Midnight. Just before I’m fully overtaken by sleep, the phone jars me awake. The call, from “Upstate ER,” concerns a patient whom the emergency physician wants to send to my academic medical center.
Ms. D, who many years ago had multiple neurosurgical procedures for a pituitary tumor, and a bone flap infection following one of the procedures, complains of a headache (like the ones she often has). I’m told that her computed tomographic scan shows a small collection of fluid in her frontal lobe that looks old, but “infection cannot be fully ruled-out.” Further, one of her previous surgeons has retired and the other says he “can’t” continue to care for the patient. In a most sympathetic tone I ask the ER physician if the on-call neurosurgeons have been called. “They wouldn’t want me to call them for this patient,” I’m told. I suggest that it would be better to call them and have them speak directly to me if they really feel Ms. D requires the specialized care available only at my AMC. I’m returning to sleep when I’m jangled awake again. This time it’s the emergency room of my AMC calling about Ms. D. Upstate ER did contact an on-call neurosurgeon who said Ms. D’s problem couldn’t be handled there and that she would have to be sent to my AMC’s emergency room.
In another case, young and otherwise healthy Ms. H suffers a rapid-onset severe headache, nausea, and dizziness, followed by some lower back pain. She is admitted to “Upstate Hospital” where she has an extensive evaluation in the medicine, neurology and neurosurgery departments. The pertinent findings are diffuse dural enhancement intracranially and some enhancement along the cauda equina. A biopsy of the dura and brain is recommended to her when all noninvasive studies are negative. At a family member’s suggestion, she transfers her care to my AMC where she is evaluated and diagnosed with a clear case of intracranial hypotension. She is successfully treated and released, without ever undergoing a biopsy, and she returns to work.
These two cases illustrate the tension between “town and gown” neurosurgeons, that is, between community and academic neurosurgeons. Clearly, some patients like Ms. D do not suffer from neurosurgical problems which strictly require the expertise of AMCs. In contrast, patients such as Ms. H definitely benefit from the added experience and multidisciplinary approach available at AMCs. In addition, resident training certainly benefits more from cases like Ms. H’s, though traditionally much of basic resident training has been completed on patients such as Ms. D. Where is the balance? What are the factors that have changed the neurosurgical landscape and is the change permanent? Do we need to consider creative solutions for the future?
While I do not have easy answers to these questions, a dialogue that addresses them is crucial to the future viability of neurosurgical education. To that end, I have asked chairs of two AMC neurosurgical departments to comment on the impact of transfers to AMCs. Commentary by William T. Couldwell, MD, at the University of Utah opens the dialogue, while insights from T.C. Origitano, MD, of Loyola University Health System in Chicago will continue it in the next issue of the AANS Bulletin.
Resident Education Among the Benefits of Patient Transfers to AMCs
William T. Couldwell, MD
An increase of transfers from community neurosurgeons and hospitals to AMCs is a trend that has become evident over the last few years. The reasons for this trend are multifold, and include a reduced number of neurosurgeons in community practice, high medical liability risk for treating high-risk neurosurgical problems, and a rise in unfunded or underfunded patients. The net effect of this trend is an overall increase in the number of patients with complex neurosurgical disorders cared for at AMCs.
This consolidation of care for difficult or complex cases produces many benefits. First, it increases the depth and breadth of cases for resident training. The 80-hour workweek for residents has reduced the potential total exposure of cases per resident during training, making the case mix more critical. The concentration of the most complex cases can somewhat counteract the work hour reduction by enhancing the intensity of the resident training experience. Second, many of the patients transferred can benefit from the interdisciplinary management that is available only at AMCs. For example, patients with aneurysmal subarachnoid hemorrhage can receive optimal, state-of-the-art management because of the availability of both endovascular management (such as coiling the aneurysm or treating vasospasm) and open neurosurgical management. For some patients, multidisciplinary teams such as a tumor board may assist with provision of complementary, rather than alternative, services. In all of these examples, patients benefit from transfer of their care to an AMC.
There is a considerable recent literature that suggests that the outcomes for patients with complex cranial and spinal neurosurgical problems directly correlate with the volume of cases by providers and hospitals. The additional benefit of families’ satisfaction at higher volume centers also has been reported. This probably reflects availability of complex services as well as important support services, such as support groups for patients with severe spinal cord injury (and their families) or dieticians who help pediatric patients undergoing chemotherapy. The increasing volume of patients with tertiary disease transferred to AMCs ultimately will lead to multidisciplinary and subspecialized care that likely will produce better outcomes for these patients and greater satisfaction for their families.
Neurosurgical residents benefit not only from seeing the greater depth and breadth of cases but also from being exposed to an optimal, multidisciplinary approach. The future of neurosurgical care will likely have more, not less, multispecialty interaction. Learning how to work cooperatively as a member of such a team is an important component of resident education.Overall, without significant medicolegal reform I see market forces in the United States continuing to consolidate tertiary neurosurgical care to AMCs, with positive consequences for resident training, and negative consequences for the fiscal survival of AMCs.
Deborah L. Benzil, MD, is associate professor in the Department of Neurosurgery at New York College of Medicine, Valhalla, N.Y. William T. Couldwell, MD, PhD, is chair of the Department of Neurosurgery at the University of Utah in Salt Lake City.