Concerns of the young neurosurgeon

Editorial

Concerns of the Young Neurosurgeon

ontributing to a discussion regarding “concerns of the young neurosurgeon” is not difficult. Certainly, there is plenty of material since there are plenty of concerns. Residency, particularly in neurosurgery, has a way of teaching lessons in prioritization, efficient use of time, and determining who and when to trust (and who and when not to trust) in assigning responsibility. This discussion is divided into five parts: (1) patient care, (2) administrative, (3) eupractice (instead of malpractice), (4) research, and (5) teaching.

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Patient Care Certainly the graduating class of this year will share the age-old patient-related concerns of neurosurgeons past. How will it feel to perform procedures and accept sole responsibility? What safeguards need to be in place to be absolutely sure that nothing is missed? How can I make sure that a patient is both getting the “state-of-the-art” care and adequate attention through follow-up visits? How can I increase my referral base? Proper choice of an initial practice should be of major concern, considering that about 50% of first jobs change within a year (according to a key speaker at a recent medical management conference I attended). Likewise, personalities and clinical capabilities of services that work in conjunction with neurosurgery in some cases (e.g., otolanyngology and anesthesiology) are not always predictable. Advancements in patient care are also important—with the amount of new techniques in each subspecialty of neurosurgery being constantly introduced, there is no question that proper “standard of care” includes consideration of these newer options. For example, many recent legal cases involve patients with vestibular schwannoma who were not offered the option of stereotactic radiosurgery. Nonetheless, there is an immense amount of literature that needs not only constant review 0090-3019/04/$–see front matter doi:10.1016/j.surneu.2003.10.042

but also filtering of applicability to one’s individual practice.

Administrative It’s been said time and time again that the most important person in your practice is the person who answers the telephone. In many ways, this person is the inner “gatekeeper”—this is the first contact with patients who will ultimately form opinions like “our doctor was absolutely great” versus “not only was I in pain, I had an awful experience with that doctor’s office.” A good support staff of nurse practitioner(s), physician assistant(s), and other assistants is by no means guaranteed to work well with you, but a winning, complementary, efficient combination certainly appears to achieve wonders when put into action together. All the steps from talking to the patient when the neurosurgeon is not in the room to keeping file cabinets of records (and films) at easy access to scheduling meetings with nonpatients as well as patients falls within this infrastructure. The delegation of this work is inevitable. While the conscientiousness of those working with you is initially unpredictable— this scenario underscores the “concerns of the young neurosurgeon” as despite past “educated guesses and gut instincts,” there is only so much one can do about hiring the right personnel, and the matter beyond this is left largely to fate. The attitude of “we’ll learn it only when we have to learn it” permeates managing the business end of a practice for many young neurosugeons, and perhaps this attitude itself is a key ingredient contributing to the quagmire of coding and billing. Little to no idea about coding and billing in residency, compounded by relying upon a billing staff that has little or no idea about the actual procedures performed, foreshadows a highly inert (or at times highly combustible) combination. While “coding and billing” courses are offered, taking advantage of these means enrolling for the course before the deadline, © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 –1710

Editorial

making the flight to actually attend the course, being awake and attentive enough to learn what’s being offered (assuming that it’s applicable and beneficial to your practice), applying it to your practice, and then actually getting results—any one of these 5 steps not being met means the course was meaningless in achieving the goal you set out to achieve.

Eupractice In today’s day and age, probably every junior high school student knows the word “malpractice,” let alone a junior resident or junior faculty member. It is all around us—from television media coverage of a 1960s-style portrayal of physicians holding rallies and threatening to leave a state whose malpractice insurance has become unaffordable to hour-long talk shows that depict some physician and hospital mistakes as the equivalent of a “747 crashing every day.” From an individual standpoint, it is apparent that this is a high-risk field— using the threat of malpractice to perform “eupractice” is constructive use; paralyzing healthcare administration because of the potential ramifications of a malpractice suit (as evidenced by ordering repetitive MRI studies and myelograms on a patient suffering from back pain, to avoid “missing something”) is shooting ourselves in the back. The threat of litigation, a topic addressed in nearly every healthcare issue periodical, is everywhere, here to stay and so we deal with it. Making rational decisions with good intentions will help minimize the risk—it will not end the risk. There probably isn’t too much more for any neurosurgeon to say about that other than facing the music and justifying your actions and hoping that a group of nonmedical people believe that you did not do wrong when you explain what happened.

Research Few medical students admit they don’t want to go into academic neurosurgery during residency interviews. Few residents actually go into academic neurosurgery. Over the years during residency, for most there is a move from academic to private practice for various reasons (economics, social, personalities, success rate, and discrepancy between actual and perceived research being some of these reasons). However, as one of my mentors put it, “as an academic neurosurgeon, you are competing for the same NIH dollars as somebody who has five times the amount of time and effort to dedicate

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to it.” This is another reality and “concern” for the young neurosurgeon—at this level, the lessons (hopefully) learned in residency regarding efficient use of time, prioritization, and productivity should help. There are examples of neurosurgeons who have successful, well-funded labs, as there are examples of those who attempted such a venture without long-term success. Fellowships during and after residency, hiring and working with people who have more time to dedicate to research, and personally having strong interest will all likely help, but this real concern remains for all young academic neurosurgery faculty.

Teaching “Teaching is one of three arms” of acquiring a successful tenured position, so they say. However, it is many times viewed as an obligation, few times regarded as enough of a “concern” to merit time away from clinical and/or research responsibilities, and so falls by the wayside. It is not taken seriously, but in residency we are doing nothing less than training the next generation of neurosurgeons. Somewhere in neurosurgery among the hierarchy, egos, personalities, emergency operations, nighttime intensive care unit management issues for the lone juniormost neurosurgery resident on call, the majority of teaching is occurring. A smaller but important portion is acquired during elective operations and conferences, where answers to questions requiring active thought on the part of residents should be encouraged. Each of us has had some teachers who are better than others, where you could learn more in five minutes from one person than you would in 30 days from another. Having been recently asked to create a curriculum for medical students rotating through neurosurgery, I needed to distill seven years of knowledge into 2 weeks as one of the key portions of this task. We see this as an opportunity to avoid the future inappropriate neurosurgical consults regarding back pain, ventriculoperitoneal shunts, and headache—we could empower the future emergency room and family physicians with the knowledge to order the proper work-up and call a consult only when an appropriate problem was noted. While residency has been a great learning experience in terms of how procedures are done and in the management of patients, perhaps even more important is to remember its lessons: what things went wrong, catching potential problems early, and restoring proper course. Properly conducted morbidity and mortality conferences significantly add

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to this experience— using such conferences solely as the ABCs (antagonize, blame, criticize) conference sends a different message than learning from these issues constructively and not repeating mistakes.

Conclusion The five aspects of neurosurgical care discussed in this article give good basis for worry for someone embarking upon the world as a “young neurosurgeon.” Had this been an article about “great expec-

Editorial

tations of the young neurosurgeon,” several enthusiastic and optimistic points would have been raised in excess of the “concerns.” Objective analysis, of course, tells us that as long as the benefits outweigh the risks, we should go ahead and go through with the procedure of being neurosurgeons. And there still appears to be significant benefit despite the risk. Ravish V. Patwardhan, M.D. Louisiana State University—Shreveport Shreveport, Louisiana