Overview and Program Details

Introduction from Program Director Dr. Perry Ball

The 7-year curriculum of the Neurosurgery Residency at Dartmouth Hitchcock Medical Center is designed to provide training in the full breadth of neurosurgery and provide ample opportunities for career development.

Overview

The program begins with an integrated PGY-1 year, including 1-month rotations in plastic surgery and otolaryngology, 3 months of clinical neurology (1 month each of general, epileptology, and stroke), and 2 months of critical care surgery, 1 month of neurocritical care, with the remaining time spent on the neurosurgery service.

PGY-2 through PGY-5 consists of core neurosurgical rotations in both adult and pediatric neurosurgery, interspersed with related neuroscience education. As a longstanding feature of our program, residents are paired with attending surgeons for 3 month rotations in an apprenticeship style teaching model. Each resident works closely with their assigned attending across the clinical service, in the operating room, and during clinic. The individual attention and patient continuity afforded by this training model maximizes the professional development of each resident. Instruction follows graduated progression through increasing levels of intellectual growth, technical proficiency, and clinical responsibility. Over this period, residents gradually assume greater responsibility for independent management and technical skill.

PGY-6 consists of a 12-month independent year designed by the resident to serve their career objectives. Recent graduates have utilized this valuable time for laboratory or clinical research, further training in a subspecialty focus of interest, enfolded fellowships, international rotations, or coursework at the Dartmouth Institute for Health Policy. Several past residents have received master's degrees via this latter opportunity.

The program culminates in 12 months as chief resident during the PGY-7 year. By this final year of training, the resident has acquired a broad education, is capable of teaching medical students and junior residents, and is able to operate with confidence across the full range of neurosurgical disorders. The chief is responsible for day-to-day clinical management of the service, and for direct supervision of the junior residents.

Residents in this program are respectfully treated as colleagues and are held to the highest professional standards. The collegial atmosphere, along with the program's apprenticeship training structure, is enabled by a small, cohesive group of residents and faculty.

Program details

Faculty subspecialty and research interests

Subspecialty interests

The subspecialty interests of the faculty provide in-depth experiences in tumor, pediatric, pituitary, spine, cerebrovascular/endovascular, critical care, peripheral nerve, epilepsy, and functional/stereotactic neurosurgery. Integrated collaborations with the Dartmouth Cancer Center, the Comprehensive Epilepsy Center, the Center for Surgical Innovation, the Center for Pain and Spine, the Cognitive Neuroscience Program at Dartmouth College, and the Biomedical Engineering Program of Dartmouth's Thayer School of Engineering are a few examples of the highly successful multidisciplinary programs that characterize the clinical and research activities.

Research interests

Research interests include tumor fluorescence, single-unit microelectrode recording in animal models of Parkinson's Disease and epilepsy, finite element brain modeling, computer-assisted surgery (including frameless stereotaxy and robotics), and outcomes research in collaboration with the Dartmouth Institute for Health Policy and Clinical Practice.

Exams and self-directed study

Beginning with the PGY-2 year, residents are required to take the American Board of Neurological Surgery (ABNS) written exam for practice, and may take the exam for credit towards certification as soon as PGY-4, at the discretion of the program director. Residents are required to pass the exam for credit prior to the commencement of chief year.

During the PGY-2 year residents are required to take the American Board of Neurological Surgery (ABNS) Neuroanatomy exam. Residents are provided with the study materials and meet weekly with the Program Director and other junior residents to review one of the Rhoton slides as part of our Chapter Review Conference.

The program provides SANS (Self-Assessment in Neurosurgery) question bank modules at regular intervals. Residents are expected to complete these as they progress through training.

Dartmouth College Biomedical Libraries, accessible to residents 24-7, is physically sited at both the DHMC campus in Lebanon and at the Geisel School of Medicine campus in Hanover. In addition, the neurosurgery section maintains its own library, and all DHMC house staff are provided an annual book stipend.

Scholarly activity

Academic productivity is an important part of the program. Residents are required to participate in at least one scholarly project per year, with the aim of publishing new contributions to the field. Residents are encouraged to attend scientific meetings; expenses are covered if presenting original research.

Courses

Each resident is offered one practical course per year, with expenses provided by the program. Examples include the SNS Fundamental Skills ("Boot Camp"), Junior Resident Course, Research Update in Neuroscience for Neurosurgeons (RUNN), or NREF/AANS subspecialty courses. At later stages, residents have the opportunity to tailor course selections towards their career objectives.

Benefits

Custom surgical loupes and lead aprons are purchased for each resident. The program provides daily hot breakfast for residents after morning rounds. The Office of Graduate Medical Education offers a competitive stipend and many additional benefits to DHMC house staff.

Conferences

Formal education through scheduled teaching conferences is an important feature of the program. Regularly scheduled conferences include:

Chapter review

Led by the Program Director, junior residents review a chapter each week from the Principals of Neurological Surgery book by Richard Ellenbogen with an emphasis on preparation for the ABNS written exam.

Weekly, Mondays at 7:00 am, neurosurgery conference room

Neuro-oncology board

Multidisciplinary board as part of the Norris Cotton Cancer Care Pavilion Lebanon, attended by neurosurgery, neuro-oncology, neuroradiology, radiation-oncology, neuropathology, and neuro-ophthalmology. Cases are reviewed with a discussion of management strategy, along with numerous research initiatives and QI projects.

Weekly, Tuesdays at 4:00 pm, radiation-oncology conference room

Neurovascular conference

Multidisciplinary board as part of the stroke center, attended by neurosurgery, neurology, and neuroradiology. Faculty and house staff review cases covering the breadth of neurovascular disorders, focusing on operative/non-operative management and radiological pearls.

Weekly, Wednesdays at noon, neurosurgery conference room

Case conference

All elective surgical, endovascular, and radiosurgery cases for the coming week are briefly summarized by the chief resident. Faculty discuss their rationale and approach for the case.

Weekly, Fridays at 7:00 am, neurosurgery conference room

Journal club

Key papers are chosen by the faculty and residents for discussion in a round table format. Over time, residents develop increased skills in biostatistics and data interpretation and are expected to offer independent critique of the scientific literature.

Monthly, Fridays at 7:30 am, neurosurgery conference room

Mega rounds

Medical students, interns, and residents present on topics of interest, often an in-depth exploration of a recent case, research topic, or QI initiative.

Monthly, Friday at 7:30 am, neurosurgery conference room

Morbidity and Mortality

Relevant cases including trackable complications and outcomes are presented by the chief resident for discussion.

Monthly, Fridays at 7:30 am, neurosurgery conference room

Didactics

Rotating didactic sessions are given by DHMC neuro-radiologists, neuro-pathologists, and neurologists, along with neurosurgical topics of interest.

Monthly, Fridays at 7:30 am, neurosurgery conference room

Epilepsy conference

Multidisciplinary conference as part of the Dartmouth Epilepsy Center, with case review and discussion of management strategy.

Weekly, Fridays at 3:00 pm, radiology conference room

Visiting professors

The department regularly invites distinguished neurosurgeons from outside institutions as visiting professors. The day typically consists of grand rounds, morning conferences, case reviews, and an evening dinner with the residents and faculty.

Held every three months.

Facilities

DHMC, located in Lebanon, New Hampshire, serves as the primary clinical training site. As the academic flagship of a progressive regional health care system serving 1.5 million people, DHMC enjoys state-of-the-art facilities. Notable highlights include:

Center for Surgical Innovation (CSI)

The Center for Surgical Innovation represents a joint collaboration between Dartmouth Hitchcock Medical Center, the Geisel School of Medicine, and the Thayer School of Engineering, with capital funding from the NIH. This facility includes three highly advanced operating suites with intraoperative MRI and CT, with direct integration of image guidance. It is the only facility in the nation approved for both clinical surgery and animal research, affording near-limitless investigative potential.

Dartmouth Cancer Center

The Dartmouth Cancer Center is one of 51 NCI-designated comprehensive cancer centers and is recognized for both patient care and research.

The Dartmouth Institute for Health Policy and Clinical Practice (TDI)

The Dartmouth Institute for Health Policy and Clinical Practice (TDI) is an internationally renowned policy institute that has played a central role in the effort to improve quality and outcomes in health care.

Epilepsy Center

The only Level 4 epilepsy center in New Hampshire, this comprehensive center is currently accredited at the highest level, with opportunities to participate in numerous clinical trials.

Cerebrovascular Disease and Stroke Program

DHMC has been recognized by U.S. News and World Report for its stroke program. The comprehensive program involves close interdisciplinary collaboration between neurosurgery, vascular neurology, and neuroradiology. DHMC is certified as a primary stroke center.

DHMC Trauma Center

DHMC is currently the only level one trauma center in New Hampshire. Learn more about the related Center for Rural Emergency Services and Trauma (CREST).

Additionally, the program utilizes dedicated operating rooms equipped with the latest generation microscopes and image guidance systems, in addition to the CSI suites equipped with intraoperative MRI and CT. Endovascular interventions are performed with a Siemens Artis Zee biplane system in a dedicated angiography suite. A Varian TrueBeam is on-site for stereotactic radiosurgery.

Laboratory facilities are available at the DHMC campus in Lebanon, and at the Geisel School of Medicine campus in Hanover.

Resident life

DHMC and Dartmouth College are in the Upper Valley region of New Hampshire and Vermont, a beautiful area surrounding the upper Connecticut River. The region is centrally located between the metropolitan areas of Boston (2 hours), New York (5 hours) and Montreal (5 hours).

Outdoor activities are abundant in the region, including fishing, hiking, camping, biking, equestrian, golf, and watersports; the nearby White Mountain National Forest (NH) and Green Mountains (VT) provide many opportunities for these pursuits. The region is especially well known for its winter sports. Dartmouth maintains its own Skiway and Nordic Ski Center, and there are many ski resorts in the area.

The area has numerous music venues, museums, and sporting facilities, while Dartmouth offers many cultural activities through The Hopkins Center for the Arts and the Hood Museum. Locally sourced food, with a mix of exceptional restaurants, is a well-known feature of Northern New England, and this region also has the highest per-capita concentration of craft breweries in the nation.

With affordable living, spacious towns, high-performing school districts, and many local activities for children, the area is perfect for raising families. A full-time daycare is available on-site at DHMC.

Work hours

The health and wellness of our residents is very important in our program. Call coverage and work hours are closely monitored so that the standard ACGME work hour regulations are strictly adhered to, including:

  • They will not work on average more than 80 hours per week, averaged over four weeks.
  • They will have one full day off out of seven when averaged over four weeks.
  • We have a night float system. PGY-2, PGY-3, and PGY-4 residents take night float call Thursday to Sunday one month at a time. The PGY-2 has 5 months of night float call, the PGY-3 has 4 months of night float call, and the PGY-4 has 3 months of night float call.
  • They will have at least ten hours off between non-call shifts.
  • They will leave the hospital no later than six hours after a 24-hour call cycle and not accept new patient assignments during those six hours. That time will only be used for continuity and transfer of care, educational debriefing and didactic activities.
  • The program director will monitor moonlighting. When moonlighting occurs in-house, that time will be added to the 80-hour total mentioned above. When moonlighting occurs out-of-house, the program director will know when and where the resident is moonlighting, following Dartmouth Hitchcock Medical Center Institutional Policy, and will watch carefully for signs that this activity may be affecting resident performance in the training program.
Dartmouth Hitchcock Medical Center tour
Upper valley life
Working at Dartmouth Hitchcock Medical Center