery residency programs across the United States. The authors summarize succinctly the current state of affairs. At the University of Miami training program, our postgraduate year 3 (PGY3) residents rotate at the Bruce W. Carter VA Medical Center for 4 months. The VA rotation at our program has become known for its breadth through the wide skillset of contracted attendings, its innovation through the robust VA infrastructure, and its flexibility to continue training opportunities at the primary teaching site through its manageable clinical obligations. All these elements add to the findings of Yearly et al,1 affirming the formative nature of a VA rotation within neurosurgery training programs when possible. BREADTH There are 3 contracted attendings at our VA center, who specialize in complex spine, functional, tumor, and general cranial. Through this range of interests, the VA resident is exposed to these areas on a one-to-one basis with the attending because they are the sole resident on service. Our VA service make-up mirrors much of what Yearly et al1 report, in that spine surgeries are the most common, but within that, the complexities range from single-level laminectomy to multilevel cervical laminoplasties and lumbar fusions. Outside spine, a variety of procedures are also performed—a recent week's example includes spinal cord stimulator placement for pain, radiofrequency ablation for spinal metastasis, and endoscopic transsphenoidal resection for pituitary tumor. By having attendings who specialize in different areas, the VA rotation can provide the rotating resident exposure to a large breadth of surgical techniques. INNOVATION The infrastructure at the VA allows our department to incorporate new concepts and materials for the better of our patients. So much so that the invested interest from our anesthesia colleagues, operating room staff, and hospital managers has allowed the VA rotation to become known for better exposure to particular techniques than some of the other teaching sites within our program. This includes navigated single-position corpectomies and fusions and percutaneous spinal cord stimulator placements (Supplemental Figure 1,https://links.lww.com/NEU/D758). Furthermore, on the horizon for approval includes robotic spine surgery and stereotactic deep brain stimulation. Our experience therefore demonstrates the potential for the VA rotation within training programs to not only expose residents to standard operative techniques but also new and emerging ones too. FLEXIBILITY A normal week at the VA for our resident includes 2 operative days and 2 clinic days. Outside these clinical obligations, the vicinity of the primary teaching hospital allows the VA resident to participate in other clinical activities at the primary site. This can include further operative time and pursuing research interests which are both encouraged pending the resident's preference. A unique aspect of our VA center is its close proximity to the primary teaching hospital of our program—across the road. This location allows the VA resident to participate in all primary site learning activities (both in the morning and in the evening), as well as talk in-house overnight call at the primary site. Although not all VA centers are located so close to the primary teaching sites, our experience demonstrates that within a flexible set of obligations, a VA rotation is not a compromise in operative and academic opportunities if appropriate arrangements and schedules can be made ahead of time. At the University of Miami training program, the VA rotation has become a key and much looked forward to rotation among the residents. This is because of both the reasons Yearly et al1 highlight, as well as the elements we detail above. The VA rotation can be a pivotal experience for neurosurgery residents in their training, and maximizing where possible its breadth, innovation, and flexibility is highly encouraged.