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Archive for March, 2011

Saturday, March 12th 2011

Studying for Free

Today I take the written neurosurgical exam for self examination, as opposed to credit. Preparing for the exam, and studying throughout residency, can be an expensive endeavor. Especially as, during the economic downturn, many programs have cut supplementary funds for residents such as book funds. Now, to be fair, with access to a well equipped library and some extra leg work you can make it through residency without spending on textbooks. And indeed, the library is probably the best free resource any resident has seeing as there is probably no way through residency without a handful of textbooks.

But for lighter studying for the neurosurgical board there are resources out there which are both free and readily accessible:

The first, and best, free resource is of one of some moral ambivalence. It’s a blog posted to from Europe. It exclusively links to scanned medical textbooks, most of them related to neurosurgery or the neurosciences. To be fair some of these posted items almost certainly violate international copyright laws and downloading them constitutes piracy. I’m sure there are other resources for downloading scanned neurosurgical texts for free, but this is one of the most prominent and easiest.

Ile Bubulina Blog

Dr. E.R. Flotte has written a great little “Outline of Neurosurgery.” An eighty page document broken into the typical disciplines, which in bulleted order goes over the basics of much of neurosurgery. It is a wonderful beginners resource.

Outline of Neurosurgery (Outline of Neurosurgery PDF)

The CNS NeuroWiki goes over a variety of neurosurgery topics in short brief, key point posts. It is a good resources to look up specific topics.
CNS NeuroWiki

Vesalius is a clinically oriented site focused on technique for all surgical specialties. However, they have free resources focused on intraoperative neurosurgical anatomy.


There are innumerous great neuroradiology sites to review. I particularly like the AFIP archives hosted by the RSNA. It’s a listing of various articles that focus on differential diagnosis and pattern recognition, including some very pertinent topics.

AFIP Neuroradiology Archives

Sylvius is an brain MRI atlas organized by structure. While very cool and with corresponding free iOS applications, the website itself is somewhat limited in its aid as you essentially have to know what you’re looking for before you utilize it and it goes into shallow detail concerning the relevance of the various structures. The portable applications are a little better as they have very good quiz functions.


The Whole Brain Atlas is another brain MRI atlas. While the functionality of the website leaves something to be desired, it may be more useful than Sylvius. It goes over normal anatomy and a whole host of basic neuropathologies as they appear on T1/T2/SPECT.

The Whole Brain Atlas

Anyone else have any really good free, online resources for the neurosurgery resident (besides say, Uncle Harvey)?

Tuesday, March 8th 2011

Admiring Donald Betwick

Don’t let anyone but this blog’s readership know, but, I admire Donald Berwick.

The director of the Center for Medicare & Medicaid Services has dedicated the majority of his adult life to studying and improving the delivery of health care. And he stepped up to one of the highest platforms within health care policy knowing the challenges to acceptance he faced. Not that I would dare that he considred such when Obama asked him to take the position. Still, to only small surprise his well versed and verbalized opinions on what health care could be have hampered his service to the Obama administration.

Several people who work with Dr. Berwick at the Medicare agency said they were disappointed that the White House had not done more to promote him. “Everybody here admires Don and the work he’s done, but he is not going to be confirmed,” a supporter said. “That’s inevitable. The Republicans will block him. There’s not a lot of optimism that the White House can do anything about it.”

Berwick, a pediatrician by training, has made an internationally recognized career of his focus on optimizing the delivery of health care and he has, at times, been frank about what such would entail,

“Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”

Although many have this particular Dr. Betwick quote it is hard for anyone, looking at the actual data, to refute such a claim. Or Berwick’s many chides that improving health care will entail a more visible and transparent rationing of such. And rationing, publicized rationing, will be the death of meaningful health care reform at present.

Not that Donald Berwick doesn’t have his supporters, but his detractors in Congress will be the end of his tenure at the head of the CMS under a recess appointment from President Obama.

[H]is past record of controversial statements, and general lack of experience managing an organization as large and complex as CMS should disqualify him being confirmed as the CMS Administrator.

I don’t agree with many of Dr. Berwick’s opinions. Not on their merits mind you but on their implications.

And that’s a troubling position from which to argue with someone. The position that I concede your points but I disagree with you nonetheless. Of course, that has been my long held position. Essentially I concede that if you desire to improve the health of this country, by most population based metrics, then reforming the delivery of care to make access more affordable is important. And to improve access will require a better planned (not that our current system is planned at all) rationing of health care; a more visible rationing.

But challenging Dr. Berwick on his credentials is something else.

Managerial skill is something he has proven not only at the IHI but throughout his professional career. And I’m not sure a career government professional is someone we desire, on that merit alone, to head the CMS as the Senate Republican letter to President Obama implies.

Dr. Berwick’s tenure will have been too short, no matter my opinion of his ideas for Medicare, Medicaid and health care in general. 17 months at the helm may be long in the life of a CMS director,

This is a substantial period of time and long enough to have set a tone at CMS and to have recruited key second and third-tier administrators to work on important pieces of the Affordable Care Act. Berwick has already jump-started the Center for Medicare and Medicaid Innovation, the best hope health reformers have for finding smart ways to cut health care spending. Under Berwick’s tenure, the federal regulation of private insurance was also brought under the CMS mantle, a power consolidation that could have long-range implications.

But arguably shorter than the respect he deserved, no matter your politics.

Monday, March 7th 2011

The Future of Medicaid

Medicaid is a matched grant program, wherein the federal government matches money spent by the states, to provide a funding source for healthcare the economically disadvantaged. Medicaid, as can be imagined, has been pushed by the Great Recession.

From 2007 to 2009, Medicaid enrollment accelerated as a result of the recession. During economic downturns, people lose jobs and incomes decline making more individuals eligible for Medicaid at existing eligibility levels. Access to Medicaid coverage remained stable over this period due to protections put in place under ARRA. Increases in enrollment stemming from the recession were the primary drivers of increased spending on Medicaid over this period. Looking over the last decade, Medicaid spending per enrollee has increased more slowly than growth in national health expenditures per capita and growth in private health insurance premiums. Despite the program’s success in holding down per capita cost growth, states are grappling with immediate budget issues related to the economic downturn and related state budget constraints coupled with the expiration of the enhanced federal Medicaid matching funds from the ARRA on June 30, 2011.

Given the level of cost-containment that has already taken place, additional reductions in Medicaid spending growth over time will depend on…broader efforts to reduce health spending across all payers

Enrollment has gone up while state revenues and budgets have been squeezed. In 2010-2011 the federal government increased the funds given to the states, effectively shouldering a greater burden of the Medicaid budget. But that extra money was a one year deal and is set to expire.

And so states, faced with budget deficits in large part attributable to Medicaid (for instance: Wisconsin’s shortfall over the next two years is made up in half by Medicaid costs) continue to struggle. And state lawmakers have been very prominent in vocalizing their displeasure with the situation. One of the problems is some of the restrictions on reducing Medicaid eligibility, basically striking some people from the rolls, that the Affordable Care Act places. Basically,

But what really makes this Medicaid fight different from ones that have come before is the impact of the health overhaul passed last year, which calls for a huge expansion of Medicaid in 2014 to low-income childless adults.

States won’t actually be on the hook for most of those costs; all but 10 percent will be paid by the federal government.

But between now and 2014, in order to get that federal money, governors basically can’t cut back on most Medicaid eligibility. That makes a lot of them, well, not very happy.

“I really believe that the federal government, with their maintenance of effort, have really tied our hands and not given us the flexibility to do what we do,” said Iowa’s Branstad. “I don’t mind being held accountable [but] I’d like to be able to set our own eligibility requirements.”

This part of the Affordable Care Act, and other provisions related to Medicaid funding, has actually been challenged in federal court along with the more media grabbing assertion that the individual mandate oversteps Congress’ authority. However the mixed success opponents, including the state Attorney Generals, have had within the judicial system, it is of note that no court has sided with the plantiffs when it comes to the requirement that the states maintain current Medicaid rolls if they want to be eligible for future federal Medicaid dollars come 2014.

And so state Governors have gone politiking,

Haley Barbour doesn’t have many nice things to say about Medicaid these days.

He says he’s frustrated with “people [who] pull up at the pharmacy window in a BMW and say they can’t afford their co-payment.”

And, he says, “Forgive me if I think people who work two or three jobs to pay for health care for their families shouldn’t be forced to pay for health care for people who can work, but choose not to.”

Some more fringe state lawmakers have even talked about opting out of Medicaid all together,

The Heritage Foundation, a conservative research organization, estimates Texas could save $60 billion from 2013 to 2019 by opting out of Medicaid and the Children’s Health Insurance Program, dropping coverage for acute care but continuing to finance long-term care services. The Texas Health and Human Services Commission, which has 3.6 million children, people with disabilities and impoverished Texans enrolled in Medicaid and CHIP, will release its own study on the effect of ending the state’s participation in the federal match program at some point between now and January.

Although that is, for all the talk, extremely unlikely,

“I can’t imagine Mississippi opting out,” [Barbour] said at a hearing on Capitol Hill Tuesday. “We’re a poor state, and it’s an important program. We want to run it better for taxpayers and beneficiaries. … I am not an opt-out advocate and I’m just being forthright about that.”

Medicaid is feeling the squeeze from the Great Recession. It will continue chugging along, but the promise of an expanded Medicaid helping to provide insurance to more than half the people theorized to be covered under the Affordable Care Act, well that might be too much to ask,

Obama’s new budget calls for spending $279 billion on Medicaid and the Children’s Health Insurance Program, down from $285.4 billion this year. In plain language, this means stripped-down health care coverage for the poor and bigger burdens for the states.

Sunday, March 6th 2011

A Voice In Residency

I’ve been thinking a while what I imagine this blog to be. Initially I imagined it focusing on issues in residency, health care policy and neurosurgical study pointers and cases. The latter has failed to materialize and I’m not sure I truly want that to be a focus of this blog in anycase. The first two have been the primary topics I’ve posted on. But I’ve done so haphazardly with my schedule as a neurosurgical resident. And while I vow to improve that, I think what would really make this blog better, to turn it into something unique, is to give away some of the responsibility for it.

I would love this to be a group blog featuring residents from a variety of specialties and to focus on unique issues in residency amongst other issues in medicine. A focus more towards complaints, pointers, tips and daily musings on life in residency.

I imagine 4-5 authors posting 2-3 times a week (or more frequently) each. I’m looking for individuals who have an interest in social media and sharing the resident experience and who feel they can give the committment to such despite their schedules. Otherwise I’m looking for a variety of view points.

This idea is, to be fair, on the encouragement of my beautiful fiancee. She’s an internal medicine resident at current and I’ve recruited her along for the ride. Anyone else who may be interested in this or who has questions about just what I’m envisioning should contact me.

Thursday, March 3rd 2011

Acute Gatekeeper

Debates over resident autonomy are nothing new. Informed patients are sometimes reasonably concerned about just how much responsibility for their care will be delegated to “their doctor”‘s trainees. Care within academic medicine, especially acute inpatient care in a public system, can and does sometimes mean going a whole admission without meeting the attending physician presumably responsible for your care as a patient. At least in my limited experience. This as a fact even as we progress towards more resident supervision.

The quality of care teaching institutions and residents provide versus community care is a mixed bag by the literature. You may be aware of the dreaded July effect.

There is a unique example of this at some major trauma centers. In most Level I trauma centers the surgical subspecialty services are, at least documented as being, readily available but not necessarily the attending surgeon him or herself. I think it is reasonable to say that, of the surgical subspecialties, neurosurgery sees a level of acuity that other surgical subspecialties simply do not deal with.

Yes, that open femur fracture is an emergency for the orthopedic surgeon but not quite of the same nature as that massive epidural hematoma.

A coronal recon of an epidural…that’s not good

A Level I trauma center has, at a minimum, an upper level general surgery resident in their fifth year of training, and more likely an attending trauma surgeon, triaging all the trauma that comes in. But as a surgical subspecialty often the first “neurosurgeon” to see a patient suffering serious neurotrauma is a lower level neurosurgery resident. A not unlikely scenario is an intern, a neurosurgeon in training who less than a year ago was still in medical school, who serves as a conduit between the patient with the head or spine injury and the attending neurosurgeon or between the patient and an upper level neurosurgery resident who then communicates with the attending neurosurgeon.

And therein lies the uniqueness.

An attending trauma surgeon is standing at bedside as a patient with an peritoneal visceral injury needing an exploratory laparotomy and he makes that determination right there without any filter. But to operate on a subdural hemorrhage is informed by what a junior neurosurgical resident reports.

Consider this report:

Hey chief, sorry to wake you, I’ve got an 88 year old man who presented status post a fall from his wheelchair at his nursing home five hours ago. He’s got a large right sided subdural. I’m measuring it now and it’s about a centimeter and a half and he’s got nearly two centimeters of shift. His basilar cisterns are already gone. Per report his right pupil was fixed and dilated at the scene. He’s an hour out from intubation and paralytic and sedation and he’s GCS 3T and he’s 5 millimeters on right and non-reactive and 3 millimeters on the left and sluggish and I’m not getting any corneals or cough.


Hey chief, sorry to wake you, there’s an 88 year old man with a right sided subdural status post a ground level fall. He’s got pretty significant shift. He got succ when EMS intubated him and I’m not sure if it’s worn off or not. Right now he’s GCS 3T, he’s anasacoric with his right pupil at 5 millimeters and nonreactive and with his left at 3 millimeters. I don’t get any corneal reflexes but that might be the paralytic. I understand he was pretty independent prior to this. Do you want me to wait and see if the paralytic wears off or just get the operating room moving now?

And that filter the in house resident provides matters I’m convinced.

Now, to be fair, there are checks. If the attending trauma surgeon in house or the upper level general surgery resident doesn’t agree with a decision made over the phone for or against surgery for a head injury they’re certainly prone to call the attending neurosurgeon. But such is dependent on the natural temperment of the trauma staff and they encounter an attending or an upper level neurosurgery resident at home who has already had his or her opinion informed by what the in house neurosurgery resident has told them.

That’s not to say I’ve ever seen this process lead to what I consider inappropriate patient care but it is certainly a heady responsibility for the in house resident to present the uncolored facts. And it is certainly something to think about when considering the level of resident responsibility, especially with acutely injured patients.