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

tremendous amount of information into curricula. Their focus

Issue: Current medical school curricula emphasize general is to ensure that graduates have knowledge of basic issues
practice principles, and this has led predictably to increasingly encountered in general practice. Subsequently, exposure to
limited exposure to subspecialties, including neurosurgery.
subspecialties, including neurosurgery, has been limited.
However, a significant amount of neurosurgical disease and/or
emergencies present in primary care settings or emergency Although often considered highly subspecialized, data from
rooms. In light of an already acknowledged shortage of national trauma banks and literature reviews demonstrate a
neurosurgery providers, this means that general practitioners high incidence of symptoms of neurosurgical disorders and
should be well educated and prepared to diagnose and manage indicate that a significant number of these patients present in
neurosurgical disease. Considering the devastating consequences
primary care or emergency room (ER) settings. In addition,
of a missed or delayed neurosurgical diagnosis, limiting future
physicians’ exposure to the field of neurosurgery is not in the best we as neurosurgeons are acutely aware of the devastating con-
interests of the patient. Evidence: In this article, the authors sequences of missed neurosurgical diagnoses, from both a
review and discuss the results of several studies investigating the patient perspective and resulting medicolegal sequelae.
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’ SUPPORTING DATA
perspectives, and how this status might impact patient care.
Finally, they offer suggestions for the improvement of High Prevalence of Symptoms Related to Neurosurgical
neurosurgical education during medical school. Implications: Disease
Despite being considered highly subspecialized, neurosurgical Among the most common presenting chief complaints
diagnosis and care is a field in which all physicians should receive
treated by primary care providers (PCPs) and ER physicians
proper education and training. To properly serve patients and
produce competent physicians, steps should be taken to re- are headache and back pain. Headache accounts for 45 million
emphasize the importance of neurosurgical education for medical doctor visits annually and 4.5% of all ER visits.1 Less than
students. 20% of patients with headache present initially to specialists;
the majority present to PCPs.1 Although headaches are often
Keywords education, emergency medicine, NBME, neurosurgery 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
INTRODUCTION risk misdiagnosis each year.2 Subarachnoid hemorrhage is
As the field of health sciences expands, medical school edu- misdiagnosed in 5% to 12% of ER cases, leading to a 39%
cators are faced with the difficult challenge of incorporating a complication rate and increased 1-year mortality compare to
patients with correct and timely diagnoses.3
Correspondence may be sent to Darlene A. Lobel, Center for Back pain carries an 85% lifetime incidence and accounts
Neurological Restoration, Cleveland Clinic Foundation, 9500 Euclid for 12.7 million ER visits each year, according to National
Avenue, S31, Cleveland, OH 44195, USA. E-mail: lobeld@ccf.org Ambulatory Medical Care Survey.4 Serious pathology,

201
202 D. A. LOBEL, M. KAHN, C. L. ROSEN, J. G. PILITSIS

including fractures and tumors, accounts for 5% to 10% of and to the medical system. Stroke care has successfully fol-
back pain.4 Delay of diagnosis of radiculopathy, myelopathy, lowed such a model.
and cauda equina syndrome (CES) often results in permanent In neurosurgery, one common example where improved tri-
neurological deficit. Missed diagnosis of CES is a significant age could help is cauda equina syndrome. Patients who
problem, as evidenced by a disproportionately high number of received decompressive surgery within 24 hours had improved
medico-legal claims.5 urinary function and seemed to have decreased incidence of
Closed head injury, the second most common traumatic chronic pain.11 As chronic pain leads to healthcare expendi-
injury, may be complicated by subdural or epidural hematoma, tures in the range of billions of U.S. dollars due to medical uti-
intracranial hemorrhage, and carotid or vertebral dissection. lization and disability, the opportunity to limit a patient’s
These diagnoses should be rapidly excluded by the triaging ER chance of chronic pain is significant.11,12 Further, 40% of med-
physician. Even though cranial computerized tomography (CT) ical lawsuits regarding missed diagnoses of CES were judged
scan is abnormal in 3% to 19% of patients with closed head in favor of the plaintiff, with an average award of
injury, there is marked hospital variability in ordering head $1.57 million USD.13 These figures clearly demonstrate how
CTs, from 6.5% to 80%, for these patients.6 Of note, rate of education, dialogue, and a better referral process would result
misdiagnosis may reach 8% when head CTs are not routinely in benefit to patients, providers, and society.
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 Current Status of Medical Student Exposure
trauma patients have a spine injury, and up to 15% of these to Neurosurgery
injuries are initially missed in multisystem traumas.7 The cer- We suggest that maximizing medical educational opportu-
vical spine is often “cleared” by plain radiograph alone, com- nities in neurosurgical disorders should be the initial step. A
monly read by ER attending physicians or housestaff. One survey of medical school deans reports that most commonly
study of ER reads on cervical X-rays revealed that only 29% internal and family medicine physicians teach students diagno-
of ER housestaff and 74% of ER attendings correctly identified sis of neurosurgical issues and that much of the material is out-
cervical spine subluxation; 21% of attendings missed an odon- dated.14 Further, in 2011, 62% of medical schools did not have
toid fracture.8 The consequences of misdiagnosis and remov- a formal neurosurgical curriculum and 90% of schools did not
ing a cervical collar in such cases are devastating. 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
Impact of Limited Neurosurgical Coverage medical school students demonstrates inadequate training in
The critical problems just described arise from a lack of diagnosis of neurosurgical conditions (Figure 1).15
training of ER physicians and PCPs in emergency neurosurgi- Previous literature has suggested the use of clinical neuro-
cal care and could be mitigated by the consistent presence of surgery electives as a method for increasing medical student
neurosurgeons in ERs. However, there is a known shortage of exposure and interest in neurosurgery. In the United Kingdom,
neurosurgical providers in some countries and/or regions of there exists “student-selected components,” which are essen-
countries, thus requiring ER physicians to triage patients for tially elective rotations in which a medical student can gain
transfer and to have at least cursory knowledge of neurological exposure and skills within specific specialties.16 Although
symptoms and emergencies. A study in Cook County, Illinois, electives are certainly a valuable way to increase exposure to
demonstrated three remarkable findings: (a) 8% of patients certain fields, several issues present themselves when discus-
waited more than 10 hours before transfer to a hospital with sing making an elective the primary means by which students
neurosurgery, (b) 15% of patients had a decline in Glasgow gain neurosurgery exposure. First, neurosurgical electives are
Coma Scale (GCS) while awaiting transfer, and (c) patients already offered at many U.S. medical schools. Second, elec-
transferred from hospitals without a neurosurgeon were twice tives by their very definition are optional, and not all students
as likely to have a decline in GCS.9 As GCS at time of inter- entering primary care fields or emergency medicine will vol-
vention is known to correlate with ultimate outcome, the cost untarily choose to take a neurosurgery elective; given the
of delayed triage and transfer to the patient and the healthcare urgent need for neurosurgical education described in the previ-
system at large is evident.10 ous paragraphs, an optional neurosurgery elective would likely
To improve triage and transfer, education is the start. The not have the significant widespread improvement in neurosur-
knowledge would improve clinical acumen and understanding gical acumen we hope to achieve. Furthermore, many of the
of emergent situations. This better understanding will in turn students who would be signing up for those electives might
improve dialogue between the generalist and the consultant. simply be students who are already desiring to pursue neuro-
Ultimately, a more streamlined referral and transport process surgery itself as a specialty; this phenomenon has been
would allow for faster treatment and less cost to the patient 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 com-
mon spine problems. Note: Three-fourths of students felt unprepared to manage spine patients, and more than 60% expressed concerns about their ability to diag-
nose neurosurgical emergencies.15

electives in other subspecialties in other countries, such as base to safely identify neurosurgical conditions. Only through
plastic surgery electives within Canadian medical schools.17 direct action, including petitioning the United States Medical
Licensing Examination Examination Committee to examine
test content in light of the aforementioned facts, may we
CONCLUSIONS ensure that common neurosurgical problems are appropriately
The quantity and quality of neurosurgical content in medi- represented on NBME examinations. Improvement in neuro-
cal school training has sparked robust debate between neuro- surgical education, as the initial step in improved dialogue
surgeons and medical education organizations. In 1997, the and streamlined referrals, would likely lead to improved diag-
American Association of Neurological Surgeons and Congress nosis, more expeditious treatment, and ultimately better
of Neurological Surgeons jointly petitioned U.S. medical outcomes.
schools deans to make curricular changes to increase exposure
to diagnosis and treatment of neurosurgical conditions that are
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