Neurosurgery at Queen Square

The day I finished studying the anatomy of brain, I knew that I wanted to pursue neurosurgery as a career speciality. A medical student getting fascinated by the mysterious workings of the human brain is not something unusual. Here, in a mere 3 pounds of living tissue, lies the complexity sufficient to incarnate and store the record of a lifetime of the richest human experience. Our brains contain the secrets of ourselves. Its mystery lies in the fact that it controls our behavior, feelings and thoughts, and also in the fact that how a physical brain is able to hold a seemingly non-physical mind. Getting inspired by all these ideas, I decided to apply for an elective in Neurosurgery through the University College London School of Medicine.

The destination for my elective was The National Hospital for Neurology and Neurosurgery, Queen Square which is the UK’s largest hospital dedicated exclusively to the treatment of neurological and neurosurgical disorders. I chose the United Kingdom for my elective because it is a lot easier to get an elective placement here as compared to the USA and Canada. Moreover, the malpractice insurance for overseas elective students is free. The National Hospital for Neurology and Neurosurgery is the largest research and clinical center for neurological diseases in the UK hence it became an ideal option for me. With 32 outpatient consulting rooms, the hospital offers around 200 outpatient clinics every week covering all aspects of neurology, neurosurgery, neuropsychology and neurorehabilitation. It has 244 inpatient beds and four operation theaters. It is treating over 6,000 inpatients, 120,000 outpatients and 8,000 day cases each year. All departments in the hospital are managed by highly trained consultants in all neurological fields including  neurosurgery, neurooncology, headache clinic, national prion clinic, neuroanesthesia, neurocritical care, neuromuscular diseases, neurogenetics, neuroimmunology, neurometabolic unit, neuroradiology, neuro-ophthalmology, neuro-otology, neuropathology, neuropsychiatry, uro-neurology, spine surgery, neurorehabilitation, acute brain injury unit and the cognitive disorders clinic. Medical students from UCL and Royal Free Medical School undertake neuroscience attachments at NHNN. Apart from that, the hospital also offers undergraduate medical student elective attachments for UK and overseas students.

As the hospital is a part of University College Hospitals Foundation Trust, I applied through University College London (UCL). I started working on my application almost a year before the start date of my elective because the elective administration demands a lot of documents. There are three parts of the elective application form. Part 1 comprises of the personal details and elective module preferences. This form must be completed and sent via post to the university as soon as possible because it takes the administration quite some time to find a consultant who is ready to supervise you. The easiest way is to email personally as many consultants as possible requesting them for an elective attachment. I did the same and in the end a consultant neurosurgeon agreed on giving me an elective attachment with her. With the supervisor in hand, all you have to do is fill in parts 2 and 3 of the application form which comprise of academic verification and health and and immunization verification respectively and send them with all the required documents to the university. The university acknowledges your application by granting you a confirmation of acceptance of studies (CAS). All that is left after this is the student visa (in case you need it) and you are on your way. Medical malpractice insurance is compulsory and can be easily attained from Medical Protection Society (MPS) for free.

My elective with the team of my consultant neurosurgeon began on the 10^th of June, 2011. I made sure that I knew the basic anatomy and physiology of the brain before reaching there which proved to be very helpful later on in the course of my elective.

The consultant starts seeing students at 7:30 am sharp for case-based teaching. That undoubtedly is the most useful session of the day. Everyone is welcome to attend the teaching whether it is a neurosurgical trainee or an elective student. Cases that were covered during my stay included the video demonstration of the clipping of an aneurysm, functional brain surgery for essential tremors, resection of meningiomas, pituitary and pineal tumors, basic spinal laminectomies, insertion of a ventriculoperitoneal shunt, third ventriculostomy, endoscopic removal of brain tumors and nerve biopsies. After attending the teaching session, the entire team makes its way to the conference room where they discuss the cases for the day. The biggest advantage of the case conferences was improvement of my scan reading skills; how they helped me differentiate between a bleed and an infarct, and a subdural and an extradural hemorrhage. Cases were presented by the registrars and the senior house officers were asked to comment on the scans. Next is the time for ward rounds. Elective students are free to follow any senior house officer for the round. As a part of the team, one is supposed to go to the patients, both pre- and post-operative, and inquire about their present physical condition. One can get a chance of performing a neurological examination on the patients and elicit all the important signs. One can also observe how the house officers order blood, scans etc. for every individual patient and observe them making referrals, writing discharge letters and ordering consults.

By the time ward rounds end (usually by 10:00 am), the four operation theaters are full and running. Next thing one wants to do is to go to the changing room, get into a nice pair of scrubs and check the list of all the surgeries going on. Surgeons are usually very happy for students to come and observe all the procedures. All one needs to do is to enter the operation theater, introduce him/herself and take permission to observe. All the neurosurgical procedures are a treat to observe. I saw numberless surgeries but the ones that I remember include spinal lumbar microdiscectomy and laminectomy, anterior cervical cord decompression, frontal tumor resection via endoscope, surgeries for pineal tumors, transsphenoidal hypophysectomies, surgery for resection of clival chordoma, resection of different types of brain tumors, evacuation of subdural hematoma, clipping of a posterior communicating artery aneurysm, foramen magnum decompression, carpel tunnel decompression, deep brain stimulation and surgical maneuvers for trigeminal neuralgia. In between the hours are lectures on neurology and neurosurgery for UCL students. Elective students are most welcome to attend these teachings which are mostly on neurological history and examination skills, and on topics like movement disorders, dementia, epilepsy, neuroradiology, neuro-ophthalmology, cranial nerves examination and multiple sclerosis. Thursday is the Gower’s grand round day which includes a live case presentation and diagnosis-making session. Whenever one finds a free hour, going to the basement and observing interventional neuroradiology procedures is always worth it. Almost every minute of the day, an aneurysm is being coiled in the radiology department. One should also try spending some time at the neurosurgical clinic that is just next to the hospital. One can sit there as an observer student and watch how the surgeons take detailed history and perform neurological examination on each and every patient and observe their criterion for ordering CT and MRI scans. Occasionally, the teacher may ask one to take history and perform examination on a patient, thus further contributing to one’s clinical knowledge and skills. The elective students are allowed to come in direct contact with the patients up to a limited extent. For instance, the students can perform physical examination on the patients but they are not allowed to draw blood or take part in invasive procedures.

An important fact that I noticed during my elective was that surgeons in the UK are addressed as ‘Mr./Miss’ but never as ‘Dr.’. I never got to know the exact logic behind this but I inferred that surgeons do not like being called doctors because they like to distinguish themselves from physicians. Another reason why surgeons are addressed as ‘Mr.’ may be because back in early days surgeons were originally not ‘proper’ medical people, but usually no more than barbers who used their skills with razors and other sharp implements to deal with amputations. Generally students think that carrying on some research project during their clinical elective will be overburdening. It is not so. One can always find an hour or so to work on some project or audit given by the supervisor. It will not only help improve one’s research skills but also add to one’s knowledge of the given disorder. During the course of the elective, one gets to meet medical students from all corners of the world. This enables one to understand the healthcare systems in other countries. One can interact with people of different cultures and end up making friends for a lifetime. Towards the end of the elective placement, students should liaise with their consultant supervisor and with the elective administrator to obtain the certificate of satisfactory completion. There is no formal evaluation, but the student has to go through an exit interview in order to obtain the certificate of satisfactory completion. The exit interview is the ideal time for the student to request their supervisor for an LOR. Writing a feedback report is not mandatory but one can always do it because it counts as a full publication. So if one wants to make the most out of his elective, he must go with some knowledge of the respective field in hand, impress his supervisor with punctuality and enthusiasm, get an LOR and certificate of satisfactory completion. In addition, taking part in some ongoing research activity and writing your elective report are bonus points which can add to your CV in the form of publications.

Unfortunately, the school does not offer any accommodation for the medical students. However, there are a lot of nearby student halls that offer accommodation to the overseas elective students.  The Russell Square tube station is only about three minutes’ walk away from the hospital. Using the London underground tube service is the easiest way to travel in London. London    is    the    world’s    leading    tourism destination, and the city is home to an array of famous tourist attractions including central London sites like the Buckingham Palace, the British Museum, the British Library, London zoo, Covent Garden, London Eye, Trafalgar Square, the Charles Dickens Museum, London Bridge, the Tower of London and many more. The food in London is amazing especially the traditional fish and chips breakfast. In short, it was an experience of a lifetime and will be remembered forever.