Workplace discrimination

Workplace discrimination

Issues concerning harassmentbullying, and discrimination are not unknown to medical specialties and are likely to be present in neurosurgery as well 1).


The role of women in Western society has changed dramatically in the past several decades. Despite this, many gender inequality still exist for professionals in the health care sector. In neurosurgery, a disproportionately small percentage of the workforce in the United States and Canada is female. These figures are lower than most reported in other medical specialties. A review critically examines factors that may be influencing women’s ability to advance in demanding subspecialties such as neurosurgery.

The literature on women in medicine, and surgery, in particular, were reviewed to identify different issues facing women currently in practice in neurosurgery. In addition, the concerns of prospective trainees were examined.

There remain many challenges for women entering neurosurgery, including unique lifestyle concerns, limited mentorship, outdated career programs, and deep-seated societal beliefs. Discrimination and harassment are also contributing factors.

If neurosurgery is to continues to progress as a subspecialty, the issue of gender inequality needs to be scrutinized more closely. Innovative programs must be developed to meet the needs of current female faculty members and to ensure attracting the brightest individuals of both genders into a career in neurosurgery 2).


Surgeons who abuse other health care workers are in violation of institutional bylaws and compliance regulations and create a hostile environment at work which adversely affects efficient productivity and violates specific State and Federal laws which prohibit discrimination based on race, color, sex, religion, or national origin 3).


The impact of workplace discrimination has gained recognition. Nearly two-thirds of all medical residency applicants reported being asked inappropriate or potentially illegal interview questions. The use of such questions during neurosurgery residency interviews has not yet been studied.

Limoges et al. evaluated the prevalence of inappropriate or potentially illegal questions in residency interviews and the impact on applicants’ rank lists.

All 2018 to 2019 United States neurosurgery resident applicants were anonymously surveyed. The survey included 46 questions focused on demographics; if they were asked questions regarding rank list, agegender, marital status, family planning, religion, sexual orientation, or disability and whether such questions affected their rank list formation.

Of 265 surveyed United States applicants, 133 (50%) responded. Most respondents were male (78%), 24% were married, and 10% had children. During the formal interview, 94% were asked at least 1 inappropriate or potentially illegal question. About 78% reported being asked about marital status, 29% were asked about intent to have children. About 46% reported being counseled on their personal life, 30% were asked about their ethnic background, and 15% were asked about their religion. A total of 2 candidates reported questions about mental illness/disability, and 2 candidates reported being asked about sexual orientation. About 45% of applicants that were asked at least 1 of these questions ranked those programs lower.

Nearly all (94%) neurosurgical residency applicants reported being asked at least 1 inappropriate or potentially illegal question during interviews. The results indicate that inappropriate questions negatively affected program rankings 4).


1)

Gadjradj PS, Ghobrial JB, Booi SA, de Rooij JD, Harhangi BS. Mistreatment, discrimination and burn-out in Neurosurgery. Clin Neurol Neurosurg. 2021 Mar;202:106517. doi: 10.1016/j.clineuro.2021.106517. Epub 2021 Jan 25. PMID: 33529965.
2)

Woodrow SI, Gilmer-Hill H, Rutka JT. The neurosurgical workforce in North America: a critical review of gender issues. Neurosurgery. 2006 Oct;59(4):749-55; discussion 755-8. doi: 10.1227/01.NEU.0000232671.44297.DF. PMID: 17038940.
3)

Jacobs GB, Wille RL. Consequences and potential problems of operating room outbursts and temper tantrums by surgeons. Surg Neurol Int. 2012;3(Suppl 3):S167-73. doi: 10.4103/2152-7806.98577. Epub 2012 Jul 17. PMID: 22905323; PMCID: PMC3422097.
4)

Limoges N, Zuckerman SL, Chambless LB, Benzil DL, Cruz A, Borden JH, Durham S. Neurosurgery Resident Interviews: The Prevalence and Impact of Inappropriate and Potentially Illegal Questions. Neurosurgery. 2021 Mar 17:nyab059. doi: 10.1093/neuros/nyab059. Epub ahead of print. PMID: 33733664.

Medical student

Medical student

For students beginning their medical education, the neuroscience curriculum is frequently seen as the most difficult, and many express an aversion to the topic. A major reason for this aversion amongst learners is the perceived complexity of neuroanatomy 1).

The National Undergraduate Neuroanatomy Competition was established in 2013 as a means for students to display this commitment as well as academic ability.

A bespoke 22 item questionnaire was designed to determine career outcomes and the role of competition attendance in job applications. It was distributed using the SurveyMonkey website to the 87 attendees at the 2013 and 2014 competitions.

Responses were received by 40 competitors (response rate 46.0%). Twenty-four (60.0%) responders intend to pursue a career in either neurosurgery (n=18) or neurology (n=6). This included 10 (25.0%) responders who had successfully entered either neurosurgery (n=9) or neurology (n=1). The performance of these 10 (n=11, 57.0% ± 13.6) was significantly better than the other responders (n=30, 46.5% ± 13.5) (p=0.036). Seventeen (42.5%) responders either included their attendance at NUNC in a post-Foundation job application or intend to.

The National Undergraduate Neuroanatomy Competition provides the opportunity for medical students to demonstrate their interest in neurosurgery. It has the potential to be used as a tool for recognizing medical students suitable for neurosurgery training 2).

Osler created the first residency program for specialty training of physicians, and he was the first to bring medical students out of the lecture hall for bedside clinical training. Historically, medical student education in neurological surgery has generally limited student involvement to assisting in research projects with minimal formal clinical exposure before starting sub-internships and application for the neurosurgery match. Consequently, students have generally had little opportunity to acquire exposure to clinical neurosurgery and attain minimal proficiency 3).

Neurosurgery seeks to attract the best and brightest medical students; however, there is often a lack of early exposure to the field, among other possible barriers.

Medical students show varying clinical practical skills when entering their final year clinical clerkship, which is the final period to acquire and improve practical skills prior to their residency. Behling et al. developed a one-on-one mentoring program to allow individually tailored teaching of clinical practical skills to support final year students with varying skill sets during their neurosurgical clinical clerkship.

Each participating student (n = 23) was paired with a mentor. At the beginning students were asked about their expectations, teaching preferences, and surgical interests. Regular meetings and evaluations of clinical practice skills were scheduled every 2 weeks together with fixed rotations that could be individually adjusted. The one-on-one meetings and evaluations with the mentor gave each student the chance for individually tailored teaching. After completion of the program, each student evaluated their experience.

The mentoring program was well-received by participating students and acquisition or improvement of clinical practical skills was achieved by most students. A varying practical skill level and interest in the field of surgery was seen.

A neurosurgical one-on-one mentoring program is well received by final year medical students and allows for individually tailored learning of clinical practical skills 4).

Lubelski et al. sought to identify successful practices that can be implemented to improve medical student recruitment to neurosurgery.

United States neurosurgery residency program directors were surveyed to determine the number of medical student rotators and medical students matching into a neurosurgery residency from their programs between 2010 and 2016. Program directors were asked about the ways their respective institutions integrated medical students into departmental clinical and research activities.

Complete responses were received from 30/110 institutions. Fifty-two percent of the institutions had neurosurgery didactic lectures for 1st- and 2nd-year medical students (MS1/2), and 87% had didactics for MS3/4. Seventy-seven percent of departments had a neurosurgery interest group, which was the most common method used to integrate medical students into the department. Other forms of outreach included formal mentorship programs (53%), lecture series (57%), and neurosurgery anatomy labs (40%). Seventy-three percent of programs provided research opportunities to medical students, and 57% indicated that the schools had a formal research requirement. On average, 3 medical students did a rotation in each neurosurgery department and 1 matched into neurosurgery each year. However, there was substantial variability among programs. Over the 2010-2016 period, the responding institutions matched as many as 4% of the graduating class into neurosurgery per year, whereas others matched 0%-1%. Departments that matched a greater (≥ 1% per year) number of medical students into neurosurgery were significantly more likely to have a neurosurgery interest group and formal research requirements. A greater percentage of high-matching programs had neurosurgery mentorship programs, lecture series, and cadaver training opportunities compared to the other institutions.

In recent decades, the number of applicants to neurosurgery has decreased. A major deterrent may be the delayed exposure of medical students to neurosurgery. Institutions with early preclinical exposure, active neurosurgery interest groups, research opportunities, and strong mentorship recruit and match more students into neurosurgery. Implementing such initiatives on a national level may increase the number of highly qualified medical students pursuing neurosurgery 5).


A medical student training camp was created to improve the preparation of medical students for the involvement in neurological surgery activities and sub-internships.

A 1-day course was held at Weill Cornell Medicine, which consisted of a series of morning lectures, an interactive resident lunch panel, and afternoon hands-on laboratory sessions. Students completed self-assessment questionnaires regarding their confidence in several areas of clinical neurosurgery before the start of the course and again at its end.

A significant increase in self-assessed confidence was observed in all skill areas surveyed. Overall, rising fourth year students who were starting sub-internships in the subsequent weeks reported a substantial increase in their preparedness for the elective rotations in neurosurgery.

The preparation of medical students for clinical neurosurgery can be improved. Single-day courses such as the described training camp are an effective method for improving knowledge and skill gaps in medical students entering neurosurgical careers. Initiatives should be developed, in addition to this annual program, to increase the clinical and research skills throughout medical student education 6).

Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by reference letters and interviews may be more important. A study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program.

questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them.

Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach.

Honestymotivationwillingness to learnproblem solving and Stress management are important for success in a neurosurgical career. This information should be transmitted to medical students at “Career Day” venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can’t be taught should be present before the start of training 7).


1)

Larkin MB, Graves E, Rees R, Mears D. A Multimedia Dissection Module for Scalp, Meninges, and Dural Partitions. MedEdPORTAL. 2018 Mar 22;14:10695. doi: 10.15766/mep_2374-8265.10695. PubMed PMID: 30800895; PubMed Central PMCID: PMC6342347.
2)

Hall S, Stephens JR, Myers MA, Elmansouri A, Geoghegan K, Harrison CH, E N, D A, Parton WJ, Payne DR, Seaby E, Border S. The career impact of the National Undergraduate Neuroanatomy Competition. World Neurosurg. 2019 Sep 25. pii: S1878-8750(19)32516-1. doi: 10.1016/j.wneu.2019.09.086. [Epub ahead of print] PubMed PMID: 31562974.
3) , 6)

Radwanski RE, Winston G, Younus I, ElJalby M, Yuan M, Oh Y, Gucer SB, Hoffman CE, Stieg PE, Greenfield JP, Pannullo SC. Neurosurgery Training Camp for Sub-Internship Preparation: Lessons From the Inaugural Course. World Neurosurg. 2019 Apr 1. pii: S1878-8750(19)30926-X. doi: 10.1016/j.wneu.2019.03.246. [Epub ahead of print] PubMed PMID: 30947014.
4)

Behling F, Nasi-Kordhishti I, Haas P, Sandritter J, Tatagiba M, Herlan S. One-on-one mentoring for final year medical students during the neurosurgery rotation. BMC Med Educ. 2021 Apr 22;21(1):229. doi: 10.1186/s12909-021-02657-0. PMID: 33882933.
5)

Lubelski D, Xiao R, Mukherjee D, Ashley WW, Witham T, Brem H, Huang J, Wolfe SQ. Improving medical student recruitment to neurosurgery. J Neurosurg. 2019 Aug 9:1-7. doi: 10.3171/2019.5.JNS1987. [Epub ahead of print] PubMed PMID: 31398709.
7)

Myles ST, McAleer S. Selection of neurosurgical trainees. Can J Neurol Sci. 2003 Feb;30(1):26-30. PubMed PMID: 12619780.

COVID-19 for neurosurgeons

COVID-19 for neurosurgeons

In every country, all surgical plans have been modified. In Wuhan, the staff was enrolled in COVID-units. In New York, the Mount Sinai Hospital Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy, some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan, the main hospital was used for urgent non-COVID patients. In New York, the neurosurgeon staff works in ICU as an advanced practitioner (APP). In South Korea, every patient is screened. In Italy, the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and rheumatologists, neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China, elective surgical procedures are performed very carefully. In New York, surgery planning will be based on the patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Role

see Role of Neurosurgeons in the COVID-19 Pandemic.

While neurosurgeons are not on the frontline of COVID-19 management and treatment, they commonly care for critically ill patients who will continue to present with subarachnoid hemorrhages, subdural hematomas, brain tumors, traumatic brain injuries, spinal cord injuries, and compressive myelopathies while the pandemic occurs. While public health measures such as quarantine and social distancing are proving effective at slowing the spread, 2) 3) surgeons remain in direct contact with their patients throughout their operations. Protecting the surgical team from contracting COVID-19 is of utmost importance as they are both a potential vector for patient contamination and a scarce resource that cannot be easily replaced.


COVID-19 appears to be principally spread, either directly or via fomites, through droplets from respiratory epithelium— especially the upper respiratory tract. Blood is not at this point a recognized vehicle; if the significant virus were present in the blood, we would be able to do a blood test for the disease. Similarly, it does not seem to concentrate on the cerebrospinal fluid. Thus, most neurosurgical procedures to the spine and head should be safe with routine face and eye protection if Personal protection equipment is unavailable.

Recommendations

COVID-19 recommendations for neurosurgeons.

COVID-19 in chronic subdural hematoma

COVID-19 in chronic subdural hematoma.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

New York City

In an Invited Commentary, Ammar et al. describe their experiences and share lessons learned regarding triage of patients, staff safety, workforce management, and the psychological impact as they have adapted to a new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City. Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City 4).

Italy

see COVID-19 in Italy.

Switzerland

Switzerland neurosurgery is doing, where urgent or elective cases are performed in a separate location, and providers and patients require negative COVID-19 tests and chest radiographs prior to entry. Furthermore, there would be greater demand for rapid data analysis and iterative systems research to ensure the best neurosurgical practices 5).

COVID-19 and central nervous system

COVID-19 and central nervous system.

Emotional impact

The emotional impact of COVID-19: from medical staff to common people was published by Montemurro from the Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy 6).

Neurosurgery in an infant with COVID-19

Administering general aneasthesia to infants with respiratory infections is a challenge because aneasthetic drugs suppress immunity and can thus contribute to intubation-related mechanical stress and inflammation. Neurosurgery in infants with coronavirus disease 2019 (COVID-19) therefore poses a dilemma because the infection is associated with relative immune suppression and a dysregulated inflammatory response, which act as drivers of the disease 7).

From Milan, Italy, we report the case of an 8-month-old male patient with a complex hydrocephalus who had a shunt malfunction during the COVID-19 pandemic. The infant presented with a mild temperature, a dry cough, and an occipital cerebrospinal fluid collection, suggestive for shunt malfunctioning. Neurological examination was negative, but the infant deteriorated and vomited repeatedly. The head CT scan indicated a shunt disconnection. A chest x-ray was negative for overt interstitial pneumonia and the nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 8)

While the baby showed upper respiratory symptoms due to COVID-19, concerns emerged regarding the need for general anaesthesia for shunt revision. To our knowledge, no reports exist regarding the risk of general anaesthesia in infants with COVID-19. Nevertheless, considering the certainty of progressive neurological deterioration if no intervention was taken, the neurosurgical intervention was arranged.

According to the available protocols for patients with COVID-19, 9)

a negative pressure operating room was set up. The staff were provided with full-head hoods, eye protection, filtering facepiece 3 masks, fluid-resistant gowns, double long-sleeved gloves, and impermeable disposable shoe covers. Surgeons and scrubbing nurses had additional sterile surgical suits and an additional pair of long-sleeved gloves. The patient was transferred from a ward dedicated to patients with COVID-19 to the surgical theatre through an isolated and restricted area by trained personnel wearing protective gear 10) Surgery lasted approximately 1 h, and the infant recovered from general anaesthesia promptly. 4 days after surgery, vomiting had worsened and a second neurosurgical revision of the shunt was done. Again, the baby underwent surgery under general anaesthesia without respiratory complications. The baby was promptly extubated, and the neurosurgical course was favourable. To the best of our knowledge, this is the first reported case of an infant with COVID-19 undergoing neurosurgical operations under general anaesthesia. This case might reflect a general observation of relative resistance of babies and children to COVID-19, 11) suggesting the possibility that paucisymptomatic infants with COVID-19 can undergo major surgical procedures without additional morbidity. This early case report needs confirmation and extension and might have broader implications for other surgical procedures addressing potentially life-threatening conditions in infants 12).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Chinazzi M, Davis JT, Ajelli M, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science. published online: March 6, 2020 (doi:10.1126/science.aba9757).
3)

Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis. published online: March 5, 2020 (doi:10.1016/S1473-3099(20)30129-8).
4)

Ammar A, Stock AD, Holland R, Gelfand Y, Altschul D. Managing a Specialty Service During the COVID-19 Crisis: Lessons From a New York City Health System. Acad Med. 2020 Apr 17. doi: 10.1097/ACM.0000000000003440. [Epub ahead of print] PubMed PMID: 32304386.
5)

Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056. [Epub ahead of print] PubMed PMID: 32302998; PubMed Central PMCID: PMC7164328.
6)

Montemurro N. The emotional impact of COVID-19: from medical staff to common people. Brain Behav Immun. 2020 Mar 30. pii: S0889-1591(20)30411-6. doi: 10.1016/j.bbi.2020.03.032. [Epub ahead of print] PubMed PMID: 32240766.
7)

Lu X Zhang L Du H et al. SARS-CoV-2 infection in children. N Engl J Med. 2020; (published online March 18.) DOI:10.1056/NEJMc2005073
8) , 9)

Wax RS Christian MD Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth. 2020; (published online February 12.) DOI:10.1007/s12630-020-01591-x
10)

Tien HC Chughtai T Jogeklar A Cooper AB Brenneman F Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS). Can J Surg. 2005; 48: 71-74
11)

Li G Fan Y Lai Y et al. Coronavirus infections and immune responses. J Med Virol. 2020; 92: 424-432
12)

Carrabba G, Tariciotti L, Guez S, Calderini E, Locatelli M. Neurosurgery in an infant with COVID-19. Lancet. 2020 Apr 22. pii: S0140-6736(20)30927-2. doi: 10.1016/S0140-6736(20)30927-2. [Epub ahead of print] PubMed PMID: 32333840.
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