
==== Front
Brain Spine
Brain Spine
Brain & Spine
2772-5294
Elsevier

S2772-5294(24)00179-6
10.1016/j.bas.2024.102923
102923
Brain
Non-technical skills for neurosurgeons: An international survey
Cavallo S.M. acv1
Pellencin E. bcv1
Carone G. bcv1
Castelli N. bcv
Ayadi R. bcv
The Non-Technical Skills Group in NeurosurgeryOlldashi F. c
Al Anazi A. d
Kanaan I. e
Garcia Colmena F. f
Ajler P. g
Socolovsky M. h
Knosp E. i
Raftopoulos C. j
Rodrigues J.C. Jr. k
Enchev Y.P. l
Xu B. m
Chul-Kee P. n
Rotim K. o
Posti J. p
Meyer B. q
Shimamoto H. r
Makhambetov Y. s
Frosen J. t
Chandra S.P. u
Cappabianca P. v
Piatelli G. w
Genitori L. x
Germanò A. y
Sabatino G. z
Bernucci C. aa
Giussani C. ab
Olivi A. z
Locatelli D. ac
Stefini R. ad
Castrioto C. ae
Mangiola A. af
Fontanella M.M. ag
Tacconi L. ah
Conti C. ai
Skrap M. aj
El Abbadi N. ak
Sharma M.R. al
Shamim M.S. am
Sharif S. an
Farias J.P. ao
Florian I.S. ap
Gushcha A.O. aq
Rasulic L. ar
Vulekovic P. as
Ang B.T. at
Lagares A. au
Diez Valle R. av
Ensenat J. aw
Ley Urzaiz L. ax
Barcia Albacar J.A. ayaz
Kupanur S.S. ba
Regli L. bb
Dunn I.F. bc
Adelson D. bd
Bederson J. be
Levi A.D. bf
Alturky A.Y. bg
Matula C. bh
Cortes B. bi
Xiang W. bj
Li T. bk
El-Ghandour N.M.F. bl
Kanai R. bm
Patir R. bn
Misra B.K. bo
Dwarakanath S. bp
Servadei F. bq
Tomasello F. br
Casali C. cy
Unsgard G. bs
Morcos J.J. bt
Souhil T. bu
Khoja I. bv
Kehayov I. bw
Vukic M. bx
Ziebell M. by
Gulisano H.A. bz
Tange M. ca
Kurozumi K. cb
Locatelli M. cc
Garbossa D. cd
Gomez Amador J.L. ce
Rodriguez A.O. cf
Ashkan K. cg
Lim M. ch
Maleki M. ci
Agrawal A. cj
Naik A. ck
Sciubba D.M. cl
Kim L.J. cm
Spinner R.J. cn
McDonald P. co
Pavesi G. cp
c Department of Neurosurgery, University Hospital of Trauma, Tirana, Albania
d Department of Neurosurgery, King Fahd Hospital of the University, Alkhobar College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
e Neurosurgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
f Clínica Privada Vélez Sarsfield, Córdoba, Argentina
g Department of Neurosurgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
h Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
i Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
j Department of Neurosurgery, Clinique Universitaires Saint Luc, Brussels, Belgium
k Department of Neurosurgery, Heliopolis Hospital, São Paulo, Brazil
l Department of Neurosurgery and ENT Diseases, Division of Neurosurgery, Medical University of Varna, Varna, Bulgaria
m Department of Neurosurgery, Liaocheng Brain Hospital, No. 45 Huashan Road, Dongchangfu District, Liaocheng, Shandong, 252000, China
n Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
o Department of Neurosurgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
p Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Turku, Finland
q Department of Neurosurgery, School of Medicine and Health, Technical University of Munich, München, Germany
r Shimamoto Neurosurgery Hospital, Fukuoka, Japan
s Department of Vascular and Functional Neurosurgery, National Center for Neurosurgery, Astana, Kazakhstan
t Department of Neurosurgery, Tampere University and Tampere University Hospital, Tampere, Finland
u Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
v Department of Neurological Sciences, Division of Neurosurgery, Università Degli Studi Di Napoli Federico II, Naples, Italy
w Pediatric Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
x Neurosurgery Department, Meyer Children's Hospital IRCCS, Florence, Italy
y Unit of Neurosurgery, AOU Policlinico G. Martino di Messina, Italy
z Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
aa Unit of Neurosurgery, H San Francesco, Nuoro, Italy
ab Neurosurgery Clinic, IRCCS Fondazione Ospedale San Gerardo Dei Tintori di Monza, Monza, Italy
ac Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy
ad Department of Neurosurgery, ASST Ovest Milanese, Legnano, Milan, Italy
ae Division of Neurosurgery, S. Maria Della Misericordia Hospital, Piazzale Giorgio Menghini, Perugia, Italy
af Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti, Italy
ag Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
ah Division of Neurosurgery, Azienda Sanitaria Universitaria Integrata di Trieste, University Hospital of Trieste, Trieste, Italy
ai Unit of Neurosurgery, ARNAS G. Brotzu, Cagliari, Italy
aj Neurosurgery Unit, Head-Neck and Neurosciences Department, Santa Maria Della Misericordia University Hospital, Udine, Italy
ak Department of Neurosurgery, Cheikh Zaid International Hospital, Abulcasis International University of Health Sciences, Rabat, Morocco
al Department of Neurosurgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
am Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
an Department of Neurosurgery, Liaquat National Hospital & Medical College, Karachi, Pakistan
ao Department of Neurosurgery, Hospital Cuf Descobertas, Lisbon, Portugal
ap Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
aq Department of Neurosurgery, Research Center of Neurology, Moscow, Russia
ar Department of Neurosurgery, University of Belgrade, Serbia
as University Clinical Centre of Vojvodina, Novi Sad, Serbia
at Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
au Department of Neurosurgery, Hospital Universitario Doce de Octubre, Facultad de Medicina, Departamento de Cirugía, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre, Madrid, Spain
av Departamento de Neurocirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
aw Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
ax Department of Neurosurgery, Ramón y Cajal University Hospital, IRYCIS, Madrid, Spain
ay Department of Neurosurgery, Hospital Clinico San Carlos, Madrid, Spain
az Complutense University of Madrid, Madrid, Spain
ba Sapthagiri Institute of Medical Sciences and Research Center, Department of Pathology, Karnataka, India
bb Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse, Zurich, Switzerland
bc Department of Neurosurgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
bd Neurosurgery, Phoenix Children's Hospital, Phoenix, AZ, USA
be Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
bf Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
bg Department of Adult Neurosurgery, King Fahad Medical City, Riyadh, Saudi Arabia
bh Department of Neurosurgery, Medical University of Vienna, Vienna Health Care Group, University Hospital Vienna, Austria
bi Souza Aguiar Municipal Hospital, Brazil
bj Hainan Women and Children's Medical Center, Hainan Medical University, Haikou, China
bk Neurovascular Center, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
bl Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
bm Department of Neurosurgery, Eiju General Hospital, Tokyo, Japan
bn Department of Neurosurgery, Fortis Memorial Research Institute, GurugramI, India
bo Department of Neurosurgery, P D Hinduja National Hospital, Mumbai, India
bp Department of Neurosurgery, NIMHANS, Bangalore, Karnataka, India
bq Department of Biomedical Sciences, Humanitas University, Milan, Italy
br Humanitas Clinical Institute of Catania, Misterbianco, Catania, Italy
bs Norwegian University of Science and Technology, Trondheim, Norway
bt Department of Neurosurgery, University of Texas Health Huston, Texas, USA
bu Neurosurgery Department, University of Abderrahmane Mira, Bejaia, Algeria
bv Medical Education Program, Syrian Virtual University, Damascus, Syria
bw Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
bx Department of Neurosurgery, Sisters of Mercy University Hospital, Zagreb, Croatia
by Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
bz Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
ca Odense University Hospital, Odense, Denmark
cb Department of Neurosurgery, Hamamatsu University School of Medicine, Handayama, Chuo-Ku, Hamamatsu, Shizuoka, Japan
cc Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Unit, Milan, Italy
cd Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
ce Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
cf Neurosurgery Service of the University Hospital of Salamanca, Salamanca, Spain
cg Department of Neurosurgery, King's College Hospital, Denmark Hill, London, UK
ch Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, USA
ci Department of Neurosurgery, McGill University Health Centre, Montreal, QC, Canada
cj Departments of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
ck Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, 85013, USA
cl Department of Neurosurgery, Northwell Health, Donald and Barbara Zucker School of Medicine, Hempstead, NY, USA
cm Department of Neurological Surgery, University of Washington, Seattle, WA, USA
cn Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
co Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
cp Neurosurgery Unit, University Hospital of Modena, Modena, Italy
cy Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico "C. Besta", Milano, Italy

Moiyadi A. cq
Padayachy L. cr
Meling T.R. czcwcx
Di Meco F. csctcxcz2
Perin A. aperin@gmail.com
czcucx⁎2
a School of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
b Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico "C. Besta", Milano, Italy
cq Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
cr Department of Neurosurgery, Brain Tumor and Translational Neuroscience Centre, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
cs Department of Pathophysiology and Transplantation, University of Milano, Milano, Italy
ct Department of Neurological Surgery, John Hopkins Medical School, Baltimore, MD, USA
cu Department of Life Sciences, University of Trieste, Trieste, Italy
cv Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale “C. Besta”, Milano, Italy
cw Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
cx Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Nazionale “C. Besta”, Milano, Italy
cz Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico "C. Besta", Milano, Italy
⁎ Corresponding author. Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy. aperin@gmail.com
1 Equal contribution.

2 Equal contribution.

30 8 2024
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© 2024 Published by Elsevier B.V. on behalf of EUROSPINE, the Spine Society of Europe, EANS, the European Association of Neurosurgical Societies.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Neurosurgery is considered a technically demanding specialty; nonetheless, it also requires non-technical skills (NTSs) to reach mastery.

Research question

This study seeks to understand how important NTSs are perceived by neurosurgeons across diverse roles and socio-economic backgrounds. The objective is to identify key NTSs and explore their role in surgical precision, teamwork, and collaboration.

Material and method

An international survey involving 372 neurosurgeons from various socio-economic and cultural contexts was conducted. The extensive sample and inclusive methodology provide a comprehensive perspective on the perceived importance of NTSs in neurosurgery.

Results

The survey results highlight the universal significance of NTSs among neurosurgeons. Attention to detail, humility, and self-awareness are considered essential for surgical precision, effective teamwork, and collaboration. The findings underscore the necessity for integrated training programs that combine NTSs with technical skills.

Discussion and conclusion

The study emphasizes the importance of effective training methods such as simulations, mentorship, and role-playing in equipping neurosurgeons to navigate the complexities of their profession. Future research should focus on optimizing teaching methods for NTSs, comparing traditional courses, online modules, and hybrid training programs. Addressing the global disparity in neurosurgical care, particularly in low- and middle-income countries, is crucial for improving patient outcomes worldwide.

Highlights

• Universal significance of NTSs: The survey results show that NTSs are essential for neurosurgery.

• Integrated Training Programs: Teaching of NTSs alongside technical skills through simulations, mentorship and role-playing.

• Curriculum: NTSs as means of selection criteria and included in neurosurgical training curricula.

Keywords

Non-technical skills
Integrated training programs
Neurosurgery
Education in medicine
Simulations
Effective communications
Self-awareness
Humility
Handling Editor: Dr W Peul
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pmc1 Introduction

Neurosurgery is renowned for its demand for exceptional technical proficiency, yet beyond the surgical act lies a profound and often overlooked truth: the most distinguished neurosurgeons excel not just in technique, but also in critical non-technical skills (NTSs) that redefine surgical success and optimal patient care. Consider a neurosurgeon during a complex operation; the ability to communicate clearly with the surgical team, make strategic decisions under pressure, lead with confidence, and manage stress, all skills that extend beyond the gesture, are crucial. Furthermore, the importance of posing sensible clinical/surgical indications, having good manners, and communicating well with patients are often overlooked skills that are now recognized as game-changers in the high-stakes environment of neurosurgery (Cobianchi et al., 2022; Hénaux et al., 2019; Hull et al., 2013; Wood et al., 2017).

Recent research has ignited a revolution in neurosurgical training, highlighting the indispensable role of NTSs. Publications on this subject have surged, from a mere 55 articles in 2005 to an astounding 225 in 2022, reflecting a shift in medical education priorities. This surge underscores a growing acknowledgment that excelling in neurosurgery demands more than just technical expertise—it requires a holistic approach to training that includes the development of these critical -so called-soft skills.

This shift has been championed by the World Health Organization (WHO) and other leading medical institutions, who are now fervently advocating for the integration of NTSs training into medical curricula. The call is clear: modern medical practice must evolve to incorporate these skills as fundamental components of neurosurgical training. However, there remains a significant challenge: identifying which NTSs are most crucial and determining the best methods for their assessment and integration into neurosurgical practice.

Despite this growing consensus, the current frameworks remain inadequate. A review by Shlobin et al. (2021) highlighted essential soft skills/NTSs for neurosurgeons, but lacked practical implementation strategies. The European Association of Neurosurgical Societies (EANS) curriculum does not provide a structured approach to these skills, revealing a critical gap between the recognized importance of NTSs and their practical application in neurosurgery (Whitfield et al., 2023).

In this paper, we dive deep into the opinions of neurosurgeons across various stages of their careers, exploring their thoughts and beliefs on the impact of NTSs on surgical performance, both inside and outside the operating room (OR). Our survey aims to determine whether these skills are perceived as innate or teachable, evaluate their importance in the field, and identify which NTSs are deemed essential in contemporary neurosurgery. Moreover, we investigate effective strategies for teaching and acquiring these skills, aiming to propose actionable solutions to bridge the current educational gap.

We collected and analyzed responses from 372 participants (including neurosurgery residents, attending neurosurgeons, and department heads) across thirty countries. Our goal was to assess the implications for training and neurosurgical practice, exploring how tailored selection and training programs could foster a new generation of neurosurgeons who are adept in both technical and social skills.

2 Methodology

2.1 The questionnaire: creation and distribution

The questionnaire was formulated based on established standards and benchmarks from the ACGME, CanMEDS, EUMS, and GMC, as well as the World Federation of Neurosurgical Societies’ Statement of Ethics in Neurosurgery, NOTSS, NOTECHS, OTAS evaluation scales, and relevant literature predominantly sourced from PubMed. Keywords used in the literature search included: “non-technical skills, technical skills, surgeon, surgery, neurosurgery, communication, teamwork, cognitive skills, interpersonal skills, behavior, training, trainees, operating theatre, and teaching”. From the identified non-technical skills and behaviors in surgery and other medical disciplines, the most frequently cited and those deemed essential to surgical practice were selected.

The questionnaire was collaboratively developed with psychologists and designed to be completed in approximately 15 min. It comprised of 34 items - 26 with closed-ended questions and 8 open-ended questions to minimize response bias. The open-ended questions provided space for feedback on the closed questions and the survey. The closed-ended questions employed a modified four-point Likert scale, multiple-choice answers, or checkboxes for responses (see Supplementary Materials).

Prior to dissemination, the questionnaire underwent evaluation for content validity by neurosurgeons working at the Fondazione IRCCS Istituto Neurologico C. Besta (FINCB) and the past president of the EANS, Andreas Demetriades.

The survey was created using Google Forms and distributed to each head of department around the world. The initial invitation was sent in May 2021, and data collection concluded in June 2021. A total of 291 department heads were invited, asking them to involve at least one attending neurosurgeon and one resident from their department (meaning that we may have obtained at least three filled questionnaires from every participating center). The response rate was above 40%.

2.2 Participants and procedure

We collected data from 372 participants across 30 countries, including Albania, Algeria, Saudi Arabia, Argentina, Bangladesh, Belgium, Brazil (41 participants, 11%), Bulgaria, Canada, China, Denmark, Egypt, Finland, Germany, India (94 participants, 25.3%), Italy (84 participants, 22.6%), Korea, Morocco, Nepal, Pakistan (24 participants, 6.5%), Portugal, Republic of Kazakhstan, Romania, Russia, Serbia, Spain (64 participants, 17.2%), Switzerland, South Africa, the UK, and the USA (46 participants, 12.4%). Respondents included 105 residents (28.2%), 164 neurosurgeons (44.1%) and 103 heads of departments (27.7%).

The countries have been divided by economic wealth. According to The World Bank's 2021 financial data, low/low-middle-income countries are Albania, Algeria, Bangladesh, Egypt, India, Morocco, Nepal, Pakistan, Serbia. Upper-middle-income countries are Argentina, Brazil, China, Croatia, Kazakhstan, Mexico, Romania, Russia, South Africa. Finally, high-income countries are Austria, Belgium, Canada, Denmark, Finland, Germany, Italy, Japan, Norway, Spain, Switzerland, Portugal, UK, USA, Saudi Arabia, South Korea.

2.3 Data analysis

The questionnaire responses were analyzed both in aggregate and by subdividing the sample, as previously described. Data analysis was performed using R (version 4.3.2, 2023-12-1, R foundation for Statistical Computing) with the dplyr, the dunn.test, the pheatmap and the ggplot2 packages.

Responses to the Likert scale questions regarding the importance of various qualities needed by a neurosurgeon were converted to numerical scores to facilitate analysis. Specifically, the Likert scale responses were assigned numerical values as follows:• Not at all: 1

• A bit: 2

• A lot: 3

• Absolutely: 4

These numerical scores allowed us to create an ordinal scale for each response, with the highest value (4) representing the highest importance. Rankings were then determined based on the highest scores. This conversion enabled us to quantitatively analyze the data and rank the various qualities effectively.

We employed non-parametric tests such as the Kruskal-Wallis test to examine differences in responses across groups based on role (department head, neurosurgeon, neurosurgery resident) and the average income of the country of origin (low, medium, high). Post-hoc analysis was conducted using the Dunn test with Bonferroni correction to identify specific differences between groups. We also calculated the Spearman's rank correlation coefficient to analyze the relationships between personality traits, followed by hierarchical clustering using the average linkage method based on the Spearman correlation distance matrix. Results were considered significant at p < 0.05.

3 Results

According to our data, most participants recognize the critical role of NTSs in neurosurgery. However, a significant portion does not see a direct link between NTSs and excellence (see Table 1). The majority believes that NTSSs are crucial for predicting excellence and should be used as selection criteria for candidates, emphasizing their importance alongside technical skills. Most participants support including NTSs in the training curriculum (see Table 2), with varying preferences as to when and how this training should occur (see Graph 1, Graph 2). Mentorship is seen as the most effective training method. Interestingly, among those who believe one can excel without NTSs, only a small minority (7.35%) oppose including NTSs in the curriculum, and just 0.8% believe NTSs are unimportant overall.Table 1 Can you become a great neurosurgeon without NTSs?

Table 1Yes	68− 36 staff neurosurgeons, 20 residents, 12 head of department

− 13 respondents from Italy, 11 from India and USA, 4 from Spain, Brazil, 3 from Russian Federation and Denmark, 2 from Romania, Republic of Serbia, Republic of Kazakhstan, Argentina, and 1 from Belgium, Nepal, Austria, Japan, Germany, Finland, China, Canada, Bulgaria, Albania

	18.28 %	
No	304	81.72 %	

Table 2 General questions regarding NTSs.

Table 2	Strongly Agree	Agree	Disagree	Strongly Disagree	
Being an ideal neurosurgeon is more innate.	11.6% (43)	42.5% (158)	38.4% (143)	7.5% (28)	
Strong non-technical skills are a predictor of neurosurgical excellence.	56.5% (210)	21.5% (80)	20.2% (75)	1.9% (7)	
These qualities and behaviors (i.e., NTSs) can act as selection criteria for getting the right people into the field.	33.1% (123)	48.9% (182)	16.7% (62)	1.3% (5)	
The qualities and behaviors listed above (i.e., NTSs) should be included in the neurosurgical training curriculum.	50.5% (188)	45.7% (170)	3.5% (13)	0.3% (1)	

Graph 1 At what point would you prefer training.?.

Graph 1

Graph 2 Which is the most effective teaching method.?.

Graph 2

3.1 Which NTSs matter most?

3.1.1 Personality traits

Personality skills are ranked in order of importance based on their average scores (Graph 3 A) as follow: Attention to Detail and Concentration (M = 2.64; SD = 0.54), Awareness of Own Limits and Strengths (M = 2.61; SD = 0.53), Commitment (M = 2.61; SD = 0.58), Resilience (M = 2.54; SD = 0.65), Intellectual Curiosity (M = 2.47; SD = 0.64), Self-Criticism (M = 2.44; SD = 0.65), Stress Management (M = 2.43; SD = 0.68), Emotional Intelligence and Empathy (M = 2.36; SD = 0.64), Proactivity and Initiative (M = 2.34; SD = 0.68), Being a Mentor (M = 2.08; SD = 0.74), Administrative Task Management (M = 1.75; SD = 0.73).Graph 3 _ Personality Traits

A: Ranking

B: Correlation matrix and cluster dendrogram.

Graph 3

To analyze the relationships between personality traits, we computed the correlation matrix using Spearman's rank correlation coefficient. This allowed us to understand the relationships between different traits. We then performed hierarchical clustering using the average linkage method based on the Spearman correlation distance matrix. The traits were grouped into clusters, illustrating the similarity between them (Graph 3 B).

By segmenting the results based on the role of the respondent, a significant difference between groups was found for responses regarding administrative task management and stress management (respectively, H = 5.98, df = 2, p-value = 0.05 and H = 13.30, df = 2, p-value = 0.001). In the post-hoc analysis, we applied the Dunn test with Bonferroni correction to examine specific differences between groups. According to results, residents consider stress management to be more important than both staff neurosurgeons and heads of department do (respectively, p-value = 0.0095 and p-value = 0.0006). Moreover, department heads assign greater importance to managerial skills than staff neurosurgeons (p-value = 0.002).

Based on analyses of data categorized according to the economic wealth of countries, it was found that, in general, low-income countries tend to regard all these personality traits as less important than middle- and high-income countries. Specifically, high-income countries place significantly greater value on skills such as attention to detail and concentration (H = 10.232, df = 2, p-value <0.05), awareness of one's own limits and strengths (H = 14.24, df = 2, p-value <0.05), emotional intelligence (H = 6.703, df = 2, p-value <0.05), intellectual curiosity (H = 11.09, df = 2, p-value <0.05), proactivity (H = 10.583, df = 2, p-value <0.05), resilience (H = 30.684, df = 2, p-value <0.05), self-criticism (H = 32.916, df = 2, p-value <0.05), and stress management (H = 18.436, df = 2, p-value <0.05).

3.1.2 Cognitive abilities

Cognitive abilities are ranked in order of importance based on their average scores (Graph 4 A) as follow: Situation Awareness and Risk Assessment (M = 2.48; SD = 0.64), Analytical and Problem-Solving (M = 2.40; SD = 0.66), Foresight/Anticipation (M = 2.40; SD = 0.7), Cognitive Flexibility (M = 2.38; SD = 0.69), Mental Agility (M = 2.38; SD = 0.68). Correlation matrix and hierarchical clustering are represented in Graph 4 B.Graph 4 _ Cognitive Skills

A: Ranking

B: Correlation matrix and cluster dendrogram.

Graph 4

Based on analyses of data categorized according to the economic wealth of countries, it was found that, in general, countries with lower income pay less attention to cognitive abilities. However, among these, only certain differences have been found to be significantly distinct. Specifically, in comparison to low-income countries, high-income countries consider the following aspects more important: analytical and problem-solving skills (H = 6.49, df = 2, p-value <0.05), cognitive flexibility (H = 12.23, df = 2, p-value <0.05), and mental agility (H = 7.68, df = 2, p-value <0.05).

3.1.3 Interpersonal skills

Interpersonal abilities are ranked in order of importance based on their average scores (Graph 3 A) as follow: Team-working (M = 2.52; SD = 0.64), Openness to Innovation (M = 2.39; SD = 0.65), Effective Communication (M = 2.33; SD = 0.64), Achievement Orientation (M = 2.28; SD = 0.66), Leadership (M = 2.16; SD = 0.73), Conflict Management (M = 2.07; SD = 0.68). Correlation matrix and hierarchical clustering are represented in Graph 5 B.Graph 5 _ Interpersonal skills

A: Ranking

B: Correlation matrix and cluster dendrogram.

Graph 5

In examining interpersonal skills, no differences were observed based on the role of individuals. In line with previous results, low-income nations generally allocate less emphasis to interpersonal skills. In particular, high-income countries, in contrast to their lower-income counterparts, place a higher importance on abilities such as achievement orientation (H = 5.884, df = 2, p-value <0.05) and openness to innovation (H = 6.2741, df = 2, p-value <0.05).

4 Discussion

Our global survey of neurosurgeons indicates that true mastery in neurosurgery transcends technical skill. The data reveal a near-universal consensus on the critical importance of NTSs, highlighting that personality traits, cognitive abilities, and interpersonal skills are perceived as crucial for a successful carrier in neurosurgery. Among these, attention to detail and self-awareness emerge as paramount. Humility, often described as “the most difficult virtue to understand and practice” (Coulehan J, 2010; Jeffrey DI, 2020), involves an accurate assessment of one's abilities and limitations without arrogance. Humble individuals recognize their imperfections while maintaining self-worth and respect for others, fostering teamwork and collaboration (Coulehan J, 2010; Jeffrey DI, 2020). Integrating self-awareness into the broader framework of NTSs would foster better collaboration and communication, enhancing overall performance in complex surgical environment. However, an apparent contradiction exists: approximately 18% of surgeons still view technical execution as the sole indicator of professional excellence. This perspective reinforces outdated stereotypes that associate surgery with decisiveness, physical strength, and emotional detachment, while undervaluing empathy and humility.

The increasing promotion of NTSs education programs signifies a shift towards dismantling these outdated views. Interestingly, even among those who consider NTSs irrelevant for neurosurgery, there is a belief that these skills should be taught or included as selection criteria. This discrepancy may stem from differing views on whether NTSs are innate or can be developed, suggesting the potential for training programs that integrate NTSs with technical skills, harnessing both intrinsic potential and teachable aspects of the profession. Such programs, utilizing diverse teaching methods like simulations, mentorship, and role-playing, aim to equip future neurosurgeons with the comprehensive skill set necessary for exceptional performance. Moreover, this apparent discrepancy may also reflect the acknowledgment of NTSs as skills that foster the acquisition and improvement of surgical skill and clinical judgement, even among those colleagues who see technical execution as the main predictor of professional excellence.

Our results also indicate that beliefs about NTSs are influenced by the specific working contexts of neurosurgeons. For instance, department heads prioritize managerial skills, while residents emphasize stress management, reflecting how different levels of responsibility and experience shape perceptions of NTSs relevance.

Another aspect worth considering is that competencies essential for making a good doctor may not be always necessary during surgery. For example, dealing with a terminally ill patient requires empathy, emotional connection, communication skills and time, whereas performing a difficult surgical procedure demands emotional detachment and intense focus. These findings call for a flexible and adaptive training approach, tailored to the varied needs and perspectives within the field.

Additionally, our analysis highlights how cultural and economic contexts significantly affect the emphasis on NTSs. Across all countries, cognitive traits such as attention to detail, self-awareness, dedication, and resilience are deemed crucial for neurosurgery. However, wealthier nations place greater emphasis on qualities like self-awareness, mentoring, intellectual curiosity, and resilience, supported by robust health and education systems. Low and middle income nations may probably face different challenges, such as high patient volumes, limited resources (especially manpower), and overburdened infrastructures. In this setting, it is highly possible that higher-level competencies take a back seat, as other more basic skills may be needed, for example, doing more with less, working in adverse conditions and resourcefulness.

The challenge now is how to effectively teach these skills. Recent studies, such as Mann et al. (2015), highlight the success of structured leadership training programs like the Future Surgical Leaders curriculum, which significantly improved residents' leadership skills and knowledge. Additionally, Alayande et al. (2024) highlight the importance of hybrid training courses combining in-person and online components to maximize accessibility and effectiveness. Future research must focus on identifying the best methods to teach NTSs, including experimental studies comparing various approaches to ensure neurosurgeons are well-equipped with the holistic skills necessary for exceptional performance.

While these findings provide valuable insights, the inherent limitation of survey-based research has to be recognized; these data reflect perceptions and opinions that may not translate into empirical evidence as they do not provide a measure of the influence of different skills on neurosurgical performance. It remains very difficult to scientifically measure the true relationship between NTSs and neurosurgical outcome.

5 Conclusion

In conclusion, our study highlights the widespread acknowledgment of the importance of NTSs to achieve professional excellence in neurosurgery. Notably, humility emerged as one of the most valued skills among neurosurgeons, highlighting the importance of self-awareness and continuous improvement in this complex field. In this view, humility may be seen a synonym for maturity. However, our survey also reveals a small but notable tendency to overlook some human aspects of the profession.

The adoption of an integrated approach may improve neurosurgical outcomes by ensuring that technically skilled neurosurgeons are also equipped with empathy and resilience to better deal with the complexities of their profession.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following is the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Acknowledgments

We deeply thank Ms. Nina Ravelli and Fondazione Giovanni Celeghin for their generous and continuous support to the Besta NeuroSim Center.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.bas.2024.102923.
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