Since the recent overruling of Roe v. Wade by the US Supreme Court, I have been thinking about how often our Supreme Court has overturned it’s own prior decisions. A quick search of the National Constitution Center’s website says that the answer is a surprising 232 cases since 1810. This list of reversals includes significant civil rights cases that we all learnt about in school, such as Brown v Board of Education of Topeka (1954), a unanimous Warren Court decision that declared that a separate but equal policy of educational facilities for racial minorities violated the 14th Amendment’s Equal Protection Clause. The overturning of Roe v. Wade cuts off 36 million American women of reproductive age from a right guaranteed to them for 50 years.
To tweak my initial question, I wonder how often the US Supreme Court has eliminated a constitutional right (vs. awarding one, as was the case in Brown v Board of Education of Topeka), and how often has it reversed “a decision reaffirmed many times over the past 45 years,” or “precedent on precedent”, as Roe v. Wade was described by Justice Kavanaugh in his Senate hearings? While I am no constitutional expert, I have an opinion, and I am fairly confident that the answer is ZERO. As President Biden put it on 6/24/22: “Today, the Supreme Court of the United States expressly took away a constitutional right from the American people that it has already recognized. They didn’t limit it. They simply took it away. That’s never been done to a right so important to so many Americans.”
In our ideologically divided country, it is natural to classify all issues into left and right wing, into Democratic vs. Republican, into liberal vs. conservative. Interestingly, the landmark 1973 Roe v Wade case was a 7 to 2 decision written by a justice appointed by a Republican President, and grounded on the Due Process Clause of the 14th Amendment of the US Constitution said to provide a fundamental “right to privacy”. In the subsequent five decades, justices appointed by four more Republican Presidents voted to uphold the principles set forth in Roe v. Wade. In light of the fact that the Supreme Court cited anti-abortion laws from the 1800s as part of their rationale to overturn Roe v. Wade, it is not unimaginable to see some of our current mainstream ‘conservative’ leaders see contraception as an abortifacient as the next step.
In this issue we commemorate two occasions, we make note of the passing of Dr. Paul M. Ellwood Jr., MD., and we acknowledge important Supreme Court rulings. We also make clear an important editorial position.
Juneteenth Day, officially “Juneteenth National Independence Day,” was declared a federal Holiday by President Joe Biden last year and formally celebrated this year. Federal offices and wall street were closed on Monday. Please review a very brief history in “tidbits.”
Allow me to take the editor’s prerogative to express my personal connection to Juneteenth Day. I was born in a Country that has been dominated by dictators since the early seventies and one that suffered immeasurable losses due to a civil war that started in 2010 without end in sight. I was fortunate to have chosen the US as my home. I became a “Naturalized America Citizen” on Juneteenth, 1980, in San Antonio, Texas. I still remember the feeling of elation and yes, liberation as I left the Federal Building and headed to buy my first pair of cowboy boots. I was on cloud nine. To have been accepted by my new fellow citizens as one of their own was one of the greatest honors of my life.
Technically, I was never enslaved, but in truth I was not liberated until I became an American Citizen. To quote a famous Civil Rights Leader: “Free at last. Free at Last. Thank God Almighty, I’m Free at Last!
Title IX fifty years later, celebrated on June 23. To mark this occasion and to continue with our determination to publish a monthly essay about “Women in Neurosurgery,” we turned to one of the most accomplished women in neurosurgery, Ann Stroink. She wrote about how Title IX influenced her life. She is presently serving as President of AANS and has served Medicine and Neurosurgery tirelessly for many years in many capacities. She is a great leader and an example for both men and women in Neurosurgery.
Paul M. Ellwood Jr., MD. Died on June 20, 2022, at the age of 95. Dr Ellwood, a Pediatric Neurologist gave up his medical practice in the late 1960s to concentrate on health care reform. He came up with the concept of Health Maintenance Organization – H.M.O. – a partnership in which doctors are paid for the number of “lives” they see, not for each service given. The incentive to delay seeing patients, not seeing them at all, or rendering their care through midlevel practioners was created. Millions and millions of Americans are covered by such systems, with various degree of satisfaction. Dr. Ellwood’s envisioned these organizations to be not for profit. Our healthcare system made sure that profit was a big part of how they function.
The Supreme Court of the United States issued three important rulings during the last few days of June:
Also included in this issue are all the regular columns.
Finally, the editorial committee would like to make it clear that all opinions in the various columns/essays in this newsletter, including the italicized comments by the editor in tidbits are those of their respective authors and do not reflect the opinion/ position of CANS.
I hope you will enjoy reading this issue and as always, please don’t hesitate to reach out to me. My email address is email@example.com and my cell # is 805-701-7007
“The enemy of good is better.” The first time I heard this was from my partner Frank Harris at Scott and White Hospital, Temple Texas. His other saying was the not-politically correct, “There are Indians around every corner.” But this was the early 1990’s, and I was a newly minted attending neurosurgeon. He followed these adages with his surgeries and as my experience grew, so did I. Meeting the goal of the operation, whether to decompress the nerve root or remove the tumor, is the good. Making a good surgery better may end up making it worse by encountering the hidden enemies around the corner.
Gun safety legislation just passed in Congress. With its limited increase in safety measures, namely for those 18-21, it may not make significant change in the gun violence we see, but we should not stop the good for want of the better. The second amendment states: “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Those 27 words penned by James Madison and ratified in 1791 have kept Congress from funding studies on gun violence, put AK 57s on our streets, allowed virtually any adult to carry a concealed weapon in many states, promoted states to pass laws (unsuccessfully) to gag doctors talking about gun safety, and divided our society. The interpretation of those words from 231 years ago is left to 9 polarizing people in the present day.
Our approach to gun violence and its prevention needs to be data driven, not politically motivated. According to the CDC, in 2020 there were 45,222 firearm-related deaths in the United States (population 332 million). There were many more victims: the families, the classmates, the parishioners, the fellow shoppers. In Japan (population 126 million), there were 9 firearm deaths in 2018 (down from 23 in 2017). Death by firearm is one of the 5 leading causes of death in the US for those ages 1-44. It was the second leading cause of death (20.6%) for those 15-24 and the third leading cause of death for those 1-4 and 25-34 years of age. It is the preferred method of suicide for those over 75 who make up 18% of the annual suicide numbers. Indeed, by looking at these numbers, the solution is not more guns. Public defenders and their “more” guns did nothing to stop the violence in Uvalde.
As a neurosurgeon, I’ve seen gunshot injuries and deaths. My first gunshot injury seen in residency was a bullet to the occipital lobe in a hunter whose friend accidentally shot him. There was the spinal cord injury after a fight for a parking lot space; the death after losing a game of Russian Roulette; the gang related C2 awake but paralyzed victim; the domestic violence girlfriend shot in the head; the failed and successful suicides. Only one case in my career could be stretched into a defensive firearm shooting. That was the shop owner who was held up, then brought his gun to shoot at the get-away car fatally injuring the one person in the back seat who was not involved.
Granted, the number of firearm fatalities in 2020 are not as high as deaths from overdoses (91,799) or COVID (350,831), but they still represent a solvable epidemic. A first-hand account survivor story from a student at Marjory Stoneman Douglas High School was in the June 27 LA Times. It is a poignant request for gun safety.
Our wild west culture won’t change in a year or a decade but if we chip away at it, it will change. Let’s not let the enemy of the good be the better.
“We are only songwriters writing our songs and that’s all
We write what we live and we live what we write is that wrong
If you think it is Mr. Music Executive
Why don’t you write your own songs”
“And don’t listen to mine, they might run you crazy
They might make you dwell on feelings a moment too long
We’re making you rich and you’re already lazy
So just lay on your ass and get richer or write your own songs”
I apologize for the salty language. But like they say in Arabic: المسبه بمحلها تسبيحه. Loosely translated, it means “a correctly directed insult is a prayer.”
This is a song written by my favorite sage, Willie Nelson. It reminds me, every time I hear it, of us physicians and how we lost control of the “Practice of Medicine.”
While we work long hours to care for our patients, keeping them safe, advocating for them, exerting a positive influence in their lives, and, yes, making them better, Insurance executives and hospital CEOs are gaining more control and getting rich.
How rich, you may ask?
The median pay of hospital CEOs is 9 million dollars, and the CEOs of the top six health insurance carriers made a combined $236 million in 2020, 45 percent more than in 2019. While physicians saw a 22 percent cut to their reimbursements between 2001 and 2022. The income of the top health insurance companies soared in the first quarter of 2022: United Health $5.03 billion, CVS $2.31 billion, Anthem $1.81 billion, Cigna $1.18 billion.
Who controls the practice of Medicine in our Country? No, it is not physicians. Yes, you guessed it: Hospital CEOs and Health Insurance Companies’ Executives. Meanwhile, the majority of physicians are now employed either by hospitals or by mega groups, including private equity groups. Even physicians in Academia have little control over how they practice within their respective institutions.
At a hospital/institution level, the administrative bureaucracy has increased exponentially; even in a small community hospital, there are dozens of middle managers who are given a say in how we treat patients. We are told that we are an “important” part of a team of “providers.” But we are no longer the captain of a ship. We simply are a cog in a bureaucratic wheel. And just in case, we decide to show some autonomy, the specter of disruptive physicians can quickly be brandished over our heads. No physician wants to be accused of such a thing, and they know it.
At a health insurance level, patients are no longer allowed to choose their own physicians, rather they are expected to choose from a pre-determined panel of “providers.” Physicians are not free to choose what medications to prescribe, rather they have to adhere to formularies that were chosen by the insurance companies to save money for the insurance companies. Nor are they allowed to choose the type of treatment, be it medical or surgical; surgery is particularly affected by the pre-authorization process. This is a process that was designed by the health insurance companies to deny care or at least delay it, pure and simple. It is often conducted by unqualified reviewers, or at best by underqualified reviewers; a perfect example is a gynecologist reviewing/deciding on the need for a follow-up MRI scan after a brain tumor resection … or a gastroenterologist reviewing a proposed spinal surgery case.
When we accept the care of a patient, we enter into a sacrosanct relationship in which we are bound to choose the best course for such a patient. The health insurance company and the hospital for that matter do not have such an obligation.
When we accept the care of a patient, we sit down and compose an elaborate symphony, of several movements. This entails a workup, a differential diagnosis, a discussion of alternative options of care, a consent process, a treatment that may include some danger, and hopefully a happy ending. It would be optimal if we were given the freedom to conduct the symphony we composed or to sing the song we wrote.
The hospital and insurance executives are not able, nor are they trained, to write an elaborate symphony that includes every facet of the care of a patient. They are not qualified, nor do they have the talent to write a simple tune.
They are quite clever, however, so they want us to continue to write our songs, but they insist on telling us how to sing them. Our songs make them rich, and they’d rather sit on their a***s and collect the profit.
I think it is time to take Willie Nelson’s advice and tell all these administrators: “why don’t you write your own songs?”
In my family, it took just one generation to go from segregation to the Supreme Court of the United States.”
~Associate Justice of the Supreme Court Ketanji Brown Jackson
Title IX of the Education Amendments of 1972 (Title IX) prohibits sex (including pregnancy, sexual orientation, and gender identity) discrimination in any education program or activity receiving federal financial assistance.
— From HHS.gov.
Setting the Stage
June 2022 marks the 50th anniversary since the passage of Title IX, that provided legislation and subsequent regulation that forever altered the course of education and sports by removing obstacles of exclusion and harassment for women athletes and students. In an era of discontent, the stage was set for change. In the late 60’s, women protested, marched, and spoke out publicly, demanding equal rights. By the early 70’s, female students were pressing for access to organized high school and collegiate sports on par with male students. Women educators wanted more women on faculty in educational institutions and even footing for access to college, graduate, law, and medical school admissions. On June 23, President Nixon signed Title IX into law, to be immediately effective on July 1, 1972.
I was transitioning from high school to college during this time and carefully scrutinizing the legislative wranglings and maneuvers to get this bill passed. I was elated to hear that the bill was signed but also knew that much time would be needed to enact the law, change culture, and complete the necessary regulations to see fruition of the law’s intent.
Having already decided to make my career in medicine, I was acutely aware of the barriers to getting into medical school as a female. So many times I was told women had to have better grades, higher test scores and show commitment to even get an interview. I held a job during my high school and college years, so resilience became my motto and the hope for change, my strength. Nonetheless, I enjoyed these years despite the challenges, and acknowledged that the changes eventually did occur, although at a snail’s pace through the optics of a very young woman.
Medical School and Residency
I felt very fortunate to get into an accelerated three-year medical school through an early decision route – convincing my father that this was a good deal financially and supplied him with a business plan to make the case. I went to the Southern Illinois School of Medicine, and I am proud that we were the first USA school to enroll 30% women. It looked like times were changing.
It became very apparent to me during college and early medical school years that my passion was for the neurosciences with an affinity for neurosurgery, which determined my future. I knew immediately that my desire and conviction was going to be beset with hurdles far more challenging than anything I already encountered. Once again, I heard all the negatives. I was advised and told that neurosurgery was the last bastion of male supremacy, women would never be able to endure the stress involved in practicing neurosurgery, you shouldn’t have children, how about marrying a neurosurgeon instead and so on. Undeterred, I persisted, pleaded my case, and was accepted at the Mayo Clinic, for which I remain eternally grateful. I have been able to serve in a community with a large regional catchment base in central Illinois that had previously suffered from a severe lack of access to timely care and built a neuroscience medical infrastructure with a team of dedicated and likeminded individuals who have and will carry on the mission.
One should never give up hope for meaningful change, especially when the goal is to serve mankind in some noble way. Title IX was the beacon that brought the necessary revision to improve and enhance our societal values regarding diversity and inclusion.
I have heard that members of the younger generations are impatient for change and suggest that those of us who “fought the fight for equality” did not do enough. I fully disagree, but add that it is not perfect, we can change to achieve gender equity, but it takes a catalyst, time, and perseverance.
The neurosurgical service at UCLA was well established when I came to UCLA to finish my residency in 1962. The founding faculty consisted of Dr. W. Eugene Stern, who had been trained at UCSF under Dr. Howard Naffziger, (also his father-in-law), Dr. Robert Rand, son of Dr. Carl Rand, who had been chief at USC, and Dr. Paul Crandall who, I believe, had been identified as a faculty member by Dr. William Longmire when in the military. Dr. Carl Rand, despite being retired, would round occasionally with the residents at Wadsworth VA Hospital. There was a substantial Clinical Faculty, which included Dr. Max Andler (survivor of the Bataan March), Dr. Charles Carton, Dr. Milton Heifetz, Dr. Avner Feldman, Dr. Duke Hanna and Dr. Eric Yuhl.
Patients were categorized as “Private” or “Clinic” patients, and it was Dr. Stern’s policy that, for a patient to be his “Private” patient, the referring physician had to write a letter – or perhaps phone -Dr. Stern; all other patients were classified as “Clinic” patients. Residents had their own out-patient clinic, with an “Attending” present – often one of the Clinical Faculty. Residents did not attend the faculty’s out-patient clinics. The full-time faculty made rounds on “Ward Patients” during the time they were on service; occasionally a clinical faculty member would cover. Dr. Stern was an exemplary bedside teacher and would have the resident present the patient at the bedside, including a demonstration of pertinent findings. Patients were admitted at least one day prior to surgery, so that they could be seen at the bedside pre-operatively. Hair clipping was originally done at the bedside on the day prior to a planned craniotomy.
We had weekly Saturday morning conferences on the 7th Floor in Westwood, at which cases for the following week would be discussed. This also included assignment of faculty for various procedures. Faculty specialized in different procedures. Dr. Rand had brought the operating microscope to UCLA, I believe originally with Dr. Ted Kurze, later Chief at USC, with whom he was friends. Dr. Rand performed microscopic trans-nasal pituitary surgery, and cryosurgery or RF lesions for movement disorders, acoustic neuroma surgery, as well as spinal surgery. He was very innovative and together with Dr. John Alksne, at that time a young attending at Harbor General Hospital, developed the technique of ferro-embolization of aneurysms. Dr. Paul Crandall specialized in epilepsy surgery and had his own technicians, Eddie Carr and Ray Smith, who helped with making and placing implantable electrodes which permitted long-time bedside EEG monitoring. This led to the development of a premier epilepsy surgery program. He also did spine surgery and started me on the path of cervical spine surgery, particularly anterior interbody fusions, the “Cloward Procedure” at which he excelled. Dr. Stern was classically trained and performed pituitary surgery exclusively by the trans-frontal approach, always endeavored to take meningiomas out in one piece, and did cervical disc surgery by the laminectomy approach. It was one of the residents, Dick Balch, who first showed him how to do a Cloward anterior discectomy approach. Dr. Stern was particularly interested in carotid-cavernous fistulae and head trauma. He did do some work in his “lab”, run by his loyal assistant, Roy Jones. Over the course of several years, a spine service was developed by me, together with my orthopedic colleague, Dr. Edgar Dawson. Spine fusions were done rarely, except for cervical AIF procedures. Instrumented fusions were not known in the early years; wire fusions were rarely performed in the upper cervical region. Loupes and headlights were brought to UCLA by me in the 1970’s.
Faculty were always present at surgery performed on “Clinic Patients”. The rule was that at UCLA exposure of the dura was the limit for a junior resident, not to be crossed. During my own senior rotation at Wadsworth VA Hospital, Dr. Gian-Fortunat Hoessly, who had trained under Dr. Olivecrona in Stockholm, would put aside his Swiss newspaper to join us in the operating rooms when the pathology was exposed. In the 1960’s we performed our own neurodiagnostic studies at Wadsworth, including pneumo-encephalograms, direct arterial punctures (with a Conant needle) for arteriograms, and pantopaque myelograms. Lumbar myelograms were sometimes done with the patient standing and holding weights (pails of water) to help bring out the disc protrusions. The resident rotation at Harbor General Hospital was established, I believe, in the late 1960’s, and we would then hold a monthly Saturday conference at HGH. Dr. Donald Becker and Dr. Charles Needham were our early faculty at Harbor. I can remember having heard about a new Hounsfield technology when I was visiting in England, and seeing my first CAT scans. I brought this information to Dr. Gabe Wilson, Chair of Radiology, who had also heard about it from Dr. Stern, and soon thereafter he ordered the first CT Scanner for UCLA, I believe in the early1970’s.
By the mid-1970’s we had a busy neurosurgical service, with special expertise in movement disorders, epilepsy and spine surgery. The service, originally housed in the main UCLA Hospital, was moved to the Neuropsychiatric Hospital in 1961, which had been equipped with air-conditioning (unlike the main hospital). A consequence of having air-conditioning was that other patients on certain medications which inhibited perspiration, were moved to the neurosurgical unit. VIP patients were housed in the Wilson Pavillion, the 9th and 10th Floors of the Main Hospital. We had weekly joint Neurology-Neurosurgery Rounds in the NPI Auditorium, with Dr. Augustus Rose, Neurology Chair, and Dr. Eugene Stern in charge. Dr. Bill Oldendorf would occasionally quip something like “neurology is what you do ‘til the contrast studies are done”, raising Dr. Rose’s blood pressure! Bill was a respected researcher himself, and had done work akin to the CT scan concept. Dr. W. Jann Brown presided over brain-cutting conferences in neuropathology, later aided by Dr. Tony Verity.
Don Becker succeeded Eugene Stern as Chief of the Division of Neurosurgery in 1985, when Dr. Stern became Chairman of the Department of Surgery. Dr. Becker formally established specialty services within the Division, later to become a Department. The specialty services included Brain Tumors, Epilepsy, Vascular, Pediatric, Spine and Functional Surgery, and the faculty expanded to include Service Chiefs of these areas. This included Dr. Keith Black, recruited from University of Michigan, Dr. Neil Martin who had trained in vascular neurosurgery with Dr. Robert Spetzler at Barrow Neurological Institute, Dr. Warwick Peacock, pediatric neurosurgeon who had trained at the Hospital for Sick Children in Toronto, Dr. Tony DeSalles specializing in treatment of movement disorders and stereotactic radiosurgery, and Dr. Michel Levesque, epilepsy surgeon from Canada. Dr. Becker himself specialized in doing pituitary surgery. The UCLA neurosurgery program flourished under Dr. Becker and expanded significantly in volume and research productivity. The Brain Injury Research Center was established under the leadership of Dr. David Hovda; brain tumor research program made significant discoveries under Dr. Linda Liau. Critical Care became part of the resident training program.
Dr. Becker retired as Chief in 2002, and was succeeded by Dr. Neil Martin, under whose tenure the Division of Neurosurgery became a separate Department. Faculty included a number of graduates from the UCLA training program, including Drs. Liau, Bergsneider, Holly and Mathern. Major advances in technology including intra-operative imaging and localization techniques were incorporated during this time. Cerebrovascular surgery, Dr. Martin’s own area of expertise, expanded into interventional radiological techniques. Laser interstitial therapy, intra-operative ultrasound technology and new spine instrumentation soon followed. Clinical fellowships were established in a number of areas and the number of residents accepted for training increased from 2 to 3 each year. In 2014 the Department moved into the just completed Wasserman Building with the purpose of having the clinical and basic science faculty, as well as the Outpatient Clinic, located in the same general area.
Dr. Linda Liau became Chair of the Department in 2017 and under her leadership the Department has continued to expand. Younger current faculty are all fellowship trained in their subspecialties bringing to the forefront additional glioma expertise, pediatric epilepsy surgery and pediatric tumor research, stereotactic radiosurgery and potential applications of artificial intelligence. Technical advances in neuronavigation and minimally invasive surgery have been incorporated, and promising progress has also been made in aiding the visually handicapped and treating severe spinal cord injuries. The Department continues to expand in all sub-specialties in the direction of advanced concepts of research and surgery.
I was recently on a flight to Chicago, and I began watching a PBS documentary on Brian Wilson of The Beach Boys.
I’d always felt a special connection to their music because my dad used to listen to their songs on the car radio along with other “Golden Oldies.” Their songs evoked the beautiful and endless summers of California and sparked such wonder and yearning in me to go. I pictured palm trees, the gentle waves along a warm beach and beautiful cherry red hot rods.
When I got older, I started listening to their older works, and of course the seminal “Pet Sounds.” My parents told me stories of Brian, and how troubled he was. Here was a musical genius and perfectionist, plagued by the hallucinations and delusions of schizoaffective disorder. His father was verbally abusive, and Brian internalized it driving himself even harder. Brian’s life, although financially comfortable, was plagued: eventually losing both of his younger brothers – first Dennis (the drummer, playboy, and amazing musician in his own right) and then Carl – the soft heart of the group, lead guitar, and the voice you heard the most on “God Only Knows,” only six years later.
Understandably, Brian was broken. He was shattered by all the loss, and of course drug abuse, and a controlling Svengali of a psychiatrist who later lost his license.
The Boys grew up in Hawthorn, about 20 minutes from the closest beach. They loved each other, fought, argued, and broke up. The years were hard on him. He is actively managed for his psychiatric issues and is somewhat stunted emotionally. Yet somehow, Brian who is well into his 70s is still writing, recording, and actually touring.
During a long and arduous residency, there is little time for licking one’s wounds. The very idea of taking a day “off” was eschewed or even mocked in most training circles. For most of us who started training before the 80-hour work week, we might have even looked down on those that came after us. And then we haughtily invoked tales of when giants roamed the earth and we worked over 100 hours per week. It is fair to say, that what sets neurosurgeons apart in many ways from our other colleagues is the number of hours spent in a supervised training environment: in the operating theater, the clinic, and with attendings and colleagues discussing treatment. Academic colleagues, today, tell me stories of young trainees making demands for time off for family or non-academic reasons.
In our chosen vocation, we face difficult choices and bifurcation after bifurcation and the cumulative effect of our decisions on patient’s lives. During the last three years, we have also endured the far-reaching effects of a global pandemic. The chaos not only wrought on patients, but also on our families and practices. Some of us had to borrow money or apply for grants and loans just to stay afloat. Perhaps some of us even had to leave or sell our practice. And still others may have actually fell ill and may still be feeling it’s effects. Lastly, there are those of us who undoubtedly lost a patient or even a loved one to the virus or its aftereffects. As I write this, I am recovering from a COVID-19 illness as well.
We have all become acutely aware of the brevity and fragility of life – even those of the “invincible” neurosurgeon. I am sure we all know or have been aware of a colleague who lost a loved one, marriage, or precious time with children. Many of us have, and so suffer from poor health due to work-related stresses.
As our lives run up into our vocation, we should realize that we all have our limits. That perhaps working, consulting, publishing, meeting, and researching 24/7 exact a toll on us, on our families.
Brian Wilson became consumed by his work and a victim of his talent. Finally, he found a balance to the illness that was his torment and possibly the source of his talent. It might be a life lesson, then, to not dismiss the fact that just because we are trained to tough and “resilient,” we should not ignore our needs as human beings. Perhaps we should take a lesson from a younger group and pepper some of our work life, with our actual life.
I recently published two articles relevant to my health policy research.
The take-home point: outcome measurement is difficult.
I know, this is not exactly groundbreaking. Article 1 showed that when including socioeconomic status into the CMS risk adjustment formulae, the expected outcomes changed. Article 2 showed that Medicaid patients had worse patient reported outcomes after lumbar spine surgery in the Quality Outcomes Database.
These articles both highlight the inherent contradictions in the “pay for performance” schemes when examined through a socioeconomic lens. Poverty is associated with worse outcomes and higher spending. Our two papers echo this in spine surgery. If physicians are to be financially penalized for poor outcomes, this dis-incentivizes providers from caring for socioeconomically disadvantaged patients. Neurosurgeons who serve a safety-net practice know this. They are already penalized by reimbursement that is a fraction of what Medicare pays. Further penalties from value-based payments disproportionally harms these safety-net systems.
Conversely, adjusting outcome statistics for socioeconomic status, in effect, lowers the bar for disadvantaged patients. By taking poverty into account for risk adjustment formulae, it would reduce expected outcomes for poor patients.
Of course, the ultimate question remains: do value based payments incentivize good outcomes? There is some evidence that improvements in metrics are just byproducts of how the risk-adjustment formulae are coded. Other studies have shown that metric fixation can worsen outcomes as hospitals engage in behaviors which increase mortality in order to meet other statistical benchmarks.These issues remain unresolved as many advocates push to increase value-based reimbursement schemes in safety-net hospitals. As our two studies have shown for spine surgery, value-based reimbursement is not as simple as “paying for good outcomes.” Value-based reimbursement requires massive central planning, with multiple formulae and statistics being tracked and coded. This is a good example of the “local knowledge problem” in economics described by FA Hayek. Planning by a central power cannot account for the universe of local knowledge. To put it another way, no statistical formula will more accurately judge the outcomes of the patient-physician relationship better than the dispersed knowledge of the millions of physicians and patients across the country.
This conflict has well-intentioned participants on either side and will not be resolved in the confines of my humble column. For now, though, I hope my two meager articles can help reiterate this point: accurately and fairly measuring outcomes is nuanced and difficult.
Thank you for your advocacy on AB 2060!
Your advocacy prevailed! By taking swift action, California legislators heard your concerns about AB 2060 by Assemblymember Quirk, which would have made California the only state in the country to have a public-member majority of its medical board.
The bill did not have sufficient votes to pass the Assembly and was moved to the Assembly’s inactive file late last week. This means that AB 2060 is no longer eligible to be acted upon this legislative session. CMA endorses AMA principles for sustainable Medicare payment reform
CMA endorses AMA principles for sustainable Medicare payment reform
Deeply alarmed about the growing financial instability of the Medicare physician payment system, the California Medical Association (CMA) is one of 120 organizations that have endorsed the American Medical Association’s (AMA) new Medicare payment reform principles. The principals provide a framework to reshape the Medicare payment system so that it works better for patients and physicians.
On July 16, 2022, the National Suicide Prevention Lifeline (800-273-8255) will be replaced with a simple, easy-to-remember three-digit number (988). The U.S. Department of Health and Human Services has awarded $105 million to 54 states and territories in advance of this date to help states meet the growing demand for mental health care.
Over the past month, a series of tragic and senseless mass shootings have, once again, ripped communities and families apart, destroyed and ended lives far too soon, and further exposed the epidemic of gun violence that grips our nation.
The latest attack hit very close to home, when a man opened fire in a medical office building on the campus of Saint Francis Hospital in Tulsa, Okla., killing four people—including two physicians—and injuring several others before taking his own life.
“The physicians of California stand in solidarity with our health care colleagues in Oklahoma and send not just our deepest condolences, but our outrage that such senseless acts of violence continue to plague our nation,” said California Medical Association (CMA) President Robert E. Wailes, M.D. “As healers, physicians are often on the front lines of gun violence, but the latest shooting in Oklahoma targeted physicians in a space that should be devoted to peace and healing. This cannot stand. CMA calls for reform to end this terrible epidemic of gun violence.”
The Tulsa hospital shooting comes just eight days after 19 school children and two teachers were slaughtered in Uvalde, Texas, and two weeks after a white supremacist attack in a Buffalo, New York, supermarket killed 10 people and an attack at a church in California where one of our own— John Cheng, M.D.—took heroic measures to stop another act of senseless gun violence, and in the process gave his life to save others.
“We cannot become numb to the nearly daily reports of gun violence and mass shootings. We cannot sit idly by and do nothing while more than 45,000 Americans die each year by gunfire,” said Dr. Wailes. “This is a uniquely American public health crisis. We must come together with a united front and call for meaningful action to save lives.”
Since 1975, more Americans have died from firearms than in all the wars in U.S. history going back to the American Revolution. Gun violence is a public health crisis, and as with other public health areas, evidence-based interventions are needed for reducing deaths and injuries.
CMA has long-standing policy recommendations for reducing firearm-related trauma, injury and death. CMA strongly supports H.R. 7910, the “Protecting Our Kids Act,” an omnibus package of eight bills focused on preventing firearm violence. With gun violence soaring, it is imperative for Congress to act now.
“CMA declared gun violence a public health crisis in 2016 and physicians will continue to demand action to end this senseless epidemic of indiscriminate violence, whether in our schools, our health facilities or our streets,” said Dr. Wailes.
What You Can Do
As physicians, our mission is to heal and to maintain health. Physicians are in a unique position to assess risk, provide education and change behaviors related to firearm violence. In 2017, the CMA Firearm Violence Prevention Technical Advisory Committee, composed of physician experts, performed a comprehensive review and analysis of CMA policy, epidemiological data and current scientific research and developed a CMA position statement on the prevention of firearm violence.
“Physicians have a responsibility as trusted public health figures to respond to the harms associated with firearm violence, both as individual clinicians and as community advocates,” says Dr. Wailes. “I ask my fellow physicians to make a commitment to ask your patients about firearms when appropriate and follow through with support and resources to keep them safe. We can make a difference, one patient at a time.”
In 2019, California Assembly Bill 521 authorized three years of funding for the California Firearm Violence Research Center at UC Davis. Building on the prior work of the UC Davis What You Can Do Initiative, the BulletPoints Project gives clinicians the knowledge and tools they need to reduce the risk of firearm injury and death in their patients.
Visit BulletPointsProject.org for more information on what you can do, as physicians, to help stop gun violence.
June 1 – Adm. Linda Fagan became the first female officer to lead the Coast Guard.
June 2 – AP News: A man who blamed his surgeon for continuing pain after a recent back operation bought an AR-style rifle and opened fire hours later at a Tulsa medical office, killing the doctor and three other people in an attack that ended with him taking his own life, police said. The gunman called the clinic repeatedly complaining of pain and specifically targeted the doctor who performed the surgery, Tulsa Police Chief Wendell Franklin said. That physician, Dr. Preston Phillips, was killed Wednesday, along with another doctor, a receptionist, and a patient. The attack occurred on the campus of Saint Francis Health System in Tulsa. The gunman carried a letter that said he was targeting Phillips. The letter “made it clear that he came in with the intent to kill Dr. Phillips and anyone who got in his way,” Franklin said. “He blamed Dr. Phillips for the ongoing pain following the surgery.” Spine surgeons beware!
June 2 – Harini Logan, a 14-year-old eighth grader from San Antonio, Texas, spelled 22 words correctly during the 90-second spell-off, beating Vikram Raju by seven. The winning word, according to Scripps, was “moorhen,” which means the female of the red grouse, because that was the one that moved her past Vikram. It was first-ever lightning-round tiebreaker in the spelling Bee’s history. The first National Spelling Bee was held in Washington, D.C. on June 17, 1925.
June 3 – National Gun Violence Awareness Day- I dream of a day when we no longer need to observe such a day!
June 3 – Ann Turner Cook, a retired schoolteacher died early Friday at her home in St. Petersburg, Florida. She was the model for the Gerber Baby sketch, by artist Dorothy Hope Smith.
June 6 – 78th Anniversary of D-Day
June 7 – The country of Turkey, with approval of the UN, officially changed its name to Turkiye, pronounced tur-key-yay. I gather they want nothing to do with our Thanksgiving bird.
June 8 – Southern California-based Huy Fong Inc., told customers in an email that it would suspend sales of its famous spicy Sriracha sauce over the summer due to a shortage of chili peppers. Time to stock up!
June 9 – Sarah Merrill, a mother of nine who started medical school when her youngest child was 4 years old graduated with her medical degree and plans to be a neurosurgeon. Merrill and her family including her kids who now range in age from 20 to 8 are now moving to Indiana, where she will begin her residency in neurosurgery at Indiana University. Never too late, and never underestimate the capabilities of a mother of nine.
June 11 – Josh Jensen, the man who brought “Pinot Noir” to California when he started Calera Vineyard in San Benito County in 1974 died. He was a man with a passion and on a mission.
June 14 – National Flag Day
June 16 – Dr. Simone Gold is a former emergency room physician, a Beverly Hills-based doctor, a Stanford Law School graduate who has over 480,000 followers on Twitter. She founded America’s Frontline Doctors. a group known for purveying COVID-19 misinformation. She has condemned COVID-19 lockdowns and promoted the use of unproven and potentially dangerous drugs as coronavirus treatments. She was sentenced to two months in prison by U.S. District Judge Christopher Cooper in Washington, D.C., for storming the US Capitol, where she delivered speeches to rioters during the mob’s attack. She is also expected to serve 12 months of supervised release after her 60-day prison term and pay a $9,500 fine. A physician and a Lawyer? Really?
June 18 – The CDC approved both Moderna and Pfizer vaccines against the corona virus for children 5 months old and older. Families will finally have some peace of mind with their children protected.
June 19 – Father’s Day! Honoring Fathers in the USA is celebrated on the third Sunday in June. Founded by Sonora Smart Dodd from Spokane in 1910. A bill to accord national recognition of the holiday was introduced in Congress in 1913. In 1916, President Woodrow Wilson went to Spokane to speak in a Father’s Day celebration and wanted to make it official, but Congress resisted, fearing that it would become commercialized. In 1957, Maine Senator Margaret Chase Smith wrote a proposal accusing Congress of ignoring fathers for 40 years while honoring mothers, thus “[singling] out just one of our two parents”. In 1966, President Lyndon B. Johnson issued the first presidential proclamation honoring fathers, designating the third Sunday in June as Father’s Day. Six years later, the day was made a permanent national holiday when President Richard Nixon signed it into law in 1972. Is it possible to have a holiday in the USA that is no commercialized?
June 19 – Juneteenth Day or Emancipation Day! It was declared a Federal Holiday by President Joe Biden in 2021 with the official name of Juneteenth National Independence Day. The day was celebrated in various states of the Union since 1865, having originated in Galveston, TX. On June 19, 1865, Union Army General Gordon Granger issued General Order No.3, proclaiming freedom for enslaved people in Texas. Order No.3 read in part: “The people of Texas are informed that, in accordance with a proclamation from the Executive of the United States, all slaves are free,” and, “This involves an absolute equality of personal rights and rights of property between former masters and slaves, and the connection heretofore existing between them becomes that between employer and hired labor.” Parts of Texas had not heard President Abraham Lincoln’s Emancipation Proclamation that was issued on January 1, 1863. This writer became a proud citizen of this amazing Country on Juneteenth day, 1980, in San Antonio, TX.
June 20 – AP – The Nobel Peace Prize auctioned off by Russian journalist Dmitry Muratov to raise money for Ukrainian child refugees sold for $103.5 million, shattering the old record for a Nobel. Previously, the most ever paid for a Nobel Prize medal was $4.76 million in 2014, when James Watson, whose co-discovery of the structure of DNA earned him a Nobel Prize in 1962, sold his. The number is simply mind boggling.
June 20 – Dr. Paul M. Ellwood Jr., who changed the way millions of Americans receive private medical services by developing the model for managed care known as the health maintenance organization, died in Bellingham, Washington. He was 95. He gave up practicing pediatric neurology in the late 1960s to devote himself to national health reform, and was often called the father of the H.M.O.
Dr. Ellwood conceived of — and in 1970 coined the term H.M.O. to describe — a partnership in which doctors are paid for the number of patients they see, not for each service given. Is there not an inherent conflict of interest in this model?
June 23 – Is the 50th anniversary of Title IX, the landmark legislation that afforded women and girls equal opportunity in education and sports across the US.
June 23 – The Supreme Court of the United States issued a ruling in New York State Rifle & Pistol Association, Inc., Et Al. v. Bruen, Superintendent Of New York State Police, Et Al., making it easier for to carry a firearm in public, thus over-ruling a 100-year-old New York Law. California has the same kind of restrictions as New York did. Will they change?
June 24 – The Supreme Court of the United States overturned Roe v. Wade – the constitutional right for abortion – in a 6/3 decision regarding Dobbs v. Jackson. Many thought that “Roe” was a settled Federal Law. Now it is up to individual States. It is unlikely that California will soon change its approach to abortion.
June 25 – President Biden signed into law a bipartisan gun bill intended to prevent dangerous people from accessing firearms and invest in mental health across the country, breaking through years of stalemate over whether to toughen the nation’s gun laws. Passage of the legislation came one month after a horrific mass shooting at an elementary school in Uvalde, Texas, left 19 children and two teachers dead. Better late than never.
June 27 – The Supreme Court ruled in Kennedy v. Bremerton School District that a high school football coach had a constitutional right to pray at the 50-yard line after his team’s games. The vote was 6 to 3, with the court’s three liberal members in dissent. Is there a conflict between an individual’s right to free speech and the Constitution’s prohibition of government endorsement of religion?
June 29 – FDA advisers recommended that the Food and Drug Administration updates coronavirus booster shots in order to target some forms of the Omicron variant that now dominate;. BA.4 make up 15.7 percent of new cases, and BA.5 is 36.6 percent, accounting for about 52 percent of new cases in the United States.
Special gratitude to NuVasive for their platinum Sponsorship!
NuVasive, Inc. is the leader in spine technology innovation, focused on transforming spine surgery and beyond with minimally invasive, procedurally-integrated solutions designed to deliver reproducible and clinically-proven surgical outcomes.
NuVasive, Inc. is the leader in spine technology innovation, focused on transforming spine surgery and beyond with minimally invasive, procedurally-integrated solutions designed to deliver reproducible and clinically-proven surgical outcomes.
Western Neurosurgical Society: Annual Meeting, September 9-12, 2022, Kona, Hawai’i, HI
CSNS Fall Meeting October 7-9, 2022 San Francisco, CA
CNS Annual Meeting October, 9-15, 2022 San Francisco