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:
First
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.
Second
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.
Third
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
Fourth
Vesalius is a clinically oriented site focused on technique for all surgical specialties. However, they have free resources focused on intraoperative neurosurgical anatomy.
Fifth
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.
Sixth
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.
Seventh
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.
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.
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.
Versus:
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.
I don’t know what I owe my sleep bank but it must be something substantial.
I probably fall asleep anywhere, anytime in less than 2 minutes and usually a matter of seconds. I wonder if it borders on pathologic, as do people around me who have witnessed me fall asleep on a dime.
That said, my constant state of fatigue obviously has it’s ups and downs. And I have trouble picking out exactly what makes me really tired. There seems to be poor rhyme and reason to it.
For example, I’m post call right now. I got no sleep on call last night. It was just one of those nights where the consults rolled in kind’ve intermittently and included an emergency cranial reconstruction and multiple sick patients. I’ve noticed, on nights like this, around two or three in the morning I hit a wall. But there’s a point where the circadian rhythms kicks in and you start feeling better as the cortisol levels rise.
That’s certainly enough to carry through the morning.
What I wonder however is why, some days, I feel like collapsing and exhausted again as my time awake approaches thirty, thirty-five, forty hours and why some days, I may not be crisp, but I feel relatively functional even well into my post call day.
Today I came home post call and took a two hour nap but awoke and I feel good now as I get ready to sit down for dinner. Granted I’m functioning on a lot of caffeine but I’m just not sure why today a two hour nap did it for me and my next post call day I may come home and crash for 12 hours straight.
Not that I’m not going to sleep well tonight probably.
A complicated hospital stay is likely to involve multiple physicians in any patient’s care.
At large academic centers there is often more than professional congeniality amongst the specialties. There are reputations and “interoffice” politics. In some cases, unfortunately, I can imagine it effecting patient care. I feel I’ve seen instances where consults, coming from certain services, were dismissed or taken lightly. I feel I’ve seen instances where recommendations from consulting services are taken with less heed because of the physician or service they came from. True, I’m not sure I can say I’ve seen negative consequences from such in specific but you can imagine such.
But being aware of the realities and paying attention to who is participating in your, or your friend or family member’s, care while you’re in the hospital can be important.
It’s well documented that having an advocate at your bedside in the hospital can aid your hospital course. Questioning the physicians you see in the hospital is important. I think it is important to keep track of every service that is participating in your care. If a provider seeing you doesn’t make it clear the first questions out of your mouth should be “What’s your name? What service are you with?”
You or your family or friends should advocate for daily calls from the consulting services to the primary service, not just a reiteration of their recommendations in the shared electronic medical records. When your primary team rounds you should inquire what recommendations the consulting services are making.
Even if you get a full annoyed looks and eye rolls.
Sanjay Gupta looks at a “bootcamp” put on for neurosurgical interns by the Society of Neurological Surgeons. I went to one of these this year and thought it was very well produced, very relevant and just generally a very good program. I hope the SNS and residency programs around the country continue to support this new program.
It’s Labor Day and I’ve made some fairly outrageous claims about the workload of a neurosurgical resident of recent. Seems a reasonable time to lay out exactly what a day on call can be like for me and my fellow residents.
To be fair an average experience may be hard to articulate. Different rotations and different days yield different…adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.
But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.
I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.
31 “When the Son of Man comes in his glory, and all the angels with him, he will sit on his throne in heavenly glory. 32 All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. 33He will put the sheep on his right and the goats on his left.
34 “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’
37 “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? 38 When did we see you a stranger and invite you in, or needing clothes and clothe you? 39 When did we see you sick or in prison and go to visit you?’
40 “The King will reply, ‘I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.’
41″Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. 42 For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, 43 I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’
44 “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’
45 “He will reply, ‘I tell you the truth, whatever you did not do for one of the least of these, you did not do for me.’
46 “Then they will go away to eternal punishment, but the righteous to eternal life.”
It was important for me to hear. Not the message of judgment necessarily, but the reminder of our obligation to serve.
Empathy is such an important part of medicine. It is favored in the medical school application process. And yet the decline in it as students and residents progress through training is well documented.
In part there’s a sense of inevitability with such. Familiarity weighs on such. Everything from callousing oneself to suffering to feelings that there is a lack of gratitude for your efforts to being tired to blaming patients for their illnesses. It all wears away the idealism and dedication to service that I think most medical students sincerely enter the profession with.
I’m guilty of it as most. And so it was good to be at church on Sunday.
I’m incredibly blessed. Not least because I am in a position to serve everyday. And I hate losing sight of that. I hate sitting in the call room at 2 am and getting a flood of pages from the ER. Those phone calls are a medical record number and some demographics and my annoyance at having more heaped onto my plate to do that night. All because some guy or gal got into their car after having too much to drink or fell off a bar stool or got into a fist fight.
There’s nothing to those judgments and my annoyance. These are people in the end who need my help. However they got to my care, here they are and I have the potential to do them great service and maybe affect their life for the better.
I want service to be central to me being a doctor. This isn’t just a job. These aren’t just hoops I have to jump through to complete training. These aren’t just operations.
These are chances to change lives; to serve.
Now just to take a deep breath late into my call nights and remember such.
There’s been a lot of dissatisfaction in surgical training with work hour restrictions. Perhaps I shouldn’t limit it to surgical residencies, merely to say, instead, that they’ve been the most vocal for my experience.
The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.
Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.
The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.
With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.
But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?
There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.
It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.
Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.
Intermittent, spotty posting is no way to run a blog. It has been a month since I posted anything; probably explains my Google Analytic numbers of recent. Luckily, I return with pretty incredible news.
Most incredibly, I’m engaged to a beautiful and wonderful girl. Off the market ladies, I apologize. I don’t know how I convinced her to marry me but she’s so far above and beyond what I deserve that I can’t ever imagine coming off this high.
In addition, about a year ago this time I did an interview with a Wall Street Journal blogger during which I was meandering and only at times coherent. I excuse myself for that, I had recently learned that I did not match after participating in the National Residency Matching Program. The interview was on the process of medical students become residents and physicians in the match and, in my case, the scramble.
I’ve spent nearly nine months serving in a general surgery preliminary residency spot and going through the residency match once again. This time with much better results. I’m going to be a neurosurgeon. Sure the path forward is rough and lengthy, but I’ve cleared a major hurdle.
The Sex Appeal Isn’t That He’s A Neurosurgeon, It’s That Hair
Anyway, I’m back to posting and I hope readers will return to reading.
