What tracts of the spinal cord do somatosensory evoked potentials (SSEPs) monitor?
Archive for the ‘Medical Education’ Category
Sunday, February 5th 2012
Somatosensory Evoked Potentials
Saturday, February 4th 2012
Childhood Glial Tumor
Thursday, February 2nd 2012
Neurosurgery Residents Oppose Duty Hour Restrictions
A survey of more than 300 U.S. neurosurgical residents found that more than 70% felt current ACGME duty hour restrictions were negatively impacting their residency training.
This national duty hour survey of neurosurgical residents reveals considerable concern over the new ACGME proposed standards. The majority of respondents believe that the new standards will have a negative effect on their residency training. Furthermore, this survey indicates an overwhelming negative attitude toward mandated duty hour regulations among neurosurgical residents.
In some surgical specialties, the rigor of training and the hours dedicated to it are a badge of honor. Especially when faced with those, your very mentors and faculty, who have gone before you who have had to endure a training regiment without duty hour protections.
I adamantly oppose the duty hours. I’m all for a reevaluation of common program training guidelines more tailored to surgical specialties, including duty hour guidelines, more focused on surgical specialties; as in breaking off the surgical specialties and forming an Accreditation Council on Graduate Surgical Education. And I’m not surprised a specialty like neurosurgery, a small community, that has, over its history, taken pride in the difficulty and rigor of its training would have residents who feel similiarly and strongly oppose the duty hour restrictions. I imagine aversion to the duty hour restrictions runs as strong in amongst neurosurgery residents as it does amongst residents training in any specialty.
Thursday, February 2nd 2012
PEEP in ARDS
What is the advantage of PEEP im acute respiratory distress syndrome?
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A. Allow for reduction in FiO2
B. Prevents atelectasis
C. Decrease pulmonary edena
D. Both A & B
E. All of the above
Wednesday, February 1st 2012
Eosinophilc Granulomas
Tuesday, January 31st 2012
Pineal Tumors
Tuesday, January 31st 2012
Impact of Admission Month & Hospital Teaching Status on Outcomes In Subarachnoid Hemorrhage
Background
It is common knowledge to avoid major teaching hospitals in July. Such is when new residents, fresh from medical school, begin as physicians. In some studies the month has been associated with more errors, including notably fatal medication errors. However, the effect continues to be questioned and debated. Even a short review of the surgical literature finds that a preponderence of studies show no worse outcomes with surgical procedures in July as compared to other months. The most notable of these studies is likely this large retrospective review of all Medicare patients undergoing CABG, CEA, AAA repair, colectomy, pnacreatectomy, esophagectomy or hip ORIF between 2003 and 2006. They found no increased mortality or reported morbidity in those three Julys as compared to the other 33 months of the study. Other studies looking just at patients undergoing CABG or patients undergoing emergent appendectomy back up those results.
Add a recent study in the Journal of Neurosurgery to the pile of evidence that new resident physicians in July don’t endanger patients.
McDonald, Robert J., Harry J. Cloft, and David F. Kallmes. “Impact of Admission Month and Hospital Teaching Status on Outcomes in Subarrachnoid Hemorrhage: Evidence against the July Effect.” Journal of Neurosurgery 116 (2012): 157-63.
Design
The study by a group out of the Mayo Clinic is a retrospective analysis of a huge proportion of all hospital admissions between 2001-2008 for non-traumatic subarachnoid hemorrhage. The study pulled all admissions with ICD codes associated with SAH from the National Inpatient Sample. This is an AHRQ national database contributed to by all hospitals in 44 states.
The admissions and their outcomes were studied with two linear regression models for both teaching and non-teaching hospitals. One looked solely at inpatient mortality. The other looked at “unfavorable” discharged; those patients with SAH being discharged to skill care.
Results
There were 52,879 admissions for non-traumatic SAH in the NIS database between 2001-2008. 36,914 were admitted to teaching hospitals and 15,965 were admitted to non-teaching hospitals. There was no monthly variation, in either teaching or non-teaching hospitals, in either model. The authors failed to find any evidence of a “July effect.”
Of note however, there was a discrepancy in outcomes in terms of hospital teaching status. The probability of in-hospital mortality for patients presenting to a teaching hospital with non-traumatic SAH was 11% lower than that or patients presenting to a non-teaching hospital. The probability of “unfavorable” discharge, likewise, was 12% lower.
Discussion
The results of this retrospective review of SAH hos -pital admissions within the 2001–2008 NIS failed to demonstrate significant month-to-month variation among outcomes including in-hospital deaths and/or discharges requiring skilled care. This pattern was observed in both teaching and nonteaching hospitals and suggests that a July effect is absent among SAH hospitalizations.
Also, for life threatening problems, such as subarachnoid hemorrhage, tertiary centers (more often than not teaching facilities) appear to be the place to go for care. At least in terms of outcome.
Tuesday, January 17th 2012
It Is Cheating But Should It Be?
This has been up and around. I’m sure within the radiology community the CNN “exclusive” was hardly news at all.
The gist of the accusation is that,
For years, doctors around the country taking an exam to become board certified in radiology have cheated by memorizing test questions, creating sophisticated banks of what are known as “recalls,” a CNN investigation has found.
No doubt what was going on constituted cheating. There were specific prohibitions against reproducing questions that test takers agreed to before the privilege of being able to take the written portions of the radiology boards.
But, I guess controversially, should it be that way?
True, it would be hardly a point of confidence if the board self published the questions on their tests and then told the resident candidates to memorize all the answers before they showed up. But the recalls are hardly that. I imagine them more as a study tool. I also imagine that studying them and getting the questions right on the board exam means the radiology residents have learned the material. And that seems the whole point of standardized testing as a method for certifying physicians for various specialties; to make sure they have a baseline, basic set of knowledge. In once sense, how does it matter how that knowledge is memorized?
Thursday, November 10th 2011
Video Anatomy
The American Association of Neurological Surgeons has a great new YouTube channel hosting videos on surgical anatomy, including some Rhoton lectures. Even some videos in 3D if you have a computer capable of playing such. I hope they keep updating it but it’s a great resource as is.
Tuesday, September 27th 2011
More On Work Hours
Currently non-intern physician residents are limited to working 320 hours in any four week period, 24 hours of patient care in any one continuous setting and most have 4 days off in any four week period amongst other rules.
The history of medicine’s self governing bodies limiting resident physician work hours in a patient protection bid has a long history, as do my complaints about such.
But I thought it worth reiterating one of the major problems with these work hours. They can only be policed by individuals who are largely negatively impacted by their violation.
Say you’re a obstetrics/gynecology resident at a program that has some rotations that regularly violate the 80 hours/week (averaged). Let’s say you, and all the other residents in your program, report those violations. That is the only way that programs (and thus medical schools and the ACGME) learn about violations…they ask their residents to report them. Mix in some other things and before you know it your program is on probation from the ACGME and then, a few years later as the work hour violations continue despite best efforts, your program is shut down.
All in the name of patient safety. Only there is evidence, despite our best intentions, that restricting resident work hours has done nothing for patient safety.
And so now you are an out of work ob/gyn resident who can only blame yourself for self reporting those duty hour violations. Now you have to go out interviewing across the country to find another residency program, costing you potentially tens of thousands of dollars. It’s true that your funding for your resident position (your salary) can travel with you as you look for a new residency program and that the ACGME will almost universally provide a waiver to any program that accepts you to increase the size of their residency program and so your odds of finding another residency program to accept you are high, even if you’re in a competitive specialty. However, that isn’t guaranteed and there’s a small chance you may not find another ob/gyn residency to accept you. Even if you do it means packing up your family and your belongings, leaving your friends and moving cross country.
There’s some evidence that the majority of residents continue to routinely violate duty hour rules, largely without complaint. For one, I’m not sure they see the adverse effects of doing such. For two, knowing the light at the end of the tunnel they swallow the long work hours. And, for three, reporting those violations most negatively impacts the resident physicians themselves.
This isn’t a call for some dramatic shift in how we track resident physician work hours or for mitigating the effects of program violations on residents. This is a call for some return to sensibility and some loosening of the work hour restrictions in the first place.
A pipe dream but I’ll dream it.
