President's Message - Medice, cura te ipsum!
The Vulgate, a IVth century Latin translation of the Bible gave us the phrase “Medice, cura te ipsum”, which has been translated as “Physician, heal thyself!”. This was not a prescription for medical therapy, but rather a sarcastic commentary on the irony of situations in which one may not practice what one preaches. Indeed, even though this proverb pre-dated Christianity, with analogous phrases found in Classical texts from as early as the VIth century BC, the sentiment behind it was essentially a criticism of hypocrisy, and a call to fix oneself before finding defect in others, or to practice what one may be preaching. The thick irony of this sentiment echoed in the taunts directed at Jesus even as he hung on the cross: “He saved others; himself he cannot save”. (Vincent, Marvin Richardson (1887). Word Studies in the New Testament (2 ed.). C. Scribner’s sons. p. 293). I wonder if it is time for the medical profession to take this phrase to heart, strip it of its cynicism, and actually use it as a launching pad for introspection and genuine healing.
Having served in various hospital leadership roles, having been an expert for the medical board, and having been involved in disciplinary procedures at a medical school, I never cease to be surprised by how hard, and sometime how harsh, physicians can be towards each other. While compassion is the foundation of our profession, we frequently lack it when dealing with each other, and even when we deal with ourselves, we are more often than not, unforgiving. Physicians can be very judgmental when reviewing each other’s peccadillos and human frailties, as seen in “Physician Wellbeing Committees”, which frequently are feared by medical staff members as a fast way to have your privileges restricted. Sham peer review is another example of “Medice, cura te ipsum”, in that, colleagues who may have little knowledge or understanding of each other’s (sub)specialty, sit in judgment as “peers”. No physician wants to be brought up in front of the medical board, as you are assured an arduous and painful process led by physicians who can’t be seen as too lenient on their own kind.
Why do we need to be so callous towards each other? Using our own example as neurosurgeons, is the disease/trauma we are treating already not hard enough?
Is the patient upset with a poor or imperfect outcome not taking enough of an emotional toll on us?; is the pressure of our hospitals tracking our every move through small and big data, many of them thinly veiled pretexts with misleadingly benign rubrics– peer review, incident report, length of stay analysis, benchmarking, quality improvement–to insert third parties between us and our patient, not enough to worry about? I notice that teamwork is our institutional mantra, though as soon as something goes wrong, everyone runs for the hills, leaving the neurosurgeon as the captain of the ship (who naturally needs to go down with that ship if necessary!). While we (correctly) expect empathetic treatment of our patients, their families, and their other caregivers, there seems to be a flagrant lack of empathy towards the physician who is dealing with difficult decisions and situations, day in and day out. Instead of “Physician, heal thyself”, perhaps we need to say “Physicians, let’s heal ourselves”, and demand the empathy we also deserve.
When you receive this Newsletter, you will have celebrated with your families and friends Memorial Day, the traditional start of the summer season. However, since the real reason behind Memorial Day is to honor and remember those who lost their lives while serving in the United States Armed Forces, I hope that each of you took a few moments to do that, and in addition reflect on the more than one million lives lost to COVID 19 in our Country since the pandemic started. I did, and I can’t get over the fact that more than 400,000 of these deaths occurred after vaccines became widely available …
You will have also mourned the senseless loss of the lives of 19 children from Robb Elementary School in Uvalde, TX, as well as two adults including a teacher. What a tragedy! One that requires action, and not just thoughts and prayers.
CANS was well represented at the Spring CSNS meeting. During the Plenary session a tribute was paid to our founding editor, mentor, colleague, and friend Randy Smith. Many in attendance expressed not only how much they miss his presence and contributions to CSNS but also how they had a “special and personal” relationship with him and how he influenced their professional career.
Jeff Cousin, who was awarded the Lyal Leibrock Award, indicated that he’d have to function as “the CSNS curmudgeon” now that Randy is gone. My answer: Randy was not a curmudgeon; he simply was a perfectionist. He expected everyone to do their best and come prepared … and if they didn’t, he’d show his displeasure.
The first in person AANS annual meeting in Philadelphia was a great success. President Regis W. Haid Jr. left his personal thoughtful touches on the program. It was good to be with colleagues whom we have not seen in a long time. Please read Dr. DiGiorgio essay in Academic Neurosurgeons’ Corner.
In this issue, you will read a profile of Odette Harris, one of our female neurosurgeons. Odette was really generous with her time. I enjoyed interviewing her. What an accomplished neurosurgeon and a special human being. Additionally, you will read an interesting essay by Andrew Ku, a medical student who draws a parallel between a Buddhist monk and a neurosurgery resident. There is a historical vignette about early neurosurgery in Ventura written by Mel Cheatham.
Please read Dr. Mark Linskey’s letter to all members who may have served in our military in California, or who may have known someone who had. Mark, with the help of our Historian Dr. Austin Colohan is working on creating an archive of California’s military neurosurgery history. It is an extremely worthwhile project.
Other regular columns include the thought provoking essays by President Siddiqi, the Private practice Corner by Brian Gantwerker, and my “Changing Times” essay about endurance. You will also find news news from CMA, AMA, CMS, the AANS/CNS Washington office, and the CDC.
I hope you enjoy reading this issue. As always, if you have any suggestions, or critiques, please e-mail me at email@example.com, or call me. My cell # is 805-701-7007
Report from Chair, Council on Ethical, Legal and Judicial Affairs
It’s been a privilege to serve on this Council since 2009, the last four years as its chair. I learned a lot and I hope that my service was of value.
I believe it is time to allow another person to take this responsibility and I urge any CANS member who is interesting in matters that are referred to this Council to apply. The selection is made by the Board of Trustees.
It would be helpful to request a supporting letter from the CANS Board as well as from your County Medical Association.
Please see below the request for Annual applications for all standing Councils and Committees.
Moustapha AbouSamra, MD
The California Medical Association (CMA) Board of Trustees, via its Committee on Nominations, iis seeking recommendations for member physicians who are interested in and willing to serve on its standing Councils and Subcommittees for 2022-2023.
- All current appointments expire at the conclusion of the CMA House of Delegates in October 2022. New appointments will begin their terms at that time, with the new terms expiring at the conclusion of the 2023 House of Delegates.
- Councils and committees meet as needed, with up to four (4) meetings per year via teleconference and potentially one (1) in-person meeting.
- Please note that current members who are eligible for reappointment must submit an application for the 2022-2023 term. Even if you previously submitted an application and there are no changes, you must complete the online form. This form includes optional, but requested, information regarding diversity and demographics, per Board action.
- Due to this requested personal demographic information, applicants are encouraged to fill out their own forms; however, applications submitted by a third party are also acceptable.
- In developing nominations, we urge special consideration for recruiting the talent and experience of your younger colleagues, as well as ethnic and women physicians, who will bring new perspectives to the Association’s policy-developing committees.
- Please submit applications through the form on the CMA website. The deadline for submission is 11:59 p.m. on Monday, June 6, 2022.
Instructions for nominations/applications:
Please verify the applicant’s willingness to serve, if selected, prior to submitting the application.
All endorsements, if secured, must be stated explicitly, either in the application form or via email to firstname.lastname@example.org.
A candidate may only apply for three (3) Councils and/or Subcommittees. (Note: You may see a warning on the website once you have selected all three, but you will still be able to continue with the submission.)
All nominations must include:
Completed application form
CV (less than 5 pages)
Statement of Interest (optional; send to email@example.com)
Your assistance and cooperation in identifying qualified individuals who are willing to participate in the Association’s activities are appreciated.
For more information, contact:
Director of Governance
Dear CMA Member,
Today, Governor Gavin Newsom signed Assembly Bill 35 (MICRA Modernization) into law, and in doing so finalized an achievement few thought was possible. Californians Allied for Patient Protection (CAPP), the Consumer Attorneys of California, Nick Rowley—author and primary funder of the November ballot measure—and both sides of the looming initiative fight over the Medical Injury Compensation Reform Act (MICRA) worked together with the Legislature and Gov. Newsom to end a decades-long political battle and usher in a new era of stability around malpractice liability.
The Governor’s action followed a bipartisan and nearly unanimous vote by the state Legislature, demonstrating broad support for this new approach. As part of the landmark agreement reflected in AB 35, proponents of the so-called Fairness for Injured Patients Act (FIPA) have removed the initiative from the November ballot.
Since California’s landmark medical malpractice laws were enacted almost 50 years ago, they have successfully struck a balance between compensatory justice for injured patients while maintaining an overall health care system that is accessible and affordable for Californians.
During that time, California’s physician and provider communities, through CAPP, have defended MICRA through expensive battles at the ballot, in the courtroom and in the legislature. CAPP is the large and diverse coalition working to protect access to health care through MICRA. Its membership includes the California Medical Association (CMA), California Hospital Association, California Dental Association, CMA’s component medical societies, medical malpractice insurance carriers, community clinics, Planned Parenthood Affiliates of California and many more.
This year, we were again facing another costly initiative battle that would have obliterated existing safeguards for out-of-control medical lawsuits and would have resulted in skyrocketing health care costs.
Instead, the two sides of the ballot measure campaign put differences aside, found common ground, and recognized a rare opportunity to protect both our health care delivery system and the rights of injured patients. The result is an agreement that puts patients first and prioritizes the stability of affordable access to health care.
Under the modernized MICRA law reflected in AB 35, which will go into effect on January 1, 2023, the underlying principles of MICRA were preserved – ensuring access to care and protecting our health care delivery system from runaway costs. Important guardrails of MICRA will continue unchanged, including advance notice of a claim, the one-year statute of limitations to file a case, the option of binding arbitration, early offer of proof for making punitive damage allegations and allowing other sources of compensation to be considered in award determinations. Furthermore, a new provision has been added to the law that protects expression of sympathy by a health care provider to an injured patient and their family, allowing physicians to express empathy, benevolence and even statements of fault after an unforeseen outcome without fear that such statements or gestures will be used against them.
The element that has garnered the most interest surrounds changes to the limit on non-economic damages in medical malpractice cases, which has been $250k since 1975. As opposed to the ballot measure, which would have effectively eliminated the cap on non-economic damages entirely, under the agreement:
Cases not involving a patient death will have a limit of $350k on the effective date of January 1, 2023, with an incremental increase over the next 10 years to $750k and a 2.0% annual inflationary adjustment thereafter.
Cases involving a patient death will have a limit of $500k on the effective date of January 1, 2023, with an incremental increase over the next 10 years to $1 million and a 2.0% annual inflationary adjustment thereafter.
Other critical MICRA guardrails that will remain in place with modest updates include the ability to pay awards of future damages over time and limits on plaintiff’s attorney’s contingency fees. CMA has prepared a publicly available fact sheet that provides additional details on this important legislation, available at cmadocs.org/micra.
CMA and the provider community remain united and committed to the principle of high-quality health care that is accessible and affordable to all Californians. For decades, we accomplished those goals in part by focusing our political resources on protecting MICRA against regular attacks. By creating long-term stability around MICRA, we can shift our focus, political influence, and resources to affect other positive changes for physician practices and improve access to care and public health for all Californians.
Best wishes for a healthy future,
Robert E. Wailes, M.D.
President, California Medical Association
Take Action: Vote No on AB 2060 – Keep the Medical Board of California a physician member majority!
Your advocacy is impactful! Legislators are hearing from their local physicians about the negative impacts of changing the composition of the Medical Board of California to a public member majority.
You prevented AB 2060 from receiving an Assembly floor vote this week; however, the author still has one final week to try to get the bill passed by the full Assembly. Your renewed advocacy during the week of May 23 will be the difference between stopping the bill on the Assembly floor and having the bill move forward to the Senate.
CMA urges your continued action, and we appreciate your voice in opposing AB 2060.
Please click here today to send an email to your Assemblymember asking them to vote “No” on AB 2060.
Women in Neurosurgery - Odette Harris, MD, MPH A Profile written by Moustapha AbouSamra, MD
What do Odette Harris and Sandra Day O’Conner have in common?
They were selected by Stanford on March 15, 2022, along with 11 other Stanford alumnae as women history makers. The list includes astronauts Sally Ride, Jessica Watkins, Ellen Ochoa, and Mae Jemison. It also includes Myra Strober, an economist, Maryam Mirzakhani, a mathematician, Simone Manuel, an Olympic gold medalist swimmer, Cecilia Burciaga, a Stanford administrator/leader, Clelia Duel Mosher, a physiologist, Mary Barra, GM’s CEO, and Tara VanDerveer, Stanford Women Head Basketball Coach. This indeed is a great honor, and it acknowledges these amazing women’s accomplishments. Our own, Odette Harris is in good company.
Dr. Odette Harris is the Paralyzed Veterans of America, Endowed Professor of Spinal Cord Injury Medicine at Stanford University. Her Endowed Professorship further distinguishes her as the first woman in neurosurgery at Stanford to receive this honor. Dr. Harris is a Professor of Neurosurgery at Stanford University School of Medicine and is the Vice Chair for Diversity, and Director of Brain Injury for Stanford Medical Center. She is the Deputy Chief of Staff, Rehabilitation (TBI/Polytrauma, SCI/D, BRS, PM&R and RT) at the Veterans Affairs Palo Alto Health Care System (VAPAHCS).
Odette has enjoyed a stellar career and her accomplishments are too many to list in this profile. She was born in Jamaica but has lived in the US since Grammar School. She is also a black woman. Her primary schooling was in an English private school. She did not feel different than anyone else until she was chosen as the valedictorian of her graduating Baccalaureate class, and was told by her principal that she should not wear her hair in braids for the ceremony- she had always worn her hair in braids.
There have been numerous instances like this during her life and career, similar to many other physicians and surgeons of color and women in the field. However, Odette dismisses these “negatives;” she always concentrated on the positives and strongly believed, much like her parents taught her that she belonged. And she credits two Stanford mentors, for having believed in her and encouraged her to do anything she dreamt of doing. The mentors in question remain close to her. They are John Adler and Larry Shuer who like most mentors learned from her as much or more than she learned from them.
When she applied to Neurosurgical residency, she was told more than once that the program was not looking to include women. Stanford welcomed her and allowed her to thrive. Unlike many programs at the time, Stanford allowed her to pursue an MPH/Epidemiology versus bench research.
Upon completing her neurosurgical residency at Stanford University, Dr. Harris was awarded the William Van Wagenen Fellowship from the American Association of Neurological Surgeons. She completed her research related to this fellowship at the University of the West Indies in Kingston, Jamaica where she presently serves as Visiting Consultant in Neurosurgery.
Dr. Harris is a Trustee for the Boys and Girls Club of the Peninsula, the Castilleja School and Dartmouth College. She is a Fellow of the American Association of Neurological Surgeons and a member of the Congress of Neurological Surgeons. Dr. Harris was appointed a Fellow of the Aspen Global Leadership Network in 2018.
These efforts/accolades are centered on mentoring and building a pipeline to the neurosciences. This is incredibly important to her and supported by the Stanford Neurosurgery Department. The department’s efforts lead in this realm, allowing access to hundreds of students each year through various programs and efforts and internships.
Odette places a lot of effort in mentoring younger students and younger neurosurgeons. She makes herself and her family available to them and feels that mentorship is a very personal endeavor.
She is enjoying the accomplishments of her two beautiful daughters, Alister and Reece, who just published a children’s book, “I Want to be a Neurosurgeon.” https://fundacionhospitaloptimista.org/neurosurgeon-ebook/ Alister is Stanford bound having been granted an early decision admission.
Now, she feels differently. Each component of her as a “person” is important, and she would like people to think of her as an accomplished neurosurgeon who is also a mother, a wife, and a black woman who is an immigrant to this Great Country.
Odette Harris, MD, MPH, an amazing human who enriches our specialty!
Changing Times -Endurance
When I read that Kate Jayden, a long-distance runner from Derbyshire, UK, completed 101 marathons in 101 days to raise awareness for what the journey is like for refugees from Syria, two thoughts came to my mind. The first: how thoughtful and empathetic is Jayden. The second: wow, what and amazing endurance! https://www.indy100.com/news/kate-jayden-marathons-syria-refugee
Is there a limit to human endurance?
I am always amazed when I read about incredible achievements. Take for example Nimsdai Purja’s accomplishment when he climbed the tallest 14 peaks in the world – over 8000 meters – in seven months. https://youtu.be/8QH5hBOoz08. Or those of Omar Hegazy, a 31-year-old swimmer who broke two Guinness World Records seven years after losing one of his legs in a car accident. He also swam across the Gulf of Aqaba in 2017 and completed a 700 km cycling challenge.
When I ran my first marathon, I was almost 53-year-old. At the time, I was advising my patients to exercise regularly, but I was not exercising at all. To address this hypocrisy, I decided to run, which culminated in running a marathon. I had never run before. I wrote about that experience and indicated that I enjoyed the company of my fellow runners who had one thing in common: they decided to stop giving themselves excuses. After completing my fifth marathon and in order to avoid the necessary lonely solo long training runs, I adopted a strategy of running a marathon every 6 to 8 weeks. I completed 16 marathons. I was really a below average runner but started to think that if I completed so many marathons, I could do more.
As you can imagine, during that time, I subscribed to Running and Runners World Magazines and started considering some exotic races. One stood out in its uniqueness, the North Pole Marathon. Can you believe that the only reason I did not consider it seriously was the need to fly on a Russian propeller plane from Finland to the North Pole, and I didn’t trust “them” Russian planes!
Seriously, however, I started reading about ultramarathons and about the type of people who run them. And about endurance.
The Badwater Ultramarathon is described as “the world’s toughest foot race.” It is a 135-mile course that starts at 282 feet below sea level in the Badwater Basin, in Death Valley, and ends at an elevation of 8360 feet at Whitney Portal, the trailhead to Mount Whitney. It takes place annually in mid-July, when the weather conditions are most extreme, and temperatures can reach 130 °F at the start but can dip to the 30s at the finish. Consequently, very few people – even among ultramarathoners – are capable of finishing the race. No, I didn’t consider running the Badwater 135 because I really dislike the heat.
Believe it or not, there are people who do crazier things. In 1989, Tom Crawford and Richard Benyo completed the first “double crossing,” which became known as the “Death Valley 300,” running from Badwater to Mount Whitney’s portal and back to Badwater again. And In 2001, Marshall Ulrich was the first runner to complete the “Badwater Quad,” consisting of two back-to-back Death Valley 300s for a total of four consecutive Badwater/Whitney runs. He completed the course, a distance in excess of twenty-one marathons, in ten days. Lisa Smith-Bachen, 54, completed the “Badwater Quad” in two weeks, on July 15, 2014, as a fundraiser for a charity she created called “Badwater4GoodWater.” Simply incredible.
It has become harder and harder to break world records. Roger Bannister, a medical student and later a neurologist from Oxford broke the 4-minute-mile barrier on May 6, 1954, when he ran the mile in 3 minutes 59.4 seconds. Hicham El Guerrouj from Morocco is the current mile record holder with a time of 3 minutes 43.13 seconds. His record achieved in 1999, has held since. On October 12, 2019, Eliud Kipchoge an Olympic gold medalist from Kenya, finally broke the two-hour-barrier, by running the Vienna marathon in 1 hour 59 minutes and 40 seconds. So now, a sub-2-hours marathon is possible, but I am certain that it will be a long time before this record will be broken.
How about the amazing human endurance? It appears that it has no limit.
It is clear that running ultramarathons, running 101 marathons in 101 days, climbing the 14 tallest peaks in the world in seven months, biking 700 km with one leg, etc., take an amazing amount of physical preparation and fitness. But it is also clear that in order to endure such grueling feats, a mental toughness is paramount. Many studies have been conducted to prove this. I recommend to you an excellent book written by Alex Hutchinson, Ph.D., a physicist who is also described as a “running geek.” The book is called “Endure” with the subtitle: “Mind, Body, and the Curiously Elastic Limits of Human Performance.”
Closer to home is a “hobby/profession” we all love. Yes, I think that Neurosurgery is an endurance sport. It requires long hours with increasingly long training; I remember distinctly, having been used to working regularly upwards of 100 hours a week, how I was indignant when the 80-hour a week limit was introduced – how will we ever provide enough training to our young residents and how will they become proficient surgeons? I was simply used to 100-hour weeks; I thought that it was a normal thing to do, much like running a marathon every 6 to 8 weeks.
Neurosurgery also requires dedication, mental toughness, maintaining a focus, and deciding to never accept excuses.
No, there is no limit to human Endurance, nor of the ability of neurosurgeons to “Endure.”.
Academic Neurosurgeons' Corner - Back in Person
I have been involved in CANS & CSNS since I was a neurotrauma fellow at UCSF. I have been fortunate to serve as a delegate to CSNS for California and be placed on the CANS executive committee. My involvement with this newsletter has been an amazing opportunity to hone my writing skills and have a voice in California neurosurgery. CANS and CSNS have been integral to my early career as a neurosurgeon.
Yet, last month in Philadelphia was my first in-person CSNS meeting with resolutions. The abridged fall meeting in Austin was a great warm up, but I finally feel that I have been a part of a real in-person CSNS event.
The contrast between residency and faculty is stark for neurosurgeons. Aside from the pay, there is the new-found autonomy and agency that one gains when leaving residency behind. Fellowship was a nice transition, as my program eased me into attending responsibility as I learned neurotrauma from some of the masters in our field. For me, COVID made that contrast between residency and faculty even more glaring.
COVID emerged during my fellowship. My life as a resident was entirely pre-pandemic. My life as faculty has been entirely intra-pandemic. The thought of a global pandemic shutting down the world economy was not even a thought in my mind as a resident. As an attending, I have only known a COVID world. My schedule seems to be filled with more Zooms than elective cases. The scattered meetings I have attended have been with COVID protocols and social distancing. My patients only know what I look like masked.
Getting to a “normal” in-person CSNS meeting was wonderful experience. There is camaraderie among the CANS delegates. I had dinner with the esteemed Brian Gantwerker and was privileged to get a front-row view of Mark Linskey’s military like adherence to CSNS bylaws. The plenary sessions, committees and resolution debates led to lively, interesting conversations. There is no substitute for being in person.
I’m hoping there is more of this going forward. “Normal” works best.
Report from AANS/CNS Washington Committee
As you may have heard from previous communications and reports, we have a potential problem that could have lasting negative consequences for our coding and reimbursement (and other advocacy) efforts.
Every five years, national specialty societies holding seats in the AMA House of Delegates must go through a review to make sure they comply with the criteria required to maintain a seat in the AMA HOD. This year it was the CNS’ turn. Based on the materials we submitted to the AMA, only676 of 3,682 (18%) CNS members are also AMA members, and the required minimum is 20%. By comparison, the AANS had its five-year review in the fall of 2018, and 787 of 3,639 (22%) AANS members were also AMA members (though this number has probably fallen off too).
Per the attached report, we will be put on probation and be given a one-year grace period to work with AMA membership staff to increase our AMA membership. We can immediately remedy the situation if we can find 60+ souls to join the AMA before June 5 (we did make some significant progress at the recent AANS Annual Meeting — thanks to those who answered the call to join!). Otherwise, we will need to work on this over the coming months.
- Failure to reach this threshold of dual CNS/AMA members means we will lose our AMA CPT Editorial Panel and AMA RUC advisory slots (and if the AANS is in the same situation when its five-year review comes up next fall, we could lose ALL our representation).
- It would also eliminate our CNS delegate slots in the AMA, further jeopardizing our ability to AMA policy.
· Additionally, individuals appointed by the AMA to external bodies, such as Neurosurgery’s Residency Review Committee, must be AMA members (we are already finding it challenging to identify potential nominees for a current AMA-appointed vacancy on our RRC because many qualified individuals are not also AMA members).
News from CMS
The Centers for Medicare & Medicaid Services (CMS) will publish the Open Payments Program Year 2021 data and updates to the previous program years’ data in June 2022.
Covered Recipient review of the data is voluntary, but strongly encouraged. Please keep in mind the following reminders:
- Disputes must be initiated by May 15, 2022, in order to be reflected in the June 2022 data publication. For more information on review and dispute timing and publication, refer to the Review and Dispute Timing and Data Publication Quick Reference Guide.
- CMS does not meditate or facilitate disputes. Covered Recipients should work directly with reporting entities to resolve disputes.
- Registration in the Open Payments system is required in order to participate in review and dispute activities.
For more information about the program, registration and the review and dispute process visit the Open Payments website.
Private Practice Corner On Maintaining an Ethical Practice “Teach thy tongue to say ‘I do not know’, and thou shalt progress.” Moses Ben Maimon (Maimonides)1135-1204
There are times in our lives as neurosurgeons when we feel a pull. Numerous pressures are applied to us in our daily practice, be it with our patients, administrators, colleagues and competitors, and of course our spouses and families. Decision making processes and their outcomes shape not only our life experiences, but also all those whose lives we touch. The thought to operate or not to operate, to stay a little longer in the clinic visit to take another moment to answer one more question(s), or the notion to check another scan on that postop patient that is taking longer to recover – these are all daily conundrums we commune with.
The question becomes, what is the right thing to do – and how do I know it when I have it?
As neurological surgeons we are taught to be steady. We are told to ignore distraction, discomfort, sleep deprivation, hunger/thirst, and even the pull of family in order to take care of our jobs and our patients. There are few other medical and surgical specialties that put such a huge demand for perfection with each and every turn in the day-to-day churn of residency and ultimately practice. We are also taught to be “moral marines,” as my former chairman would emphatically state during Wednesday morning conferences.
The decision we make as surgeons often lead to a butterfly effect, with each subsequent event reverberating in our lives and those of our patients. What is unique, though to our vocation, is the significant consequences affecting life and limb. Where we often fail to appreciate this gravitas. In extreme cases we have seen from the lessons of dangerous hubris in the case of surgeons who ended up on the front page of a large circulation paper, “asked to leave” due to poorly indicated surgery, or even convicted of murder. These surgeons were no doubt supervised and graduated from their training programs. Obviously, others missed the warning signs.
But how do we know when we start to cross the line? When do we know when we go wrong?
The overly confident, moderately charismatic, and mildly narcissistic neurosurgeon is the archetype of our profession. We have seen many television shows and movies depicting us as self-assured, smug jerks who often cannot see past the tip of our own noses. We do have moments, in popular media, when our softer side is showcased on shows like Grey’s Anatomy and some of the popular reality shows like “Lennox Hill.” But these are less frequent and still when I introduce myself, then about 3 questions in, when we finally get past “a doctor,” “a surgeon,”, and get to “neurosurgeon” and the reaction is sometimes awe, but mostly an assumed aloofness I must possess. There is almost instantly a line drawn between me and them. We are sometimes placed on a bit of a pedestal. Perhaps we enjoy it. Most of the neurosurgeons I know are iconoclastic and very down to earth and funny, self-aware and compassionate. Nearly all of us did about 15-16 years of schooling and training to get to call ourselves neurosurgeons. The overconfidence, and demigod like cache we garner can lead some to do wrong.
What is your guiding star to sail by? Many of us look to philosophers, religious sages, mentors, and even our parents to decide how to be an ethical surgeon. But there is no exact standard of how we stay with bounds. We read of many surgeons who have gone off the reservation and done unspeakable things. And how do we speak up when we see people, we think are becoming a danger?
Recently, one of my colleagues from another area of California asked me what I thought about his own partner who seemed to have a heavy hand surgically. This person was doing multilevel fusions seemingly on very little indication, and leading to more surgeries to fix the issues the index surgeries caused. As an RVU based employment, this obviously leads to a financial gain.
The potential human toll here cannot be overemphasized.
On a personal note, I have seen a patient with a subdural empyema who had a prior craniotomy by another surgeon, who was subsequently dismissed from their care, and who had sat around 2-3 days before I became aware of them and within an hour of seeing the purulent discharge from their craniotomy incision had to perform emergency surgery. There are other instances when small acts are committed out of convenience. Curb-side consults instead of seeing the patient, not taking time to look at a wound personally and trusting someone else’s eyes on its status. But is this not moral? Is it bad medicine? Is it unethical?
I have to admit, and maybe we all do that we do not know sometimes when we go wrong.
Seeing wrong and doing wrong and then doing nothing about it are progressive spirals down a deep dark chasm. It is difficult to judge other people’s actions until you’ve been in similar circumstances. But when you are in them, you have to think about what would you do if this were your own mom, dad, or child sitting in front of you?
The answer to that would very likely be the best thing for the patient. And that is why we do what we do, and how it is done.
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to update healthcare providers, public health departments, and the public on the potential for recurrence of COVID-19 or “COVID-19 rebound.” Paxlovid continues to be recommended for early-stage treatment of mild to moderate COVID-19 among persons at high risk for progression to severe disease. Paxlovid treatment helps prevent hospitalization and death due to COVID-19. COVID-19 rebound has been reported to occur between 2 and 8 days after initial recovery and is characterized by a recurrence of COVID-19 symptoms or a new positive viral test after having tested negative. A brief return of symptoms may be part of the natural history of SARS-CoV-2 (the virus that causes COVID-19) infection in some persons, independent of treatment with Paxlovid and regardless of vaccination status. Limited information currently available from case reports suggests that persons treated with Paxlovid who experience COVID-19 rebound have had mild illness; there are no reports of severe disease. There is currently no evidence that additional treatment is needed with Paxlovid or other anti-SARS-CoV-2 therapies in cases where COVID-19 rebound is suspected.
Regardless of whether the patient has been treated with an antiviral agent, risk of transmission during COVID-19 rebound can be managed by following CDC’s guidance on isolation, including taking other precautions such as masking.
Staying up to date with COVID-19 vaccination lowers the risk of getting COVID-19 and helps prevent serious outcomes of COVID-19, such as severe illness, hospitalization, and death.
Historical Vignette Neurosurgery in Ventura County in the early days Melvin, L Cheatham, MD Moustapha Abou-Samra, MD
Anyone who suffered an injury that required neurosurgical care in Ventura County before 1962 was likely out of luck. A few exceptionally lucky ones were “saved” by Dr. Jim St. John from Santa Barbara if he was available to make the drive to Ventura, or the patient was able clinically to be transferred to Santa Barbara. The patient would have been prepared for surgery by the residents and faculty of the Family Practice Residency Program at the “General Hospital,” now Ventura County Medical Center; the residency program is highly regarded.
In the early 1960s, Dr. William James, a Rear Admiral in the Navy, head of the Neurosurgery Department at the Balboa Naval Hospital in San Diego, who trained at Boston City Hospital, was contemplating retirement. He selected Ventura as his retirement Haven, with plans to play a lot of golf.
As soon as he settled in Ventura in 1962, the sisters of Mercy at St. John’s Hospital in Oxnard learned that a dedicated Catholic neurosurgeon had moved to the County. They prevailed on him to attend to some of their neurosurgical emergencies. The word was out. Dr. James acquired a burr hole kit that he carried with him everywhere he went, in the trunk of his car. He was therefore prepared to attend to neurosurgical emergencies, not only in Oxnard, but also at the General Hospital in Ventura. He became busy overnight.
Before long, he realized that he was too busy and was not having enough time to enjoy golf. In 1964, he recruited Dr. Paul Karlsberg who was finishing his training at UCSF. “Ventura Neurosurgery” was established. It later became “Ventura County Neurosurgical Associates” Medical Group.
Dr. Melvin L. Cheatham joined the group in 1967 after completing his general as well as neurosurgical training at the University of Kansas, and after serving two years in the Air Force. He thought that he’d only stay two years, then move back to the University of Kansas to accept a joint appointment in the Neurosurgery and Anatomy Departments as well as the position of assistant dean of the medical school. However, upon coming to know and love Ventura County, and the wonderful people there, and seeing the opportunity and the need for extending excellent neurosurgical care to Western Ventura County, he decided to stay and help bring the latest in Neurosurgical technology to Ventura.
A Ventura industrialist, Fritz Huntsinger, who built a very successful offshore oil drilling support company that became “VETCO” a multinational corporation with international presence, developed a strong friendship with Dr. Cheatham. On a Saturday in 1974, as was his custom, he knocked on the Cheatham’s door to bring them some avocados from his farm. But this time, he shared with Mel an article he read in one of his industry publications about a new imaging machine of the brain, the EMI scanner. His question to Mel was: “is there a need for this machine at Community Memorial Hospital, the private non-profit hospital, in Ventura?”
Fritz asked Mel to investigate this new machine and if he felt that it was something that Ventura should have, to go ahead and buy it. After placing the order, Mel spent two weeks in London learning about the EMI scanner and its uses. Community Memorial Hospital in Ventura received the second EMI scanner west of the Mississippi, the first was bought by Stanford University’s Palo Alto Medical Group. Please see photo below.
In reality, Community Hospital had the distinction of receiving the 4th such scanner in the Nation. The first two were installed at Massachusetts General Hospital and Mayo Clinic-Rochester. A veritable coup for a small community hospital!
It was surprising that the EMI scanner was not readily accepted by the community neurologists and other referring physicians; it took a strong effort to convince them and the medical community to start ordering EMI/CT scans. In fact, the Community Hospital Administrator decided to provide the scans for free for two months, with the understanding that if the EMI scanner did not become routinely used, it would be put in storage and its space used for something else. Luckily the strategy worked.
Ventura continued to be at the forefront of neurosurgical innovations, and the Ventura County Neurosurgical Associates expanded. A few neurosurgeons eventually moved to the East County in Thousand Oaks and Simi Valley. Drs. James and Karlsberg have since died. Dr. Cheatham is the senior neurosurgeon in Ventura County.
The rest, as they say, is history …
Calling All California Military Neurosurgeons Past & Present
Dear colleagues who may have been military neurosurgeons or who were friends and colleagues of military neurosurgeon, now passed on.
Our CANS Historian, Dr Austin Colohan, has asked me to put together a History of California Military Neurosurgery for the CANS historical archives. This is a very worthwhile and very daunting task. California has a rich military medical history dating back to the Spanish-American War. Our military neurosurgery history began through volunteer efforts in World War I, which actually accelerated the start of all neurosurgery in California. In World War II California had a massive military presence, and as the main west coast military platform, our importance to military neurosurgery continued through the Asian-Pacific theatres including the Korean Conflict and the Vietnam War.
Unfortunately, the national Base Realignment and Closure (BRAC) efforts of 1988 and 1993 and continuing on a periodic basis led to massive closure of Army, Navy and Airforce facilities across the State of CA. Much of the historical records from these facilities have either been lost, or stored in hard-to-access, and/or poorly archived and indexed facilities on the east coast such as the Uniformed Services University (USU) archives in their James a. Zimble Learning Resource Center. The one active duty military Neurosurgeon currently serving at David Grant Medical Center at Travis AFB, and the five active duty military neurosurgeons currently serving at Naval Medical Center San Diego (NMCSD), represent the totality of active duty neurosurgeons in California as of Spring 2022. Most of these officers are right out of residency training serving their Health Professions Scholarship Program (HPSP) active duty pay-back obligation.
The key to putting together a meaningful archival history for military neurosurgery in California will be through obtaining oral interviews and histories from CA neurosurgeons who previously served in the US military, or who were friends and colleagues of other CA neurosurgeons who served. CA military neurosurgeons have served our country and our profession (e.g the invention of the Jackson-Pratt drain). They went on to become important contributors to CA neurosurgery in general, and since 1973, to CANS. We wish to capture, highlight and honor all that we can.
We are particularly interested in documentation and photographs from CA neurosurgery facilities, activities and deployments. All material will be treated as precious resources, carefully scanned and/or photographed, and returned to their individuals of origin in pristine condition. Currently our largest “holes” are for the period 1946 – 1965 as well as 1973 – the present. I would love to hear from any neurosurgeons who has served at Letterman Army Hospital and Oakland Naval Medical Center before they were both decommissioned in 1994 and any who have served at either David Grant Medical Center at Travis AFB or at NMCSD.
Please contact me at: Mark Linskey firstname.lastname@example.org to make sure that the voice and memories of you and possibly that of your colleague(s) now passed, are recognized, heard, and documented in our archives. Thank you very much for considering and contributing your memories, your stories and sharing your memorabilia!
Quote of the Month
To see takes time, like to have a friend takes time.
Medical Students’ Essay | Seeking Nirvana in Neurosurgery
One of my most vivid memories of neurosurgery has nothing to do with the OR or patients. It has to do with my third-year neurosurgery elective rotation, on a slow day in a workroom. One image stuck in my mind. That of my chief resident leaning over a board review textbook, fixed on pages filled with questions. At first, the look of intense concentration reminded me of something that I couldn’t figure out. It wasn’t until later that night when I figured out where my sense of deja vu came from ‒ I had seen a similar facial expression at a Buddhist monastery.
When I was ten my mother took me to a Buddhist monastery where I saw a monk meditating on desire and personal suffering. To me, neurosurgery and monastic studies are surprisingly similar. Both require sacrifices for a greater goal and seek to decrease suffering: one through inner reflection and the other through research and the practice of medicine. Both require lifetime study as the price of admission.
Neurosurgery remains unique to me where residents seem to enjoy their length of training. Everyone in the field realizes that lifetime commitment from graduation to retirement with continual learning are prerequisites. Similar to how a newly initiated monk is only on the path to nirvana, being board certified only comprises part of the training—to be truly great requires relentless practice. Neurological surgery more than any other field takes this lifelong dedication as the cost of entry, and necessarily so, since any procedure only has a few millimeters between good and bad results.
Lifetime study of the most complex system coincides with my broad interests, as the nervous system touches every other body part. The constant pursuit of perfection, paired with the most brutal diseases and outcomes instills in me a sense of profound humility and deep inspiration greater than any I’ve felt at a temple. Humility from both the deadly diseases that neurosurgery hopes to manage and the catastrophic sequelae that can result from small mistakes, and inspiration from the single-minded devotion to Arete, or excellence in purpose shown by doctors in the field. The requirements for research and forging moral virtue provide intense motivation that attracts me to this profession.
I knew for sure that I wanted to enter neurosurgery on the last day of my rotation when I left a friendly gathering early to help a resident put in an EVD. The next day the resident texted me that the patient started moving again, and I felt an indescribable feeling. I realized that years of training and study could be exchanged for preservation and occasionally return in function for others. At that moment I realized nothing would sway me from pursuing this specialty.
I harbor zero illusions that neurological suffering will be ended any sooner than personal desire and suffering. Neither will likely be eliminated in our lifetimes. Perhaps they never will be, but while the aspiration to end personal desire and suffering is a fine goal, I can think of no nobler and intellectually fulfilling calling than to ease the suffering of others through the dogged pursuit of excellence.
May 2 – A bat used by baseball hero and Dodgers’ Star Jackie Robinson in the 1949 All-Star Game sold at auction on Saturday for $1.08 million. Robinson, who broke Major League Baseball’s color barrier in 1947, played the Mid-Summer Classic at his home park, Ebbetts Field in Brooklyn, the same year that he claimed the National League Most Valuable Player Award.
May 3 – Fifty years ago, the American Psychiatric Association A.P.A. announced that it would reverse its nearly century-old position, declaring that homosexuality was not a mental disorder.
May 3 – AP – The endangered California condor returned to soar the skies over the state’s far northern coast redwood forests for the first time in more than a century. Two captive-bred birds were released from a pen in Redwood National Park, about an hour’s drive south of the Oregon border, under a project aimed at restoring the giant vultures to their historic habitat in the Pacific Northwest.
May 7 – Over the past three decades, it has become increasingly common in the U.S for women to delay having children. The U.S. Census Bureau reported that over the years women are delaying pregnancy from their 20s to their late 30s and early 40s. The trend has pushed the median age of U.S. women giving birth from 27 to 30, the highest on record.
May 9 – Andy Warhol’s “Shot Sage Blue Marilyn” sold for a cool $195 million, making the iconic portrait of Marilyn Monroe the most expensive work by a U.S. artist ever sold at auction.
May 11 – After being closed for two years, Hearst Castle in San Luis Obispo County began welcoming back guests.
May 12 – The U.S. surpassed 1 million Covid-19 deaths, a once unthinkable scale of loss even for the country with the world’s highest recorded toll from the virus. The number was reached at stunning speed: 27 months after the country confirmed its first case of the virus. Sometime last week, the National Center for Health Statistics tallied the 1 millionth death certificate that listed COVID-19 as a primary or contributing cause of death. By week’s end, that provisional death toll was up to 1,000,659. Sadly 400,000 deaths occurred after vaccines became widely available. What a terribly sad milestone!
May 12 – Last year, fentanyl — an opioid manufactured in a lab — caused more overdose deaths than any other drug has in a single year. The second-deadliest drug was meth, which is also produced in lab. Together, fentanyl and meth helped make 2021 the worst year for drug overdoses in U.S. history. According to the CDC the death toll for 2021 topped 100,000 for the first time. Another grim milestone!
May 12 – is the birthday of Florence Nightingale. It is also International Nurses Day! The day honors nurses for their contributions worldwide and marks the conclusion of National Nurses Week, which began on May 6. The International Council of Nurses has celebrated the day since 1965.
May 16 – California Medical Association President Robert E. Wailes, M.D., issued the following statement after this weekend’s shooting in Laguna Woods: “Our nation continues to be plagued by an epidemic of gun violence. Physicians as healers are often on the front lines of these tragic events, treating the wounds of the victims of gun violence. Today, we learned that 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.
May 17 – This week a congressional committee held the first hearings on UFOs, or Unexplained Aerial Phenomena – UAPs – since 1969.
May 18 – After a long fight, US Soccer has agreed to a landmark equal pay deal for women.
May 19 – Mercedes-Benz confirmed that it recently sold the world’s most expensive car. A very rare 1955 Mercedes-Benz SLR coupe that had been kept in the German automaker’s collection was sold to a private owner for $142 million. That price makes it the most expensive car known to ever have been sold.
May 20 – World Bees Day! In 2017, the United Nations General Assembly adopted a resolution declaring this a day to remind people the importance of preserving bees and other pollinators.
May 23 – California could soon hold social media companies responsible for harming children who have become addicted to their products, permitting parents to sue platforms like Instagram and TikTok for up to $25,000 per violation under a bill that passed the state Assembly.
May 24 – A Sacramento County resident who recently traveled to Europe may have the first confirmed case of the monkeypox virus in California.
May 24 – 19 children and two adults including a teacher died in a mass shooting at Robb elementary school in Uvalde, Texas. The gunman, an 18-year-old bought the weapons he used, legally, when he turned 18. It’s the deadliest elementary school shooting in a decade and the 27th in a school this year and the 212th mass shooting in our Country. I can’t find a way to describe this horror.
May 25 – National Wine Day. Cheers!
May 27 – California lost 117,552 human residents in 2021, but it gained tens of thousands of new residents that love the state’s increasingly hot and arid climate. Rattlesnakes are thriving here, according to a recent joint Cal Poly San Luis Obispo and University of Michigan study, which reveals that the seven species of rattlesnakes found in California are among the fastest growing animal population in state. Why? It’s the same answer that may be driving some to leave the Golden State altogether: climate change.
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Neurosurgical Society of America: Annual Meeting, June 12-15, 2022, Maui, HI
Rocky Mountain Neurosurgical Society: Ann. Meet., June 18-20, 2022, Coeur D’Alene, ID
New England Neurosurgical Society: Annual Meeting, June 23-25, 2022, Chatham, MA
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