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.

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?

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.

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.

I’ve written before about a sense of urgency sometimes lacking amongst patients and family and friends when asking permission for surgery. The majority of the time that appears to come from being overwhelmed, rarely it comes from a lack of trust.

I was thinking about situations in which physicians need to establish trust in very short order. I suppose that’s always the case in the patient-physician relationship. But there’s something to be said for the acuity of a hospital visit and what things like resident work hours, increased physician hand offs, co-management of patients between different physicians have done for the inpatient-physician relationship and what it means for establishing trust during a scary period for most people – when they’re in the hospital.

Last night, for example, I was cross covering at the county hospital. Basically I’m on rotation at another hospital, but because the county hospital, with its high level of neurotrauma, is the only participating facility in my residency that we take in house call at they need residents at the other facilities to come take call there some nights.

Not quite inevitably but often there are inpatients at the county hospital who are going to the operating room the next day and who have not been consented for surgery. And so that responsibility falls to me overnight.

This is a situation where I’ve never met this patient before, haven’t participated to this point in his care and in our first encounter I’m going to go over, amongst other things, what potentially horrific sounding things could happen to him during brain surgery.

It’s not easy presenting it with some confidence, humility, frankness to someone you’ve just met and leaving the situation with them feeling confident in the major step they’re taking tomorrow. I’ve certainly bungled it, and seen many another physician bungle it, even when they have a good pre-existing relationship with the patient.

I think the key is being confident, friendly but professional and dedicating some time to explaining the situation.

That may seem obvious, but sometimes the response on a busy cross cover night is to rush the situation. The patient usually knows they’re going to surgery tomorrow and has a general idea why and what for. Sometimes amidst the ICU and the consults the idea is to do the consent as quickly as possible and move on.

Being frank about who you are, your role in the introduction, describing the surgery and then being frank and honest but apologetic and realistic in the risks are good strategies for making patients as comfortable as possible as they contemplate surgery the next day. Doing it earlier, rather than later in the evening is also a good move.

And then poof, after such an important life discussion you’re gone. As for that patient I consented last night there is a good chance I may never see him again. That probably says something about physician coverage, work hours and the like but I’m not sure what in full.

The sense of smell is a special afferent skill facilitated by the first numbered cranial nerve, the olfactory nerve.

The first order neurons of the olfactory nerve are the olfactory sensory neurons. These are bipolar cells whose dendrites project g-coupled olfactory receptors into the olfactory mucosa. Dissolved molecules within the mucosa act as ligands at these receptors and trigger an action potential which travels ‘up’ the bipolar olfactory sensory neurons. The axons of these cells colasce into processes which head through the cribiform plate. These processes truly represent the olfactory ‘nerve’.

The processes which make up this short nerve end as they synapse on the second order neurons at intracranial olfactory bulb. The olfactory bulb is complexly organized however the primary secondary neurons are the mitral and tufted cells. The axons of these secondary neurons make up the olfactory tract. Of note, a very small number of these mitral and tuft cells will synapse onto the neurons of the anterior olfactory nucleus, just at the junction of the olfactory bulb and tract. The role of the anterior olfactory nucleus is extremely poorly understood.

The majority of the second order neurons however continue through the olfactory tract and just anterior to the anterior perforating substance the tract splits into striae, primarily lateral and medial striae, however many texts also list an intermediate striae.

The lateral striae ends in the primary olfactory area where the second order neurons synapse on third order neurons of the pyriform area; primarily in the cortex of the amygdala and entorhinal area in the temporal lobe. These third order neurons provide the primary projections from the olfactory system to the rest of the brain. Meanwhile the third order neurons found at the end of the axons of the medial striae are found in nuclei of the subcollasal and preseptal areas. We should note that some fibers from the medial striae cross at the anterior commisure to synapse in the contralateral subcollasal regions.

Projections from the primary olfactory area, the termination for the second order neurons of the lateral striae, include Brodmann Area 28.

From subcallosal nuclei projections extend through the medial forebrain bundle to the hypothalamus. Other projections carry through the retroflex fasciculus to the habenular nucleus. From the habenular nucleus and the hypothalamus projections go the reticular formation, superior salivatory nucleus, inferior salivatory nucleus, dorsal vagal nucleus and elsewhere.

Beyond fractures through the ethmoid bone which may lead to transection of the olfactory nerve and anosmia, the primary clinical consideration (at least as far as the Board Exam goes) is likely Foster-Kennedy Syndrome [PDF]. Here you get a collection of typical symptoms:

• Anosmia
• Optic Atrophy
• Papilledema
• Unilateral central scotoma
• Sometimes frontal lobe injury signs such as emotional lability or personality changes

This related to a large anterior skull base mass causing, typically unilateral, olfatory tract compression.

New physicians, known as interns, entering residency, which is the training physicians go through after medical school, can no longer take overnight call in the hospital without supervision from a more advanced resident or from a faculty physician. In addition they cannot work more than 16 hours straight. This as of July 1st.

For me this means a situation in which I’m taking essentially the same amount of overnight call as I did last year but, if the interns were part of the overnight call pool I’d be taking substantially less. Let this stand as my disclosure for this post.

The rules for interns are part of new regulations on resident physician work hours from the Accreditation Council for Graduate Medical Education.

For the past decade, the move to limit resident working hours has been a constant debate and struggle. I’ve written about it in the past here and here. Part of the situation is that it has become accepted that longer duty hours, less sleep for resident physicians, who are intimately involved with patient care at teaching facilities, leads to iatrogenic harm and worse patient care.

In moves to improve patient care and, in no small measure, to stem any public outcry and to make sure that resident duty hour regulation remains part of medicine’s self govern mandate the rules on resident work hours have become subsequently more restrictive through three iterations.

The problem is however that no matter how intuitive it may seem that limiting the amount of time resident physicians can work should mean they’re more rested should mean fewer mistakes when treating patients, it turns out that the evidence for such was highly circumstantial when resident work hours were first implemented and has not been borne out since the implementation.

It’s true that there are witnessed attentional mistakes in medicine that lead to patient harm. And it’s true that there is evidence from studies outside of medicine, and our own everyday anecdotal experience, that fatigue worsens attentional mistakes.

A very small 2004 study in the New England Journal of Medicine, 24 interns partook, randomized but did not blind the schedules of these physicians-in-training to a traditional schedule with 30 hour call shifts, where the residents routinely but not always worked over 80 hours a week, and to a float system where the residents worked 16 hour shifts and did not work over 80 hours a week. The interns working more and working longer shifts, made more errors.

But since implementation of resident physician work hour restrictions almost no change in patient’s harmed by errors or in patient outcomes has been seen. This from multiple large retrospective studies looking at data from millions of patient visits to teaching hospitals.

In a very good recent piece in The New York Times Magazine, Dr. Darshak Sanghavi, tried to explain why. The article was aptly titled “The Phantom Menace of Sleep Deprived Doctors,”

About 98,000 people die every year from medical errors. Some of those mistakes are made by doctors whose judgment has been scrambled by lack of sleep. But fixating on work hours has meant overlooking other issues, like lack of supervision or the failure to use more reliable computerized records. Worse still, the reforms may have created new, unexpected sources of mistakes. Shorter shifts mean doctors have less continuity with their patients. If one doctor leaves, another must take over. Work-hour reductions lead to more handoffs of patients, and the number of these handoffs is one of the strongest risk factors for error. As a result, many hospitalized patients are at the mercy of a real-life game of telephone, where a message is passed from doctor to doctor — and frequently garbled in the process.

Shorter shifts mean more patient handoffs, where oncoming new residents have to learn what is going on with complex patients in a short amount of time. As well, other issues are at play, including a lack of standardization of resident supervision by faculty physician.

The point of Dr. Sanghavi, and one that I agree with, is that efforts focused largely on resident work hours have failed to yield the desired results. And it likely isn’t because we haven’t gone far enough in banishing the sleep deprived doctor. I would say it’s probably because the myth of the sleep deprived doctor was contributing very little to poor outcomes. We should be looking at other factors when it comes to resident’s role in patient safety.

To be fair the new instructions from on high have a focus on more than just work hours. For instance, above I complain about the fact that interns cannot work without supervision in the hospital. But further restrictions on how much they and other residents can work likely is only an impediment to patient care. Certainly it hasn’t achieved what the ACGME or the IOM or anyone else hoped in terms of its end result in reducing iatrogenic patient harm.

There are other factors in play here, namely political ones and public perception, but if we were rational about this the next ACGME panel to revise the resident work hour rules would look retrospectively as well and consider not only the possibility of further constricting how much residents can work but also potentially lightening the restrictions which, clearly to date, have failed.

I can dream I suppose.

I’ve been thinking a lot of late about informed consent. I mean the ethics of trying to explain, in sufficient detail, what exactly you propose to do to a patient, what the potential benefits of such are, what the potential risks of such are, what the potential alternatives are.

Excuse me rehashing; I know it isn’t a new topic.

But I think often we fall far short of informed consent, at least what I was taught informed consent encompassed in medical school. And I’m not sure it is a fault of our own.

Medicine, more than any other consumer transaction (and I use that term loosely) has an informational imbalance. It is a situation wherein the physician has a much greater level of knowledge than the patient can often ever hope to. And often, with the nuances of and individuality befit every separate case, the majority of the patient’s knowledge must come from the physician.

If I take my car in and the mechanic hands over a bill for $700 for a new altinator I can research the symptoms of a failing altinator and compare them to my car’s own and if I want I can research the step by step specifics of how to replace an altinator and probably, if I was so inclined, manage it myself.

Facing the description of a medical procedure, the risks of it, the description of the pain and what to expect in recovery however is something else. There is a final step to reality that often times, if the patients and families lack a comparable experience to draw on, cannot be made.

I can try to convey the pain I’ve seen other patients go through after a surgery but without previous experience it often seems meaningless to patients. I can try to explain exactly what I propose to do to a patient step by step with models and diaphragms but the brutal reality of surgery is often somewhere lost between the clinic and the operating room. I can try to explain the plethora of risks I’m instructed to list out to the most dramatic, but quoting 1 in 1 million chance of contracting HIV with this transfusion is almost meaningless. 1 in 1 million, what does that even mean? How to comprehend that? What to compare it to? How to weigh it against the alternative?

Supposedly those are the questions informed consent is supposed to put into perspective. But in patients with limited education, limited health literacy, with no comparable experiences within the health care system, it sometimes seems no amount of time spent on consent will leave them informed.

Quizzical looks fading into resignation and repeated, non-sequitor questions I don’t think are always a symptom of my performance in trying to obtain informed consent. I think they’re just the nature of the situation sometimes.

I certainly have never thought my views on medicine, on the patient-physician relationship paternalistic but sometimes; sometimes it feels the best informed consent is to lay out, as best you can, why a procedure needs to be done, in very basic terms what the procedure is, your experience with the procedure, the fact that bad things can happen and let the minutiae stay aside. Maybe informed consent is something different for each patient, for each situation.

I know that isn’t reality and there are medicolegal and other aspects to consider but that feels ethical to me.

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.

Ile Bubulina Blog

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.

Outline of Neurosurgery (Outline of Neurosurgery PDF)

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.

Vesalius

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.

AFIP Neuroradiology Archives

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.

Sylvius

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.

The Whole Brain Atlas

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