New spine procedures and technologies are increasingly crossing specialty lines, and the question of who is trained to perform them safely has followed. The North American Spine Society took that question on directly, releasing a patient safety position statement on education, training and competency for spine interventions.
The statement calls for physicians to complete structured education and clinical training — including supervised procedural experience and objective competency assessment — before performing these procedures independently. Minimum case requirements may be one component of that training, the NASS said, and educational courses should complement structured clinical experience rather than replace it.
For Kern Singh, MD, those principles describe how training already works in his program. He is chief of the spine section and co-director of the Minimally Invasive Spine Institute at Midwest Orthopaedics at Rush in Chicago, where he trains spine fellows and hosts visiting surgeons through STEP, the group’s endoscopic training program.
“Before a fellow ever touches an endoscope, I want to see that their open and microsurgical fundamentals are already solid — they know the anatomy cold, they’re comfortable managing bleeding and anatomic variation without a camera doing the work for them, and just as important, they’re comfortable converting to open when something isn’t going the way they planned,” Dr. Singh told Becker’s. “Endoscopic and biportal technique doesn’t replace that judgment, it sits on top of it.”
He also looks for dexterity and comfort working off a screen rather than direct line of sight, and said prior arthroscopy or scope experience is usually a good early signal. Just as telling is a fellow’s willingness to start with the simplest cases and progress deliberately, rather than reaching for the hardest pathology first because it looks impressive.
Once training is underway, Dr. Singh said, volume is an incomplete measure of progress.
“Case numbers matter, but they’re a floor, not a finish line; hitting a volume threshold tells you someone has had exposure, not that they’re independently competent,” he said.
Instead, Dr. Singh relies on a graduated autonomy model. Trainees move from observation to performing defined portions of a case under direct supervision, then to serving as primary surgeon with Dr. Singh scrubbed in and able to step in immediately. Through each stage, he tracks markers that a case log does not capture.
“Along the way, I’m watching for things that are hard to reduce to a single number: OR time trending down and stabilizing, how they handle a deviation from the plan without needing to be coached through it in real time, and whether their instinct to convert or ask for help kicks in at the right moment rather than too late,” he said.
That combination of supervised progression and objective, observable markers, Dr. Singh said, is what the NASS is describing when it calls for structured training and objective competency assessment rather than a course certificate or case count alone.
The same distinction shapes how he views courses and site visits. A course is valuable for building the mental model, he said: portal placement principles, equipment setup and troubleshooting, watching an experienced surgeon avoid trouble before it happens, and seeing a volume and variety of cases a surgeon’s home institution may not offer yet.
“What it can’t give you is the tactile, hands-on feedback of actually doing the case yourself: managing bleeding in real time, developing the instinct for when to push forward versus stop and reorient, and building the bimanual coordination that only comes from repetition under your own hands with real consequences attached,” Dr. Singh said.
In his view, a course should also build a kind of self-awareness that technique alone does not provide.
“I’d add one thing: a good course should also teach you to recognize the edge of your own competence, so you know when a case in front of you is outside what you’ve been trained for yet,” he said.
That self-awareness is often what’s missing in the mistakes Dr. Singh sees most from surgeons early in the learning curve. Some are planning errors: rushing localization instead of being meticulous about confirming level and approach, which compounds every problem downstream, and progressing to complex pathology such as revisions, significant stenosis or deformity before fully mastering straightforward primary cases. With biportal technique specifically, he said, failing to respect fluid and pressure management carries real neurologic consequences.
The error he flagged above the others is losing visualization or anatomic landmarks and continuing to work instead of stopping to reorient.
“That’s less a technical gap than a discipline and ego issue, and it’s the single biggest predictor of a complication I see in review,” Dr. Singh said.
For programs weighing how quickly to bring endoscopic technique to their surgeons, his advice runs against the instinct to accelerate.
“The learning curve for bimanual endoscopic coordination is real, and the surgeons who get into trouble are usually the ones who skipped steps in it, not the ones who went too slowly,” he said.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
