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Q. Is it possible to complete a Psy.D. while doing Residency as a Neurosurgeon?A. Neurosurgery is among the most competitive specialties to match into. It is probably the most taxing of all residencies. I have seen malignant programs where residents were dismissed in their final year of training. It is not one that you can coast through. It is doubtful that you would be able to complete a Psy.D. And why would you want to? It would be a useless degree, not helpful in your practice. (Unless you are considering double boarding in Neurology and Psychiatry, which are completely different specialties. Combined Training Programs - ABPN.)A neurosurgical resident's typical dayNeurosurgery (Specialty)11 Things I Wish I Knew Before I Became a NeurosurgeonA Day in the Life of a Neurosurgeon – SERIOUSLY?Malpractice Risk According to Physician Specialty — NEJM (Neurosurgery extremely high risk)A neurosurgical resident's typical dayCOLIN SON, MD | EDUCATION | DECEMBER 1, 2010I’ve made some fairly outrageous claims about the workload of a neurosurgical resident recently. Seems like a reasonable time to lay out exactly what a day on call can be like for me and my fellow residents.To be fair an average experience may be hard to articulate. Different rotations and different days yield different … adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.7 a.m I meet with the post call junior resident and the chief at the county hospital. We table round, looking at images from last night and going over any new consults. The list has 60 patients on it. And that truly is a conservative number. Approximately half of them are our primary and half we are consults on.8 a.m. The chief and post call resident run up to round on the unit and the approximate 5 primary patients up there and the 15 consults (let’s make the ICU players add up to 20 for simplicity, which is reasonable for our list).I run down to see the 40 patients on multiple floors. I start at the top and work my way down.9 a.m. My partner in crime is done rounding with the chief and is putting in basic orders and notes, without plans, on the patients in the ICU. I’m still seeing patients on the floor.10 a.m. Our T9 fracture we added on for today gets an OR room. We were supposed to get to him on Friday, but couldn’t. Luckily I’ve seen everyone on the floor, unfortunately there are three people waiting to get out of the hospital as I run down to the OR. My fellow junior resident manages to discharge two of the people.11 a.m. I’m in the OR. My fellow resident is getting some of my floor work done but none of my notes.12 p.m. In the OR I get a consult for a hypertensive bleed with intraventricular extension. I scrub out and run down and see her. My fellow junior resident meets me and checks out. The ICU attending wasn’t going to be available to round until the afternoon and so that task falls to me.I run back upstairs and let my chief know I think this head bleed needs an external ventricular drain (EVD). I scrub back in and we close quickly.1 p.m. While we’re putting in the EVD the intensivist calls me to see if I’m available to round.2 p.m. I run upstairs and round with the ICU attending for 2 hours. Luckily I’m able to put in orders as we go on a computer on wheels. To give an issue of how many times I’m getting interrupted by other providers in the hospital my beeper goes off 15 times in those 2 hours including another consult for a C2 lateral mass fracture down in the ER.I manage to put in admission orders for the head bleed downstairs on the computer on wheels while I’m rounding with the attending.3 p.m. Still rounding in the ICU.4 p.m. I run downstairs to see the cervical fracture. While I’m down there they have another consult with a small volume traumatic subarachnoid bleed. I see him as well.5 p.m. Then I run upstairs to see the post op on the floor and the EVD we placed, she has made it to the ICU. I sit down (it’s the first time I’ve sat down since 8 this morning) to add my last discharge and then write my consult notes and add the plans to the notes for the ICU patients. I follow up on a stat head CT the ICU attending had wanted while rounding, I call him with the results.6 p.m. While starting my notes for the floor patients I get called about a patient in the ICU whose EVD has stopped working. I go downstairs and indeed it doesn’t flush or withdraw and the patient needs the ventric. I call my chief and prepare to replace the EVD.7 p.m. EVD is in and go and see a guy I got called on with multiple parenchymal melanoma mets. I go upstairs and write that consult note, my procedure notes, dictate the op report from earlier in the day and then start on my notes for the floor patients.8 p.m. I’m still writing my forty floor notes. I get called on a patient with some desaturations on a floor patient. I go and see him, check the CXR, see the atelectasis and with him doing okay go back to writing floor notes.9 p.m. Still writing floor notes. Done I go downstairs and grab some chicken strips for dinner. I go upstairs and walk the ICU.10 p.m. Another consult from the ER. A gentleman who fell from standing on Coumadin. There is 2 cm of shift from the subdural. His INR is supratheraputic. I call my chief, who calls my attending. They call me back and I call the OR. I order mannitol and more fresh frozen plasma. I go and talk to the family at length and consent for the procedure. I have to physically run and get the FFP myself.11 p.m. I scrub into the decompressive crani.12 a.m. Still in the crani and closing I get called about a teenager with some subarachnoid and an apparent giant basilar aneurysm on an outside CT-angiogram (CTA).1 a.m. I write my consult note on this emergency craniotomy and dictate the operative report and put in admission orders. I run up the PICU where this new consult has already been admitted. I try to track down the outside CTA; this will be an adventure.2 a.m. I finally get the CTA and indeed even I can identify the aneurysm. I call my vascular attending and email him some of the pictures from the CTA. I then go down and consent the family for a potential angio later that day.3 a.m. As I’m writing my consult note I get a call about one of our ICU consults, actually on the trauma service, having a seizure. I go up there just to see if the trauma guys need anything. I then go back to writing my consult note on the pedi patient with the aneurysm.4 a.m. I get called on a thoracic burst fracture down in the ED on some gentleman who jumped from a 2nd story window likely related to a positive drugs of abuse screen. I go downstairs and see him and as he’s intact I’ll just keep him in bed. I write my note.5 a.m. I head back upstairs and start working on the list for the morning. Moving people around, taking the discharges off, adding the new patients and getting the labs for all the new patients and the 20 guys in the unit. I run and make copies for the chief and the junior resident coming on.6 a.m. I pull up all the images from overnight on all the consults and on anyone who got uprights or repeat head CTs or MRIs.7 a.m. The junior coming on and the chief show up. We table round going over all the images and everyone on the list. I’ll see the ICU patients today.8 a.m. Me and the chief resident go up to the unit and round on the ICU patients including the consults up there. Let’s say we signed off on some of the consults yesterday and so even with the new admissions I still only have 20 ICU patients. There are the daily little things to do like drawing CSF.9 a.m. I start writing my ICU notes.10 a.m. The ICU attending wants to phone round today and so I take his call and run all the patients with him. It’s a little bit shorter over the phone. I’m able to sit at a computer and put in orders while we’re talking.11 a.m. I finish up my notes in the ICU.12 p.m. I check to see if my fellow resident needs any help and I get out with an hour to spare.As with any service I’m taking numerous pages and answering questions and doing the basics for my patients, 20+ on the floor and 5+ in the ICU, during this whole time. I’m also constantly reviewing results such as sodiums for hypertonic therapy and repeat head CTs at 6 and 24 hour intervals for head bleeds.I’ve written more than 60 notes, rounded on 80 patients, done 2 EVDs, scrubbed 2 operations, seen 5 consults in 29 hours. Often fun and always rewarding hopefully but like any training program difficult at times. Even with the work hours.Colin Son is a neurosurgical intern who blogs at Residency Notes.Submit a guest post and be heard.TAGGED AS: RESIDENCY, SPECIALIST, SURGERYNeurosurgeryOverview of the SpecialtyNeurosurgery is a medical discipline specializing in the operative and nonoperative management, prevention, diagnosis, evaluation, treatment, critical care and rehabilitation of disorders that affect the central, peripheral and autonomic nervous systems including their supporting structures and vascular supply and the operative and nonoperative management of pain. As such, neurosurgery encompasses the modern treatment of disorders of the brain, meninges, skull and their blood supply including the extra cranial, carotid and vertebral arteries; disorders of the pituitary gland; disorders of the spinal cord, meninges and spine; disorders of the cranial and spinal nerves throughout their distributions; and disorders of the autonomic nervous system.Training RequirementsTraining consists of a minimum of six years of postgraduate education which includes a minimum of one year of training in an ACGME-accredited program in general surgery or at least one year of a program accredited for the acquisition of fundamental clinical skills, which must include at least six months of structured educational experience in surgery other than neurosurgery. There were 105 neurosurgery residency training programs accredited by the ACGME for 2014/15 that offered 210 positions.Matching Program Information and Match StatisticsNeurosurgery residency training programs participate in the National Resident Matching Program (NRMP). Match results and competitiveness information for neurosurgery residency training positions are summarized in the U.S. Match Statistics table below.Subspecialty/Fellowship TrainingSubspecialty/fellowship training following completion of neurosurgery residency training program is available in endovascular surgical neuroradiology. Detailed information about the scope of this subspecialty training program, number of positions offered and length of training is available in the GMED. Further information can be obtained from the American Medical Association and the Fellowship and Residency Electronic Interactive Database Access page.American Medical Association (AMA)FREIDACareer InformationFREIDA physician workforce information for each specialty includes statistical information on the number of positions/programs for residency training, resident work hours, resident work environment and compensation, employment status upon completion of program and work environment for those entering practice in each specialty.11 Things I Wish I Knew Before I Became a NeurosurgeonThere isn't always one "right answer" for how to treat a patient.As told to Arielle PardesApr 13, 20161. Neurosurgery is more art than science. When I was in medical school, I understood everything in medicine as evidence-based. You have clinical trials, which you randomize, and you draw scientific conclusions. But in many cases, you're not able to do clinical trials because it's not ethical. For example, you'd never be able to run a clinical trial comparing surgery versus no surgery for removing a brain tumor, because no patient would want to be in the "no surgery" group (and most doctors and research review boards would be uncomfortable "experimenting" on patients this way). So the practice of neurosurgery involves more educated guesswork than most people would expect. Because the stakes are higher in neurosurgery than in some other fields, there is less likely to be a clinical trial establishing superiority of some treatments over others, which can lead to variability in practice. Every surgeon ends up doing what they think is best for the patient, but there isn't always one "right answer."2. If you're working with brain trauma, be prepared to handle life-or-death decisions every day. I work at the largest level-one trauma center in the Midwest. Level-one centers are hospitals that are equipped to handle the most severe total body emergencies, so as a trauma neurosurgeon, I treat whatever comes in the door, and generally on very short notice. The first question the family asks when someone's had a traumatic incident is, "Are they going to live?" And if they are, the second question is, "Are they going to really live?" Meaning, will they be able to speak and interact and function the way they could before? Will they drive? Will they work? For many families, it's the most harrowing experience they'll ever have; for neurosurgeons, this is just the daily routine. Nearly every patient is a high-stakes case, which can make this work feel incredibly important but also nerve-wracking.3. Delivering bad news never gets easier. In a microsecond, things can change for the worse, and it makes you realize that life is so precious and so short. Telling people that their loved one won't be the same is very difficult and very draining. Most adult neurosurgery involves things like older people falling or car accidents, and with that kind of stuff, people already expect a poor outcome. So if you can save somebody, they're so grateful. The good outcomes definitely outweigh the bad ones, by about 10 to one.4. When someone else's brain health is in your hands, you have to take exceptionally good care of yourself. If I'm operating, I make sure to go to bed early the night before, eat a hearty breakfast, and drink tons of water. I'm vigilant about that stuff, because you never want to be in a situation when you're not at your best. The one time I tried to exercise in the morning before a surgery, I had to leave the operating room because I was dehydrated from not drinking enough water after working out, so now I only exercise in the evenings. You absolutely cannot be sloppy about your own health, because doing so could affect your patient's health.5. A scientific study can be interpreted to say anything you want it to say. Here's a good example: A recently published study said 30 percent of men who played contact sports would develop a form of dementia in adulthood. That conclusion was all over the media, but when you actually read the paper, it turned out that they were asymptomatic from this form of dementia, meaning it's not clear that they had dementia at all. As a scientist and a clinician, I have to read the data from other people's research myself and draw my own conclusion to inform my practice.6. Neurosurgery is heavily male-dominated, so don't expect to always have mentors who look like you. Finding female mentors in neurosurgery can be tough. Only about 6 percent of all board-certified neurosurgeons in the country are women, and in academia, it's even fewer. Some of the women ahead of me have provided me with great mentorship, but I've also had fantastic male mentors. The best mentors are people who have a vested interest in your success — often, the people who hired you — and if you emulate the behavior of people you admire, you will succeed.7. Often, you'll have to make a choice between being a surgeon and doing research. I've been very lucky to work in a hospital system that values my work as a researcher, so I'm able to work in a clinical setting three days a week and work on research two days a week. It's a fantastic arrangement, and we just started one of the largest brain studies in the country. That said, it's becoming less common for hospitals to allow their neurosurgeons to work on research, since it's more economical for a hospital to have them operating all the time.8. Try a bunch of different things before you commit to a specialty. It's very common now to choose a subspecialty of neurosurgery during residency. This could be focusing on something like cerebrovascular surgery, spine surgery, neurotrauma, or pediatric neurosurgery. When I first started out, I planned on doing pediatric neurosurgery, but then I had a kid of my own and realized I was not emotionally capable of doing it. It was too upsetting to see a negative outcome with a child. So now I specialize in trauma, and I'm much happier.9. There's no "good time" to have a kid. After medical school, you have seven years of residency and then one or two additional years of fellowship before you can even become a neurosurgeon. I had a baby when I was a resident, and it was really hard, even with an extraordinarily supportive family. I was working about 140 hours a week during my pregnancy. When I gave birth, I took 12 weeks off and when I returned, I was senior enough to cut down my hours to a very leisurely 90 hours a week. I missed out on so many things — my son's first steps, his first day of preschool, his classroom presentations. Now, I work about 70 hours a week, but I still miss a lot, which can be very hard as a parent.10. Surgery is all about teamwork. People tend to think of operating rooms as very austere, isolated places, but you're always working with a team, and everyone plays an important role. I work with neurosurgery residents, a scrub nurse, and an anesthesiologist; as with any team, you're only as strong as your weakest member. No one person can make or break the operation, but if one person makes a mistake, another person needs to catch it. Something as trivial as failing to check a preoperative laboratory value can have fatal consequences. The stronger your team, the easier it is to avoid that situation.11. Each day at work feels like solving a complicated, beautiful puzzle. I often tell my friends I have the highest job satisfaction of anyone I know. It's challenging work, yes, but when I'm operating, it feels like the whole world melts away because I'm so engrossed in what I'm doing. I don't look at the clock, ever. And when I leave the operating room, I'm hungry and exhausted, but I'm also so satisfied. I think I work a little bit too much — usually 12-hour days, and I tend to go in on the weekends — but that's my own doing. The gratitude you see in people's eyes when you tell them an operation went well and their loved one wakes up from surgery — that's not something you can replicate in the typical 9-to-5 job.Uzma Samadani, PhD, MD, FACS, FAANS, is an attending neurosurgeon at the Hennepin County Medical Center, where she serves as Rockswold Kaplan endowed chair. She is also an associate professor of neurosurgery at the University of Minnesota and is currently leading the largest single-center traumatic brain injury study in the country.A Day in the Life of a Neurosurgeon – SERIOUSLY?Thursday, December 10, 20096:00 am – Out of bed, to the shower6:35 am – Wake up 11 yo son, remind him to take ADD medicine this morning6:40 am – Feed 3 hungry cats, out the door to work7:00 am – Sign and update day’s surgical H&P’s, type an overdue office note into EMR so procedure can be precert’d for Friday7:10 am – Breakfast, grits and poppyseed muffin, with premed student who’s shadowing this month7:30 am – See first surgical patient in preop, sign chart, dress in scrubs7:45 am – Call medical records to assure them I did the overdue discharge summaries last night and I’m back on staff8:00 am – Do first case, small outpatient procedure8:40 am – Talk with first pt’s family, see next patient in preop holding, write postop orders, handwrite prescriptions since EMR printer not working AGAIN9:00 am – Start next case, 2-hour outpatient procedure. Get page about emergency cerebellar stroke pt en route to ICU from sister hospital, need to consult9:30 am – Review films of stroke pt during short pause in surgery, obviously needs emergent craniectomy. Book case, give anesthesia instructions while operating.10:30 am – Still operating on pt #2; get paged about another consult, not emergent but needs to be seen today.11:10 am – Finish case, stroke pt not here yet. Speak with family, write postop orders, decide to proceed with next case (1 hour inpt surgery) while waiting for stroke pt11:40 am – Start case #3 after difficult awake fiberoptic intubation. Play Christmas music to improve mood. Get paged about consult #3 – brain mass. Start getting irritable, since this was supposed to be a short day (get home at 6:30, actually see family and get dinner made, start decorating tree we brought home on Saturday). There goes any chance of getting home before 9:30 AGAIN, on a day I’m not on night call.12:45 pm – Finish case #3, talk to pt family, write postop orders. Run upstairs to see stroke pt. Awake but with ominous “pressure” headache. Discover the internist started him on blood thinners 2 days ago (including Plavix), and he had a dose this am. Delay emergency OR so platelets can be transfused.1:15 pm - Cancel last 2 scheduled elective cases to accommodate emergency. There goes Dec 18th’s light schedule. Soothe angry patients who have to be fixed before their deductible starts over Jan 1.1:30 pm – Field call from our other hospital’s trauma committee chief, chewing me out for taking too long to see a trauma patient in their ER two weekends ago on call. Explain that when I got their call, I was operating on the day’s second emergency case in the other town and couldn’t leave that patient on the table. Called partner for help, who wouldn’t come in. After finishing case, drove straight to ER 30 min away at 11:30 pm after operating since 8:00 am. Got stopped by police for speeding. Took pt straight to OR, operated until 4:00 am. Pt survived and had great outcome. “Oh, okay, I guess the circumstances were understandable.”1:45 pm – Drop by doctor’s lounge for a cup of soup while platelets are being prepared. Watch news about health care reform. Wonder how many hospitals will have to close with Medicare cuts, and how many physicians will be able to stay out of hospital employment situations. Realize there’s nothing I can do about it.2:30 pm – Pt rolls into OR.3:00 pm – Begin emergency surgery. More Christmas music, reminding me I haven’t done any shopping or even thought about what to get for which people.4:58 pm – Still operating. Get paged about consult #4. On call partner takes over at 5:00 pm. Hospital called him first, but he told them to call me.6:00 pm – Finish emergency. Speak with family, write postop orders. Review films on postop pt in rehab with new leg pain. Can’t tell if his graft has migrated. Order CT scan.6:15 pm – Change out of scrubs, see patient with brain mass. Order additional testing, type consult note.7:00 pm – Answer text from husband to tell him I won’t be home for dinner AGAIN. Attach sad emoticon. Advise him to use olive oil to make couscous for the vegetarian exchange student who lives with us during the week. Remind him to make sure son takes anxiety meds tonight. Husband texts back that son only got sent out of one class today for disruptive behavior. Progress.7:05 pm – See consult #3, pt with back pain. MRI films aren’t here, instruct pt’s family to bring tomorrow so we can make decisions. Type consult note.7:45 pm – Field question from floor nurses about a postop patient, preventing the need to disturb the on call partner.7:50 pm – See consult #4, pt with back pain. Explain to family why I didn’t get here earlier. Discuss treatment plan, not surgical. Enter orders and type consult note.8:30 pm – Check on craniectomy pt in ICU. BP is 210/130. Start Cardene drip. Otherwise doing well. Hug family member.8:50 pm – Stop by office to check messages. Ignore inbox on my desk (known to my staff as “ Mount Surgeon .”) Review To Do list, realize I can’t mark off a single item. (There are 18.)8:55 pm – Glance at call schedule accidentally, reminding myself that I’m on call Christmas(Thurs-Mon) and on backup for New Year’s.9:00 pm – Rest for 5 minutes to read this blog, am inspired to write this guest post.9:20 pm – Start wiping away tears as I think about what I’ve just written. I used to love my career, but I am realizing how sick and tired I am of this workload - of not seeing my family, not being ready for holidays, using weekends to catch up on charts… of being dumped on by partners and pushed around by insurance companies. I can’t remember what I used to do for fun, and I can’t figure out why I’m still getting out of bed for this, day after day. Why would anybody want to have a day like this, or worse, 5+ days a week? I know, it’s supposed to be hard, and the culture of neurosurgery is to suck it up and avoid asking for help, because that’s a sign of weakness. Maybe my fellow residents were right after all, and I’m just lazy. Maybe I just need to finally reconsider my options and decide whether this has devoured enough of my life.Malpractice Risk According to Physician Specialty — NEJMProportion of Physicians Facing a Malpractice Claim Annually, According to Specialty. Across specialties, 7.4% of physicians annually had a claim, whereas 1.6% made an indemnity payment. There was significant variation across specialties in the probability of facing a claim, ranging annually from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. Specialties in which physicians were most likely to face claims were not always specialties in which indemnity claims were most prevalent. Our estimates of rates of overall and paid claims were unaffected by adjustment for physician age, year, and state of practice.Size of Malpractice Indemnity PaymentsAmount of Malpractice Payments, According to Specialty. shows mean and median indemnity payments per physician for each specialty after the exclusion of claims that did not result in an indemnity payment. Across specialties, the mean indemnity payment was $274,887, and the median was $111,749. The difference between the mean and median payment reflects the right-skewed payment distribution. Specialties that were most likely to face indemnity claims were often not those with the highest average payments. For example, the average payment for neurosurgeons ($344,811) was less than the average payment for pathologists ($383,509) or for pediatricians ($520,924), even though neurosurgeons were several times more likely to face a claim in a year.Outlier awards, which were defined as those exceeding $1 million. Among all physician-years, 66 payments exceeded this amount, accounting for less than 1% of all payments. Obstetrics and gynecology accounted for the most payments (11), followed by pathology (10), anesthesiology (7), and pediatrics (7).

One big problem is misinformation due to cut and paste. Hospital and clinic electronic medical records typically have many doctors taking care of one patient on multiple admissions, discharges and visits. The electronic record can contain significant errors.For example, a doctor could be working on a patient's electronic chart and a nurse interrupts with a question about another patient. The doctor logs into the other patient's record to look up results. After addressing the question at hand, the doctor may forget that he's on the wrong patient and complete a summary that is totally inaccurate.Other doctors will later use this information to cut and paste their consultations. This can perpetuate inaccurate health information throughout the record.Here's an example:"A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic medical record (EMR) and noted a history of "PE" listed under the Past Medical History section. This raised his suspicion for the possibility of a pulmonary embolus (PE). After initial testing excluded a cardiac etiology, a computed tomography (CT) scan of the chest was ordered to rule out a PE. When the physician approached the patient to explain why he was ordering the diagnostic test, the patient denied ever having a PE or being treated with blood thinners.""Puzzled by the conflicting reports, the ED physician returned to the EMR and noted that this mistaken history of PE dated back several years. It even appeared in the "problem list" section of his EMR. Investigating further back, the ED physician discovered that the letters "PE" were first noted nearly a decade earlier where it was clearly intended to reflect a "physical examination" rather than a "pulmonary embolus." A physician likely copied and mistakenly pasted "PE" under "past medical history," after which this history of pulmonary embolism was carried forward time and time again. The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation error. The EMR was updated to reflect, "This patient never had a pulmonary embolism."Unfortunately these types of simple errors with potentially devastating consequences are not rare."High-risk copy-and-paste errors, which are defined as mistakes with high potential risk for patient harm, fraud, or tort claim, have been reported in 10% of patient EMRs.(4) Medication reconciliation discrepancies are particularly noteworthy, since such errors are noted in almost 40% of EMR patient medication lists.(5) There are also reports of incredible copy-and-paste persistence and absurdity. These include a consultant's note that was copied forward by multiple authors for 7 years, and dietary and follow-up instructions provided to a deceased patient.(6) While these kinds of documentation errors undoubtedly occurred in the pen and paper era, they are rampant with EMRs."Morbidity and Mortality Rounds on the WebThis is pretty scary stuff for both patients and doctors. Proponents of EMR so far have ignored this problem. But users of EMR where multiple physicians and nurses access and input data are increasingly aware of it.It's also turning out that electronic records isn't the great panacea for reducing healthcare costs and medical errors that proponents envisioned. The big push for electronic records was a result of a 2005 RAND study, commissioned of course by GE and Cerner. They've profited nicely with the implementation. Cerner's revenue has tripled since 2005.The RAND study claimed that America's health system would save a minimum of $81 billion a year. But guess what? There are no savings to be had. Why are healthcare consultants and systems analysts so surprised? Subsequently the Congressional Budget Office has "harshly criticized" the RAND study.“RAND got a lot of attention and a lot of buzz with the original analysis,” said Dr. Kellermann, who was not involved in the 2005 study. “The industry quickly embraced it.”"But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.""Health care spending has risen $800 billion since the first report was issued, according to federal figures. The reasons are many, from the aging of the baby boomer population, to the cost of medical advances, to higher usage of medical services over all.""Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted."“The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow,” Dr. Brailer said.This stuff isn't cheap. A typical system for a multi-physician office can cost $40-50 thousand to implement and $5 thousand a year to maintain. So I guess you could include that as another problem that doctors have.And some of the doctors are striking back:"Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously."Electronic Records Systems Have Not Reduced Health Costs, Report Says

Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It enables appropriate testing to rule out possibilities and confirm a final diagnosis.The list might be prioritized by likelihood and urgency.Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.e.g.BackgroundAn obese Caucasian male, with a history of hypertension and smoking, complains of severe lower back pain that has lasted four days.The back pain is accompanied by occasional vomiting and radiates intermittently to both lower quadrants of the abdomen. The increased severity of back pain had awoken him on the morning he sees his doctor.Vital signs are normal except for a mild elevation of the systolic blood pressure. Dr. A assesses the patient at 0500 hours and finds no significant physical abnormalities. Femoral pulses are strong and symmetrical. A flat plate X-ray of the abdomen is read and later confirmed as normal. A complete blood count (CBC) is normal. The preliminary diagnosis by Dr. A is musculoskeletal back pain. Narcotic analgesics are administered.At shift change the patient's care is transferred to Dr. B, who reviews the patient and agrees with the previous diagnostic impression of mechanical back pain.Dr. B subsequently discharges the patient with a prescription for analgesics and the instruction to find a family doctor for follow-up care.OutcomeTwo days later, the patient is found dead at home.An autopsy reveals a ruptured abdominal aortic aneurysm (AAA) with 3,000 cc of blood in the retroperitoneal space.The patient's family threatens a legal action against Dr. B, alleging failure to diagnose the condition and failure to provide adequate discharge instructions.Think about itWhat can we learn from this case?Lessons learnedLeaking AAA may mimic renal colic, mechanical back pain, and diverticulitis/gastroenteritis.In particular, AAA might be considered in the differential diagnosis of an older patient with symptoms suggestive of renal colic.Severe radiating pain is a common symptom. Syncope and vomiting may also be associated with AAA.A patient with persistent symptoms may warrant a new evaluation. As appropriate, alternative diagnoses including the "worst case" possibility should be considered.Patients with pain require analgesia. Even if appropriate doses of narcotics control the patient's pain, it may still be prudent to review the patient to determine if the diagnosis is being masked by the analgesia. When appropriate doses of narcotics fail to control pain, the patient's diagnosis should be reassessed.In appropriate clinical circumstances, the medical record should indicate that the diagnosis with the worst prognosis, in this case AAA, was considered and was pursued if reasonable to do so.The rationale for not investigating should also be clearly documented.