Teaching and Learning in Medicine, 27(2), 201–204 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011656
Medical Student Education in Neurosurgery: Optional or Essential? Darlene A. Lobel Center for Neurological Restoration, Neurological Institute at the Cleveland Clinic, Cleveland, Ohio, USA
Max Kahn Albany Medical College, Albany, New York, USA
Charles L. Rosen Department of Neurosurgery, West Virginia School of Medicine, Morgantown, West Virginia, USA
Julie G. Pilitsis Department of Neurosurgery, Albany Medical College, Albany, New York, USA
Issue: Current medical school curricula emphasize general practice principles, and this has led predictably to increasingly limited exposure to subspecialties, including neurosurgery. However, a significant amount of neurosurgical disease and/or emergencies present in primary care settings or emergency rooms. In light of an already acknowledged shortage of neurosurgery providers, this means that general practitioners should be well educated and prepared to diagnose and manage neurosurgical disease. Considering the devastating consequences of a missed or delayed neurosurgical diagnosis, limiting future physicians’ exposure to the field of neurosurgery is not in the best interests of the patient. Evidence: In this article, the authors review and discuss the results of several studies investigating the prevalence, presentation, diagnosis, and management of neurosurgical disease in emergency and general practice settings. They then discuss the current status of neurosurgical education in medical schools, both from the educators’ and students’ perspectives, and how this status might impact patient care. Finally, they offer suggestions for the improvement of neurosurgical education during medical school. Implications: Despite being considered highly subspecialized, neurosurgical diagnosis and care is a field in which all physicians should receive proper education and training. To properly serve patients and produce competent physicians, steps should be taken to reemphasize the importance of neurosurgical education for medical students. Keywords
education, emergency medicine, NBME, neurosurgery
INTRODUCTION As the field of health sciences expands, medical school educators are faced with the difficult challenge of incorporating a Correspondence may be sent to Darlene A. Lobel, Center for Neurological Restoration, Cleveland Clinic Foundation, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA. E-mail: [email protected]
tremendous amount of information into curricula. Their focus is to ensure that graduates have knowledge of basic issues encountered in general practice. Subsequently, exposure to subspecialties, including neurosurgery, has been limited. Although often considered highly subspecialized, data from national trauma banks and literature reviews demonstrate a high incidence of symptoms of neurosurgical disorders and indicate that a significant number of these patients present in primary care or emergency room (ER) settings. In addition, we as neurosurgeons are acutely aware of the devastating consequences of missed neurosurgical diagnoses, from both a patient perspective and resulting medicolegal sequelae.
SUPPORTING DATA High Prevalence of Symptoms Related to Neurosurgical Disease Among the most common presenting chief complaints treated by primary care providers (PCPs) and ER physicians are headache and back pain. Headache accounts for 45 million doctor visits annually and 4.5% of all ER visits.1 Less than 20% of patients with headache present initially to specialists; the majority present to PCPs.1 Although headaches are often benign, one in 100 is caused by serious pathology, including vascular abnormalities, hydrocephalus, or tumors.2 Unless the triaging doctor has proper training, nearly 500,000 patients risk misdiagnosis each year.2 Subarachnoid hemorrhage is misdiagnosed in 5% to 12% of ER cases, leading to a 39% complication rate and increased 1-year mortality compare to patients with correct and timely diagnoses.3 Back pain carries an 85% lifetime incidence and accounts for 12.7 million ER visits each year, according to National Ambulatory Medical Care Survey.4 Serious pathology,
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including fractures and tumors, accounts for 5% to 10% of back pain.4 Delay of diagnosis of radiculopathy, myelopathy, and cauda equina syndrome (CES) often results in permanent neurological deficit. Missed diagnosis of CES is a significant problem, as evidenced by a disproportionately high number of medico-legal claims.5 Closed head injury, the second most common traumatic injury, may be complicated by subdural or epidural hematoma, intracranial hemorrhage, and carotid or vertebral dissection. These diagnoses should be rapidly excluded by the triaging ER physician. Even though cranial computerized tomography (CT) scan is abnormal in 3% to 19% of patients with closed head injury, there is marked hospital variability in ordering head CTs, from 6.5% to 80%, for these patients.6 Of note, rate of misdiagnosis may reach 8% when head CTs are not routinely ordered for trauma evaluation, and as high as 73% in cases of subarachnoid hemorrhage.3,6 Such variation could be minimized by improving training in neurosurgical emergencies. According to the National Trauma Databank, nearly 10% of trauma patients have a spine injury, and up to 15% of these injuries are initially missed in multisystem traumas.7 The cervical spine is often “cleared” by plain radiograph alone, commonly read by ER attending physicians or housestaff. One study of ER reads on cervical X-rays revealed that only 29% of ER housestaff and 74% of ER attendings correctly identified cervical spine subluxation; 21% of attendings missed an odontoid fracture.8 The consequences of misdiagnosis and removing a cervical collar in such cases are devastating.
Impact of Limited Neurosurgical Coverage The critical problems just described arise from a lack of training of ER physicians and PCPs in emergency neurosurgical care and could be mitigated by the consistent presence of neurosurgeons in ERs. However, there is a known shortage of neurosurgical providers in some countries and/or regions of countries, thus requiring ER physicians to triage patients for transfer and to have at least cursory knowledge of neurological symptoms and emergencies. A study in Cook County, Illinois, demonstrated three remarkable findings: (a) 8% of patients waited more than 10 hours before transfer to a hospital with neurosurgery, (b) 15% of patients had a decline in Glasgow Coma Scale (GCS) while awaiting transfer, and (c) patients transferred from hospitals without a neurosurgeon were twice as likely to have a decline in GCS.9 As GCS at time of intervention is known to correlate with ultimate outcome, the cost of delayed triage and transfer to the patient and the healthcare system at large is evident.10 To improve triage and transfer, education is the start. The knowledge would improve clinical acumen and understanding of emergent situations. This better understanding will in turn improve dialogue between the generalist and the consultant. Ultimately, a more streamlined referral and transport process would allow for faster treatment and less cost to the patient
and to the medical system. Stroke care has successfully followed such a model. In neurosurgery, one common example where improved triage could help is cauda equina syndrome. Patients who received decompressive surgery within 24 hours had improved urinary function and seemed to have decreased incidence of chronic pain.11 As chronic pain leads to healthcare expenditures in the range of billions of U.S. dollars due to medical utilization and disability, the opportunity to limit a patient’s chance of chronic pain is significant.11,12 Further, 40% of medical lawsuits regarding missed diagnoses of CES were judged in favor of the plaintiff, with an average award of $1.57 million USD.13 These figures clearly demonstrate how education, dialogue, and a better referral process would result in benefit to patients, providers, and society.
Current Status of Medical Student Exposure to Neurosurgery We suggest that maximizing medical educational opportunities in neurosurgical disorders should be the initial step. A survey of medical school deans reports that most commonly internal and family medicine physicians teach students diagnosis of neurosurgical issues and that much of the material is outdated.14 Further, in 2011, 62% of medical schools did not have a formal neurosurgical curriculum and 90% of schools did not have a designated neurosurgical textbook.11 In addition, 59% of the deans felt that neurosurgery is an unnecessary student rotation.11 Our report as well as a recent survey of graduating medical school students demonstrates inadequate training in diagnosis of neurosurgical conditions (Figure 1).15 Previous literature has suggested the use of clinical neurosurgery electives as a method for increasing medical student exposure and interest in neurosurgery. In the United Kingdom, there exists “student-selected components,” which are essentially elective rotations in which a medical student can gain exposure and skills within specific specialties.16 Although electives are certainly a valuable way to increase exposure to certain fields, several issues present themselves when discussing making an elective the primary means by which students gain neurosurgery exposure. First, neurosurgical electives are already offered at many U.S. medical schools. Second, electives by their very definition are optional, and not all students entering primary care fields or emergency medicine will voluntarily choose to take a neurosurgery elective; given the urgent need for neurosurgical education described in the previous paragraphs, an optional neurosurgery elective would likely not have the significant widespread improvement in neurosurgical acumen we hope to achieve. Furthermore, many of the students who would be signing up for those electives might simply be students who are already desiring to pursue neurosurgery itself as a specialty; this phenomenon has been described as a motivating factor behind why students choose
MEDICAL STUDENT EDUCATION IN NEUROSURGERY
203
FIG. 1. Results of a survey sent to senior medical students regarding their sense of preparedness to diagnose and manage neurosurgical emergencies and common spine problems. Note: Three-fourths of students felt unprepared to manage spine patients, and more than 60% expressed concerns about their ability to diagnose neurosurgical emergencies.15
electives in other subspecialties in other countries, such as plastic surgery electives within Canadian medical schools.17
CONCLUSIONS The quantity and quality of neurosurgical content in medical school training has sparked robust debate between neurosurgeons and medical education organizations. In 1997, the American Association of Neurological Surgeons and Congress of Neurological Surgeons jointly petitioned U.S. medical schools deans to make curricular changes to increase exposure to diagnosis and treatment of neurosurgical conditions that are commonly seen in general medical practice. However, a formalized neurosurgical curriculum that was suggested to the deans has not been instituted in the majority of medical schools as of 2011.11 Reasons likely include the lack of emphasis of neurosurgical content on National Board of Medical Examiners (NBME) general and subject exams as well as the perceived rarity of neurosurgical disease seen by PCPs. Content of medical school curricula is often driven by NBME subject matter and content on such exams is driven by medical school curricular content. Such cyclical reasoning leaves limited avenues to introduce changes to education. As the critical need for neurosurgical training for all medical students may not be evident to all educators, it is our duty as neurosurgeons to ensure that medical students receive education in our field. Organized neurosurgery has developed several initiatives to achieve this goal including development of a medical student curriculum, recommended reading lists, and mentorship programs. We are working to increase awareness of these resources to all medical schools. Our efforts will fall short, however, if the importance of educating future physicians about our specialty is not accepted. One of the best ways to solidify the importance of these topics is to increase their presence on licensing exams. Currently, neurosurgery-related issues account for 1% of the overall focus of the United States Medical Licensing Examination Steps 2 and 3 and 10% coverage on the neuroscience and surgery shelf exams. This percentage, which has remained stagnant for years, does not provide graduating physicians with the necessary knowledge
base to safely identify neurosurgical conditions. Only through direct action, including petitioning the United States Medical Licensing Examination Examination Committee to examine test content in light of the aforementioned facts, may we ensure that common neurosurgical problems are appropriately represented on NBME examinations. Improvement in neurosurgical education, as the initial step in improved dialogue and streamlined referrals, would likely lead to improved diagnosis, more expeditious treatment, and ultimately better outcomes.
REFERENCES 1. Gibbs TS, Fleische Jr AB, Feldman SR, Sam MC, O’Donovan CA. Healthcare utilization in patients with migraine. Headache 2003;43:330–5. 2. Evans RW. Diagnostic testing for the evaluation of headaches. Neurologic Clinics 1996;14:1–26. 3. Kowalski RG, Claassen J, Kreiter KT, Bates JE, Ostapkovich ND, Connolly ES, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. Journal of the American Medical Association 2004;291:866–9. 4. Centers for Disease Control and Prevention. Ambulatory health care data. Accessed 2014. Available at: http://www.cdc.gov/nchs/ahcd/ahcd_prod ucts.htm. 5. Gardner A, Gardner E, Morley T. Cauda equina syndrome: A review of the current clinical and medico-legal position. European Spine Journal 2011;20:690–7. 6. Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhaure MA, et al. Variation in ED use of computed tomography for patients with minor head injury. Annals of Emergency Medicine 1997;30:14–22. 7. National Trauma Data Bank. Accessed 2014. Available at: http://www. ntdbdatacenter.com. 8. McLauchlan CA, Jones K, Guly HR: Interpretation of trauma radiographs by junior doctors in accident and emergency departments: A cause for concern? Journal of Accident and Emergency Medicine 1997;14:295–8. 9. Byrne RW, Bagan BT, Slavin KV, Curry D, Koski TR, Origitano TC. Neurosurgical emergency transfers to academic centers in Cook County: A prospective multicenter study. Neurosurgery 2008;62:709–16; discussion 709–16. 10. Pilitsis J, Atwater B, Warden D, Deck G, Carroll J, Smith J, et al. Outcomes in octogenarians with subdural hematomas. Clinical Neurology and Neurosurgery 2014;115:1429–32. 11. Fox BD, Amhaz HH, Patel AJ, Fulkerson DH, Suki D, Jea A, et al. Neurosurgical rotations or clerkships in US medical schools. Journal of Neurosurgery 2011;114:27–33.
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12. Smith M, Davis MA, Stano M, Whedon JM. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for year 20002007. Journal of Manipulative and Physiologic Therapeutics 2013;36:2–11. 13. Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU. Review of medicolegal cases for cauda equina syndrome: What factors lead to an adverse outcome for the provider? Orthopedics 2012;e414–9. 14. Resnick DK. Neuroscience education of undergraduate medical students. Part I: Role of neurosurgeons as educators. Journal of Neurosurgery 2000;92:637–41.
15. Pilitsis JG, Beverly S, Mazzola C, Ashley WW, Colen C, Asadi K, et al. Neurosurgeon and student perspective on the current medical education in neurosurgery. AANS Neurosurgeon 2013;22. 16. Kolias AG, Trivedi RA. Enhancing the exposure of medical students to neurosurgery. British Journal of Neurosurgery 2013;27:706. 17. Tahiri Y, Lee J, Kanevsky J, Thibaudeau S, Gilardino M. The differeing perceptions of plastic surgery between potential applicants and current trainees: The importance of clinical exposure and electives for medical students. The Canadian Journal of Plastic Surgery 2013;21:178–80.
Copyright of Teaching & Learning in Medicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Medical Student Education in Neurosurgery: Optional or Essential? Darlene A. Lobel Center for Neurological Restoration, Neurological Institute at the Cleveland Clinic, Cleveland, Ohio, USA
Max Kahn Albany Medical College, Albany, New York, USA
Charles L. Rosen Department of Neurosurgery, West Virginia School of Medicine, Morgantown, West Virginia, USA
Julie G. Pilitsis Department of Neurosurgery, Albany Medical College, Albany, New York, USA
Issue: Current medical school curricula emphasize general practice principles, and this has led predictably to increasingly limited exposure to subspecialties, including neurosurgery. However, a significant amount of neurosurgical disease and/or emergencies present in primary care settings or emergency rooms. In light of an already acknowledged shortage of neurosurgery providers, this means that general practitioners should be well educated and prepared to diagnose and manage neurosurgical disease. Considering the devastating consequences of a missed or delayed neurosurgical diagnosis, limiting future physicians’ exposure to the field of neurosurgery is not in the best interests of the patient. Evidence: In this article, the authors review and discuss the results of several studies investigating the prevalence, presentation, diagnosis, and management of neurosurgical disease in emergency and general practice settings. They then discuss the current status of neurosurgical education in medical schools, both from the educators’ and students’ perspectives, and how this status might impact patient care. Finally, they offer suggestions for the improvement of neurosurgical education during medical school. Implications: Despite being considered highly subspecialized, neurosurgical diagnosis and care is a field in which all physicians should receive proper education and training. To properly serve patients and produce competent physicians, steps should be taken to reemphasize the importance of neurosurgical education for medical students. Keywords
education, emergency medicine, NBME, neurosurgery
INTRODUCTION As the field of health sciences expands, medical school educators are faced with the difficult challenge of incorporating a Correspondence may be sent to Darlene A. Lobel, Center for Neurological Restoration, Cleveland Clinic Foundation, 9500 Euclid Avenue, S31, Cleveland, OH 44195, USA. E-mail: [email protected]
tremendous amount of information into curricula. Their focus is to ensure that graduates have knowledge of basic issues encountered in general practice. Subsequently, exposure to subspecialties, including neurosurgery, has been limited. Although often considered highly subspecialized, data from national trauma banks and literature reviews demonstrate a high incidence of symptoms of neurosurgical disorders and indicate that a significant number of these patients present in primary care or emergency room (ER) settings. In addition, we as neurosurgeons are acutely aware of the devastating consequences of missed neurosurgical diagnoses, from both a patient perspective and resulting medicolegal sequelae.
SUPPORTING DATA High Prevalence of Symptoms Related to Neurosurgical Disease Among the most common presenting chief complaints treated by primary care providers (PCPs) and ER physicians are headache and back pain. Headache accounts for 45 million doctor visits annually and 4.5% of all ER visits.1 Less than 20% of patients with headache present initially to specialists; the majority present to PCPs.1 Although headaches are often benign, one in 100 is caused by serious pathology, including vascular abnormalities, hydrocephalus, or tumors.2 Unless the triaging doctor has proper training, nearly 500,000 patients risk misdiagnosis each year.2 Subarachnoid hemorrhage is misdiagnosed in 5% to 12% of ER cases, leading to a 39% complication rate and increased 1-year mortality compare to patients with correct and timely diagnoses.3 Back pain carries an 85% lifetime incidence and accounts for 12.7 million ER visits each year, according to National Ambulatory Medical Care Survey.4 Serious pathology,
201
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D. A. LOBEL, M. KAHN, C. L. ROSEN, J. G. PILITSIS
including fractures and tumors, accounts for 5% to 10% of back pain.4 Delay of diagnosis of radiculopathy, myelopathy, and cauda equina syndrome (CES) often results in permanent neurological deficit. Missed diagnosis of CES is a significant problem, as evidenced by a disproportionately high number of medico-legal claims.5 Closed head injury, the second most common traumatic injury, may be complicated by subdural or epidural hematoma, intracranial hemorrhage, and carotid or vertebral dissection. These diagnoses should be rapidly excluded by the triaging ER physician. Even though cranial computerized tomography (CT) scan is abnormal in 3% to 19% of patients with closed head injury, there is marked hospital variability in ordering head CTs, from 6.5% to 80%, for these patients.6 Of note, rate of misdiagnosis may reach 8% when head CTs are not routinely ordered for trauma evaluation, and as high as 73% in cases of subarachnoid hemorrhage.3,6 Such variation could be minimized by improving training in neurosurgical emergencies. According to the National Trauma Databank, nearly 10% of trauma patients have a spine injury, and up to 15% of these injuries are initially missed in multisystem traumas.7 The cervical spine is often “cleared” by plain radiograph alone, commonly read by ER attending physicians or housestaff. One study of ER reads on cervical X-rays revealed that only 29% of ER housestaff and 74% of ER attendings correctly identified cervical spine subluxation; 21% of attendings missed an odontoid fracture.8 The consequences of misdiagnosis and removing a cervical collar in such cases are devastating.
Impact of Limited Neurosurgical Coverage The critical problems just described arise from a lack of training of ER physicians and PCPs in emergency neurosurgical care and could be mitigated by the consistent presence of neurosurgeons in ERs. However, there is a known shortage of neurosurgical providers in some countries and/or regions of countries, thus requiring ER physicians to triage patients for transfer and to have at least cursory knowledge of neurological symptoms and emergencies. A study in Cook County, Illinois, demonstrated three remarkable findings: (a) 8% of patients waited more than 10 hours before transfer to a hospital with neurosurgery, (b) 15% of patients had a decline in Glasgow Coma Scale (GCS) while awaiting transfer, and (c) patients transferred from hospitals without a neurosurgeon were twice as likely to have a decline in GCS.9 As GCS at time of intervention is known to correlate with ultimate outcome, the cost of delayed triage and transfer to the patient and the healthcare system at large is evident.10 To improve triage and transfer, education is the start. The knowledge would improve clinical acumen and understanding of emergent situations. This better understanding will in turn improve dialogue between the generalist and the consultant. Ultimately, a more streamlined referral and transport process would allow for faster treatment and less cost to the patient
and to the medical system. Stroke care has successfully followed such a model. In neurosurgery, one common example where improved triage could help is cauda equina syndrome. Patients who received decompressive surgery within 24 hours had improved urinary function and seemed to have decreased incidence of chronic pain.11 As chronic pain leads to healthcare expenditures in the range of billions of U.S. dollars due to medical utilization and disability, the opportunity to limit a patient’s chance of chronic pain is significant.11,12 Further, 40% of medical lawsuits regarding missed diagnoses of CES were judged in favor of the plaintiff, with an average award of $1.57 million USD.13 These figures clearly demonstrate how education, dialogue, and a better referral process would result in benefit to patients, providers, and society.
Current Status of Medical Student Exposure to Neurosurgery We suggest that maximizing medical educational opportunities in neurosurgical disorders should be the initial step. A survey of medical school deans reports that most commonly internal and family medicine physicians teach students diagnosis of neurosurgical issues and that much of the material is outdated.14 Further, in 2011, 62% of medical schools did not have a formal neurosurgical curriculum and 90% of schools did not have a designated neurosurgical textbook.11 In addition, 59% of the deans felt that neurosurgery is an unnecessary student rotation.11 Our report as well as a recent survey of graduating medical school students demonstrates inadequate training in diagnosis of neurosurgical conditions (Figure 1).15 Previous literature has suggested the use of clinical neurosurgery electives as a method for increasing medical student exposure and interest in neurosurgery. In the United Kingdom, there exists “student-selected components,” which are essentially elective rotations in which a medical student can gain exposure and skills within specific specialties.16 Although electives are certainly a valuable way to increase exposure to certain fields, several issues present themselves when discussing making an elective the primary means by which students gain neurosurgery exposure. First, neurosurgical electives are already offered at many U.S. medical schools. Second, electives by their very definition are optional, and not all students entering primary care fields or emergency medicine will voluntarily choose to take a neurosurgery elective; given the urgent need for neurosurgical education described in the previous paragraphs, an optional neurosurgery elective would likely not have the significant widespread improvement in neurosurgical acumen we hope to achieve. Furthermore, many of the students who would be signing up for those electives might simply be students who are already desiring to pursue neurosurgery itself as a specialty; this phenomenon has been described as a motivating factor behind why students choose
MEDICAL STUDENT EDUCATION IN NEUROSURGERY
203
FIG. 1. Results of a survey sent to senior medical students regarding their sense of preparedness to diagnose and manage neurosurgical emergencies and common spine problems. Note: Three-fourths of students felt unprepared to manage spine patients, and more than 60% expressed concerns about their ability to diagnose neurosurgical emergencies.15
electives in other subspecialties in other countries, such as plastic surgery electives within Canadian medical schools.17
CONCLUSIONS The quantity and quality of neurosurgical content in medical school training has sparked robust debate between neurosurgeons and medical education organizations. In 1997, the American Association of Neurological Surgeons and Congress of Neurological Surgeons jointly petitioned U.S. medical schools deans to make curricular changes to increase exposure to diagnosis and treatment of neurosurgical conditions that are commonly seen in general medical practice. However, a formalized neurosurgical curriculum that was suggested to the deans has not been instituted in the majority of medical schools as of 2011.11 Reasons likely include the lack of emphasis of neurosurgical content on National Board of Medical Examiners (NBME) general and subject exams as well as the perceived rarity of neurosurgical disease seen by PCPs. Content of medical school curricula is often driven by NBME subject matter and content on such exams is driven by medical school curricular content. Such cyclical reasoning leaves limited avenues to introduce changes to education. As the critical need for neurosurgical training for all medical students may not be evident to all educators, it is our duty as neurosurgeons to ensure that medical students receive education in our field. Organized neurosurgery has developed several initiatives to achieve this goal including development of a medical student curriculum, recommended reading lists, and mentorship programs. We are working to increase awareness of these resources to all medical schools. Our efforts will fall short, however, if the importance of educating future physicians about our specialty is not accepted. One of the best ways to solidify the importance of these topics is to increase their presence on licensing exams. Currently, neurosurgery-related issues account for 1% of the overall focus of the United States Medical Licensing Examination Steps 2 and 3 and 10% coverage on the neuroscience and surgery shelf exams. This percentage, which has remained stagnant for years, does not provide graduating physicians with the necessary knowledge
base to safely identify neurosurgical conditions. Only through direct action, including petitioning the United States Medical Licensing Examination Examination Committee to examine test content in light of the aforementioned facts, may we ensure that common neurosurgical problems are appropriately represented on NBME examinations. Improvement in neurosurgical education, as the initial step in improved dialogue and streamlined referrals, would likely lead to improved diagnosis, more expeditious treatment, and ultimately better outcomes.
REFERENCES 1. Gibbs TS, Fleische Jr AB, Feldman SR, Sam MC, O’Donovan CA. Healthcare utilization in patients with migraine. Headache 2003;43:330–5. 2. Evans RW. Diagnostic testing for the evaluation of headaches. Neurologic Clinics 1996;14:1–26. 3. Kowalski RG, Claassen J, Kreiter KT, Bates JE, Ostapkovich ND, Connolly ES, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. Journal of the American Medical Association 2004;291:866–9. 4. Centers for Disease Control and Prevention. Ambulatory health care data. Accessed 2014. Available at: http://www.cdc.gov/nchs/ahcd/ahcd_prod ucts.htm. 5. Gardner A, Gardner E, Morley T. Cauda equina syndrome: A review of the current clinical and medico-legal position. European Spine Journal 2011;20:690–7. 6. Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhaure MA, et al. Variation in ED use of computed tomography for patients with minor head injury. Annals of Emergency Medicine 1997;30:14–22. 7. National Trauma Data Bank. Accessed 2014. Available at: http://www. ntdbdatacenter.com. 8. McLauchlan CA, Jones K, Guly HR: Interpretation of trauma radiographs by junior doctors in accident and emergency departments: A cause for concern? Journal of Accident and Emergency Medicine 1997;14:295–8. 9. Byrne RW, Bagan BT, Slavin KV, Curry D, Koski TR, Origitano TC. Neurosurgical emergency transfers to academic centers in Cook County: A prospective multicenter study. Neurosurgery 2008;62:709–16; discussion 709–16. 10. Pilitsis J, Atwater B, Warden D, Deck G, Carroll J, Smith J, et al. Outcomes in octogenarians with subdural hematomas. Clinical Neurology and Neurosurgery 2014;115:1429–32. 11. Fox BD, Amhaz HH, Patel AJ, Fulkerson DH, Suki D, Jea A, et al. Neurosurgical rotations or clerkships in US medical schools. Journal of Neurosurgery 2011;114:27–33.
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D. A. LOBEL, M. KAHN, C. L. ROSEN, J. G. PILITSIS
12. Smith M, Davis MA, Stano M, Whedon JM. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for year 20002007. Journal of Manipulative and Physiologic Therapeutics 2013;36:2–11. 13. Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU. Review of medicolegal cases for cauda equina syndrome: What factors lead to an adverse outcome for the provider? Orthopedics 2012;e414–9. 14. Resnick DK. Neuroscience education of undergraduate medical students. Part I: Role of neurosurgeons as educators. Journal of Neurosurgery 2000;92:637–41.
15. Pilitsis JG, Beverly S, Mazzola C, Ashley WW, Colen C, Asadi K, et al. Neurosurgeon and student perspective on the current medical education in neurosurgery. AANS Neurosurgeon 2013;22. 16. Kolias AG, Trivedi RA. Enhancing the exposure of medical students to neurosurgery. British Journal of Neurosurgery 2013;27:706. 17. Tahiri Y, Lee J, Kanevsky J, Thibaudeau S, Gilardino M. The differeing perceptions of plastic surgery between potential applicants and current trainees: The importance of clinical exposure and electives for medical students. The Canadian Journal of Plastic Surgery 2013;21:178–80.
Copyright of Teaching & Learning in Medicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
