The Evolution of “Neurosurgical Consultation with Triage”
Since embarking on my “Celebration of Career Transition” over the past few weeks, a new, rather specific opportunity has arisen. And that opportunity is that of “The Evolution of the Neurosurgical Consultation with Triage”. When working hard as a busy neurosurgeon doing my surgical procedures for nearly 40 years, I would never have paused to consider this need. Let me introduce you to this new concept.
Usually, a neurosurgical patient is referred by a primary care physician, physiatrist, neurologist, rheumatologist, walk-in clinic or emergency department – or some other source – for surgical evaluation. But after many years of experience, I can tell you that the chance that at that first visit, I will immediately advise surgery is much less than 50%.
I have reminded myself that frequently, when the patient consults with the neurosurgeon, it becomes clear that the patient needs more imaging, more conservative care, a medical clearance or help with other pre-op clearance issues, etc. etc.
Certainly, these recommendations will best be made by a surgeon. Yet, this preoccupies surgeons appointment schedules with non-surgical work. Furthermore, some of the best surgeons for this job will be the busiest surgeons or very senior surgeons, who have spent many years making these decisions. And it may be hard to get the prompt referral appointments that the referral sources desire.
So what surgeons might be interested in this work? Options will include busy surgeons, who wish to add this feature to their surgical practices – and take the time our of their busy appointment schedules. Or, more likely, it may prove to be successful surgeons, who are retired, yet wish to continue caring for patients with surgical problems because of the personal rewards they experience while doing this kind of work.
Over the years, I have encountered patients that have needed a new C-MRI scan or new C-CT scan or dynamic C-spine x-rays before the best surgical procedure can be determined. I have been referred patients that don’t want surgery – even though the scan clearly suggests that there is an indication for surgery. These patient’s may need a physiatry or rheumatology or neurology referral.
I have seen patient’s referred for neck pain but the patient actually had rather severe low back pain. Clearly, a L-MRI scan was needed to see if the lower extremity numbness was due to cervical spinal cord compression vs lumbar cauda equina compression – or both.
I have seen patients that have had a clear cut lumbar disc herniation but who also have had no conservative care at all. Or maybe a patient for which there is a surgical indication but who has an abnormal coagulation test for reasons that are totally unclear.
I have been referred patients with metastatic cancer that have needed an oncology referral for more comprehensive understanding of where a spine surgery sits in relation to the other problems the patient is suffering.
And on and on goes this list of conditions identified by the surgeon at the first visit that needs subsequent additional evaluations and testing before the decision can be made to go ahead with surgery.
And again – in many of these scenarios it will be a neurosurgeon – or orthopedic spine surgeon – that will best know how to triage these issues. Probably better than other specialities.
1). As a neurosurgeon having identified the need for “Consultations with Triage”, I am most likely going to be much more available and ready to see your patients than a neurosurgeon engaged in an active surgical practice.
2). Since I am doing “Consultations with Triage”, my aim will be to service the needs of the referring source. Therefore, I will refer to the surgeon that will best fit with the preference of the referring source and/or patient – definitely not a surgeon that would not fit with these considerations.
3). So, finally, please spread the word that a principal interest of mine is that of “Neurosurgical Consultation with Triage” in keeping with the above discussion.
Sanford Wright MD