Ask a neurosurgery resident anything
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Not to, I can't think of another word for it, but "dickride," but that was very poignantly and eloquently put. Man, you are almost at "person that influenced you the most" level for me.
In short, yes I have seen it. We tend to use a lot of propofol for anesthesia and it suppresses seizures. For tumors in eloquent areas we do an awake craniotomy, meaning the patient is wide awake, and use a microstimulator to pass current to the different cortical areas to provide an intraoperative functional map. This allows for improved planning for resection. We can actually, inadvertently, trigger a seizure during stimulation. When it happens the patient may or may not have other clinical manifestations like motor activity, but the brain turns purple and swells out of the craniotomy site. We have ice cold saline on the back table to irrigate the field and if need be ask anesthesia to administer an antiepleptic. From what I gather, the patient did not have any further neurological sequelae from the seizure.
Family life is an important thing and many neurosurgeons of the past have been known for being strangers in their own home. The joke "where do you hide a dollar" for the various specialties: medicine, under a dressing; radiology: with the patient, orthopaedics, in a book; plastics: you can't; neurosurgery: with his son, has a vein of truth. Clearly, it is a rather demanding job with respect to hours worked and so on and some of those factors implicitly can not be changed. Having a partner who is understanding and supportive helps immensely. In my program we have residents who are married with or are expecting kids. Each family handles things differently, but the general sense I get is that they remain as involved as possible. While I don't have kids, my father is a physician in a time demanding field. He couldn't drive us to and from school every day or be our little league coach, but he made a point to make the time he spends with us quality time. Many of my friends growing up remarked how involved my dad was, despite not always being available in comparison to their dads who were readily available but minimally involved.
One thing I don't understand about brain surgery is how it doesn't cause stroke like damage afterwords?
What I mean is, if you're cutting into the brain aren't you killing a lot of brain cells? In stroke, it only requires a few millimeters of dead brain cells to cause its characteristic dysfunction. How is brain surgery even possible as I assume you're killing more than a few square millimeters of cells.
What I mean is, if you're cutting into the brain aren't you killing a lot of brain cells? In stroke, it only requires a few millimeters of dead brain cells to cause its characteristic dysfunction. How is brain surgery even possible as I assume you're killing more than a few square millimeters of cells.
Fortunately, there has been an abundance of research in the past to build our knowledge of neuro-anatomy and function. True, a small stroke of even a few milimeters, in the right location, can cause dramatic deficits.
Brain surgery is a rather delicate en devour. For every surgery, we look at an abundance of information including patient age, comorbidities, clinical signs and symptoms, and diagnostic imaging and then weigh the risk and benefit of an intervention.
A lot of the surgeries we do are not "in the brain," meaning if we take out an epidural or subdural hematoma, clip an aneurysm, or take out a meningioma we open the skull and/or dura/pia arachnoid but do not actually enter the brain tissue. For others, such as intraparenchymal hemorrhage or intra-axial (inside the brain) tumor we weigh the risk and benefit.
Some areas of brain are more important than others (motor strip, brain stem, etc.) so harming those areas with a surgery may not be worth the risk. That being said, if a surgery is still indicated we take every precaution during the surgery such as the wake craniotomy with cortical mapping I described earlier that allows for us to avoid delicate structures.
Even with the most cautious technique patients can have deficits afterward, either from direct injury or from swelling from the surgery.
Thanks bud, I'm quite flattered.
What has been your favorite surgery to be a part of...either actively or as observer? Even before I knew medicine was the path for me, I have always been interested in neurosurgery. I can't thank you enough for this. It's been insanely insightful.
Do you read frequently? If so what do you read? Books? Newspaper? Magazine?
Since the cat is out of the bag, do you feel that neurosurgeon attendings are overcompensated for what they do? I understand the lifestyle, the enormous amount of training, the emotional and physical toll and the risk of being sued are immense, but do you feel it warrants most neurosurgeons making 450k+ a year?
I guess also, do you feel most physicians are overcompensated in general?
I'm sure you don't want to let us know where you are (ah, the joy of annonymity!) BUT could you possible list a few programs you 'd recommend for residency? I'd like to plan my electives to hit the right places. I would imagine that program reputations are not equal from specialty to specialty (a place that has a great rep for cardiovascular interventionists wouldn't necessarily be great for neurosurgery)...
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I have a lot of favorite surgeries. A ruptured aneurysm is always exciting because it is technically challenging and the patient is very sick. A trauma that needs a craniotomy can be fun because of how quickly everything needs to come together. Epilepsy surgery is very neat because of the anatomy and generally good outcomes. I like instrumented spine, just the tactile feel of a good pedical screw and building a solid construct. Tumor surgery, especially in eloquent cortex is neat that we can have an awake patient that we are talking to as we take the tumor out of the brain.
I read all of the time. I get the red and white journals (neurosurgery and journal of neurosurgery, respectively) as well as world neurosurgery. My favorite neurosurgery books are schmidek and sweet, youman's, and rhoton. I'll pick up a novel when I have some free time and prefer the classics, history, or biographies. For newspapers I'll skim headlines of the WSJ and NYT as well as my current hometime paper, and the papers where I went to high school, college, and medical school. I'll glance at news aggregation sites like drudge report or reddit. I used to read more magazines like the atlantic, wilson's, the new yorker, and the economist but found the subscription price wasn't worth it because I would end up with a stack of hardly read magazines.
Most neurosurgeons seem fairly compensated for what they do and the services they provide. I have friends from high school and college who were making >$100,000 out of college working in the finance sector or consulting. Now that it's several years down the road they are likely making quite a sum more than that, though a lot of it is performance based and in bonus form. Most doctors are not overcompensated and most do not live lavish lifestyles. A recent analysis suggests that a neurosurgeon adds close to $3 million in direct value to a hospital https://docs.google.com/viewer?a=v&...Wo60FS&sig=AHIEtbTRt9XS0pROBqEAga2Jq-F_iCvu9g Compensation of $450,000 or 15% of this additional value seems fair.
Residency location preference is a very individual, multi-factorial decision. The guys over at uncleharvey seem to like to debate which programs are "top" http://uncleharvey.com/index.php/forums/viewthread/3431/ but when you are looking for a program you have to take a lot of things in to consideration. Do you have a family or need to be near somewhere in particular? Do you want a small, close-knit feel or a big nameless machine? Different institutions allow for different levels of resident autonomy. What is your goal of training, do you want to go in to academics or private practice? Does one particular sub-section of neurosurgery particularly interest you more than others? That being said, find a program that fits your personal description. Someone who needs to be near an ocean would hate being at Oklahoma or West Virginia whereas someone who wants a lot of research opportunities and to live in a big city would love UCSF, MGH, or Columbia.
Every surgery and hospital care has direct fixed costs for things like operating room time, hospital days, and disposable things used during hospitalization like ted hoes.
We do often have patients who are un- or under- insured. Typically we do the surgery anyway and sort things out afterwards. The hospital has a number of programs for repayment and a number of grants/charity organizations that help offset costs for people who can not afford it.
That being said, I doubt most people out there would be able to afford a a brain surgery if they were paying out of pocket. The costs aren't just the surgery itself or the hospitalization, but also possibly a rehab stay, being out of work for several weeks to recover, and chemotherapy or radiation therapy.
Would having a major in Neuroscience help the ambitious endeavor of going into neurosurgery?
Also, how many Osteopathic neurosurgeons do you know? I am considering Osteopathic medical school because of the difference in teaching.
Also, how many Osteopathic neurosurgeons do you know? I am considering Osteopathic medical school because of the difference in teaching.
What do you think about inducing an infection as an experimental treatment for glioblastoma?
Hi Arijos, you might wanna check out http://uncleharvey.com. They have match lists for the past several years posted.
I don't suspect majoring in neuroscience will help or hurt going in to neurosurgery. The day to day practice often does not involve much basic neuroscience, but understanding the integration of the different systems and how it creates function, or lack thereof, is fundamentally important to neurosurgery.
Osteopathic physicians have a separate medical school and residency training system. I know of two DO graduates who are currently in allopathic residency programs, but it is the exception rather than the rule. Evidently, the ACGME and AOA made an agreement recently wherein the two graduate medical education governing bodies will work together in the future to ensure a standard of training.
I find it hard to believe, but the notion has been mentioned by many different people as an anecdotal observation. A neurosurgeon was recently sanctioned and banned from human research for investigating the topic http://www.sacbee.com/2012/07/22/4648415/2-uc-davis-neurosurgeons-accused.html
Yep, this is exactly what I was referring to. What do you think about this? Do you think the decision to ban them from research was justified? How common is it to do experimental procedures in terminal/critically ill patients, and are these procedures always reported to an IRB or ethics committee?
Also, thanks so much for your answers! Your feedback has been extremely helpful, and it is much appreciated.
My grandmother recently died of ALS and I decided to devote my life to the lives of others. Can a Neurosurgeon do research and clinical trials on patients with ALS? So they can help find a cure?
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Neurology is probably a better bet, but for what it is worth I know of a few neurosurgeons who are involved in certain aspects of ALS, mostly devices and wheelchairs capable of being used by ALS patients to enhance their mobility and independence.
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Sorry to butt in on neuseu's responses as I'm not sure to what extent neurosurgeons deal with ALS, but neuromuscular specialists in neurology deal with a lot of ALS patients and clinical trials.
In the book "Brain Surgeon" by Keith Black, MD he mentioned you have to do at least 50 brain surgeries per year to maintain proficiency. Does that sound about right? That would make it out to be about one surgery per week, that doesn't seem that bad.
I can't say I am convinced it actually provides a benefit. While I do not know the intimate details, the report indicates the study was, in some fashion, approved by the IRB. Nonetheless, all of the patients did poorly. Was it from the experiment or the disease? Tough to tell. That is why a properly designed study is important.
While their study may have been reviewed/"approved" by the IRB (for a single, experimental purpose) it was neither well constructed, nor powered. Likewise, most wound infections are not from GI flora, or probiotics, but rather skin flora or another Staph species. Furthermore, not treating a septic patient was never a consideration in the anecdotal studies reported.
Experimental studies in terminally ill patients is rather common. In some cases, it is a game changer. Is this one of those? We shall see. Nonetheless, they went about it entirely incorrectly.
ALS is actively researched both in neurosurgery and neurology. Active management of patients with ALS is generally by neurologists and critical care or neurocritical care physicians.
Understanding neurodegeneration and how to prevent it, on all fronts be it ALS, alzheimers, parkinsons, huntingtons or the other numerous neurodegenrative disorders is important to neurosurgery. Likewise, understanding neuroregeneration, and how to augment loss of neurons remains an important interest. As others have mentioned, this may be a field better fitting for neurology. Nonetheless, that isn't to say you couldn't pursue it as a neurosurgeon. Unfortunately, at the moment, there are no surgical interventions available to prevent, or postpone, the effects of ALS. Perhaps though, with future investigation there will be.
Unfortunately, I have not read Dr. Black's novel. Regardless, neurosurgery remains a diverse field with respect to the variety and technical challenge of a particular procedure. Meaning, does it require doing 50 craniotomies for subdural hematoma a year to remain competent? I doubt it. Does it require 50 craniotomies a year for a basilar tip aneurysm? Show me a surgeon who does 50 a year. Then again, there are spine or peripheral nerve focused neurosurgeons who do zero brain surgeries per year.
Regardless, who would want to only maintain proficiency? Part of our drive is to be the best at what we do.
I understand that your knowledge of biostatistics may be limited, but can you offer any perspective on how useful PhD training in biostats could be to neurosurgical research?
Thanks so much! 🙂
Thanks so much! 🙂
Biostats is pretty important in any clinical research. A lot of people are not versed in the techniques and outsource it to someone trained in biostats at their institution. Having a PhD would likely be useful, but then again it may be overkill.
That's a tough question. I enjoy open clipping more than endovascular coiling, and despite the advances in endovascular the gold standard remains clipping. Likewise, there are some cases that are just not amenable to coiling so clipping is the only option. Anymore though, it seems a cerebrovascular surgeon has to be trained in both, there just isn't the volume of cases to have a practice solely as an open cerebrovascular surgeon. Fortunately, neurosurgery as a field had the foresight to adapt and embrace innovation. It very easily could have gone the other way and cerebrovascular would be like cardiovascular.
ISAT (http://www.sciencedirect.com/science/article/pii/S0140673605672145) and The Barrow Ruptured Aneurysm Trial (http://thejns.org/doi/abs/10.3171/2011.8.JNS101767?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&) both compared endovascular coiling to open surgery and supported the safety of the method and showed lower morbidity and mortality with coiling at 1-year. Both studies commented on the long-term (or 10-year) outcome has yet to be determined for coiling. Likewise, the concept of equipoise may be at issue for randomization. With respect to using "gold standard" I mean that there was significant cross-over to clipping, and clipping is the treatment modality that has established long-term outcome and safety profile. It's not entirely unlikely that in the future endovascular treatment will be the gold standard. Nonetheless, some aneurysms may still need to be clipped due to inability to be coiled.
We're probably 20-30% clip and 70-80% coil.
I'm a 4, I take it you're a 5? Have you begun looking for a fellowship placement? Maybe you can give me some advice down the road when I'm looking.
Thank you for the reply. It is not everyday you have a physician directly answering a Pre-Med's questions. Thank you for your time on the forum, your responses and time are GREATLY appreciated 🙂
And to do research, would you have to be an academic neurosurgeon to accomplish this? Could you conduct research on neurodegenerative diseases and say, if your interest is in spine surgery, could both go hand in hand? Or would that be inconceivable?
This thread has been very interesting.
I am currently shadowing a neurosurgeon who owns his own clinic. How common is this? He still works with the local hospitals but his outpatient stuff is done at his personal clinic.
If you attend a medical school that doesn't offer a rotation in neurosurgery but you feel really interested in it, what types of things should you look into?
I am currently shadowing a neurosurgeon who owns his own clinic. How common is this? He still works with the local hospitals but his outpatient stuff is done at his personal clinic.
If you attend a medical school that doesn't offer a rotation in neurosurgery but you feel really interested in it, what types of things should you look into?
Do you have an idea of how Health Economics and Comparative Effectiveness Research will be viewed in comparison to basic science or engineering research when trying to match into neurosurgery?
Thanks! 🙂
Thanks! 🙂
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What are your thoughts on how physician reimbursement will change (FM and specialties) in the near future? When will it not be worth the rigor of medical school and residency?
There is plenty of opportunity for research in both the academic and nonacademic settings. Academia tends to be more enabling for research with preexisting infrastructure. You could have a separate clinical interest from your basic science interest, or try to link them in some way that was not thought of previously.
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To add my $0.02 to this, the UTSW SAMPRISS Coil/Clip trial had to be stopped prematurely since there were a high number of mortality rates associated with the coil group. From what I heard from some docs at UTSA whom I was shadowing, those mortality results were most likely just sheer statistical chance though.
I don't know how accurate this is though, but those same docs told me that there was some criticism of the ISAT trial since the surgeons operating were not neurosurgeons but rather trauma surgeons (or something similar to that). I don't know about the Barrow trial though, and I'm honestly not too sure if what I've got here is an accurate transcription of what they told me.
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This is actually pretty common. Most neurosurgeons in the country are in private practice be it in a single provider practice, a group practice, or a hospital based private practice. The former two tend to provide more autonomy and can be more lucrative. The latter is typically part of a managed care arrangement so the salary, though comparatively lower, is somewhat more stable/secured.
If you go to a school without a neurosurgery department it can be more work to get involved in neurosurgery. If you have neurosurgeons at your school or in the community, look in to research opportunities or shadowing availability. Certainly, do away rotations during the 4th year of medical school. If you can, adopt a nearby program as your home program. Try to do research with a department, either ongoing throughout medical school, for a brief intense period between 1st/2nd years, or take a year off and do research.
To be honest, I have not given much thought to predicting the future trends in compensation as they vary immensely based on policy. Compensation, though, is not the major issue facing health care costs today but often is trotted out as the thing that will fix the problem. Fundamentally, medicine is switching from a free-market cottage industry of solo practice physicians to a big-medicine environment with fewer players. A sound management strategy is to create the widest differential between the revenue created by a physician and the lowest pay that he is willing to accept. Is this good for doctors, or healthcare? Probably not.
Medicine has lost it's luster for many, and for many it is not worth the rigor so they pursue other fields like finance. Financially, at the moment, medicine can still be afforded. If tuition keeps growing and reimbursement stays flat, however, this may change at some point in the future. No one will go in to medicine if it can not be afforded. It's just that simple.
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