April has been an eventful month for your Association. Following up on CANS activities at the Council of State Neurosurgical Societies, I’m pleased to report that all of our resolutions that were authored by CANS members and put forth were approved by the CSNS House of Delegates. These resolutions involved fundamental issues of paramount importance to the welfare of our patients and our profession. Topics addressed included critical issues regarding timely payment on pre-approved procedures, professional financial literacy, improved due process for peer review, reimbursement structure for advanced practice providers, regulation of healthcare administrative managers, and injury prevention at the US-Mexico border, among other topics.
With active input from the CANS delegation and other state delegations, the results were well thought out and nuanced. I want to take this opportunity to congratulate Dr. John Ratliff, our 2018-19 CANS past president, for taking the top leadership role at the CSNS, succeeding Dr. Joseph Cheng (Cincinnati, OH). Dr. Ratliff showed during this spring meeting his superb management skills and clear objective approach to the resolution process.
We are also proud of Dr. Moustapha AbouSamra, the 2023 CSNS Lyal Leibrock Lifetime Achievement Award recipient, recognizing his years of service to CSNS and neurosurgical advocacy. Dr. Abousamra needs no further introduction in these pages as he has served with distinction as newsletter editor, past president of CANS, the Western Neurosurgical Society, and the Neurosurgical Society of America, among numerous other positions. A recipient of multiple recognitions during his distinguished career in neurosurgery, he will continue to be an energetic supporter of our profession long into the future. A sincere and heartfelt thanks goes to Moose.
Again, your support and membership in CANS are the critical linchpins for our efforts to make your voice heard on the state and national level at venues such as within organized neurosurgery and state politics.
I’m eager to hear your perspectives and opinions, so please contact us with your experiences and ideas to help further our efforts.
Over the last year, there has been increasing controversy over US News and World Report education rankings. USNWR was, in its time, an also-ran in the realm of weekly news magazines, falling a distant third behind Time and Newsweek. Time and Newsweek have fallen victim to the changing landscape of media over the last 30 years and are a mere shadow of their former selves. USNWR has maintained some modicum
of relevance through its panoply of rankings. These cover diverse areas such as education, health institutions, law firms, automobiles, states, countries, etc.
These rankings have caused much hand-wringing amongst the entities subject to them. Over the last year, several elite institutions have decided to stop providing data for the USNWR rankings for various reasons. The reasons for withdrawal have been laid out as a two-point argument: 1) the methodology is flawed, and 2) the invalidation of the entire concept of rankings in that they may not serve larger societal goals. Yet another wrinkle in the story is the pressure to boost institutional rank with falsification of submitted data, such as what happened at Columbia University, USC, Oklahoma, and others (N.B.: these incidents did not involve the medical schools at these institutions).
The arguments against rankings tend to be rather torturous and unintuitive in nature. One may suspect that, with or without the participation of the institutions, such rankings will continue to be produced, debated, and closely scrutinized. This is for a good reason. Rankings and ratings of academic institutions have existed well before USNWR, and they have often been produced without the cooperation of the subject institutions. The hunger for such rankings is deep, for it is in the consumer’s interests.
As consumers, ratings are important in determining a product’s value independent of the brand. Ratings can build brands and can also tear them down. By eliminating ratings, those product producers may hide behind unfounded or irrelevant marketing claims. In the academic realm, these have included appeals to tradition and cherry-picked stories of individual student and faculty activities and experiences.
One may criticize the methodology, but if we are comfortable rating things like cars and appliances a la Consumer Reports, why should there be controversy about ranking educational institutions? Is it not justifiable to have a means by which the consumer (and potentially their parents) may determine where to spend a large amount of time, effort, and financial resources? Why would it be problematic to have information useful to avoid a low-value product?
The focus of controversy at the top end of the rating scale appears immaterial since these are all highly resourced learning institutions. It is doubtful that there is much in the way of meaningful differences between #1 and #20. Some of the hand-wringing at this level is a reflection of bourgeois neuroses. However, there is a huge difference between #20 and #120. Simply put, the #120 school is less likely to have the resources to provide sufficient exposure to the trainee that will allow them to fully explore and develop a full range of interests within the allotted time frame compared to the #1-20 schools. As such, rating systems can be important in making clear these sorts of segmentations in the marketplace.
The continuing drive towards opacity from the schools themselves will ironically further drive the value of rankings of institutions by the prospective consumer. Oftentimes, the less that one objectively knows of an entity, the greater the mystique. Where USNWR might be pushed to the side, there will still be the Times Higher Education Supplement, the QS Universities Ranking, and many others.
It, however, should be made clear that rankings and ratings should only be part of a complex decision-making process for applicants and their families. Location, finances, range of offerings, and “fit,” as well as other intangibles, are and should be part of a decision-making process. Yet, the quality of the mystique is so compelling that it warrants some examination.
During my graduate studies, I recall a discussion with an eminent and brilliant professor on the topic of publishing in “good journals” and “bad journals.” Why did there seem to be a pecking order of scientific and medical journals? Why was “Nature” better than “Neuron” and “Neuron” better than “Brain Research”?
The wise professor concluded that an unspoken hierarchy of groupthink, peer pressure, vanity, and self-fulfilling biases compel authors to self-select and direct their submissions to more or less “prestigious” journals. As a young and stupid student, this lesson took a while to sink in fully.
Journal prestige was a significant issue in the past, guaranteeing higher exposure to a manuscript. When we used to visit the libraries, the prestigious journals were well-fingered, their spines broken, and occasional pages ripped out. As such, journal prestige had been incredibly important as a means to draw “eyeballs.”
Current technology, e.g., PubMed, has flattened the hierarchy, now making the wording of a manuscript title and abstract more important to the marketing of the paper than the prestige of the journal in which it appears. Journal prestige is being replaced by the “impact factor” and related measurements resulting from individual submissions’ performance. The explosion of publication venues and platforms, such as John Adler’s “Cureus” threatens to upend the hierarchy of publications.
I suspect that similar processes are at work in the realm of educational institutional prestige.
The resistance of institutions to being measured and ranked risks an unintentional outcome in which the institutions become commodified and fungible. It is fair to speculate on the potential effects of such commodification on medical education consumers.
And for the graduate, the value of hard work striving to be among the elite is similarly being deprecated. A culture of “ticket punching” and degree creep has established itself to provide a minimum floor of fungible qualifications. And a new direction of data collection establishes itself to look at different metrics, this time in service of the institutions: patient satisfaction scores and RVU production.
April was a busy month for the Board of Directors of CANS members.
CANS Board Meeting
On April 16, President Joseph Chen convened the Spring 2023 Board Meeting. Some key take-home points from the six hours Zoom meeting are below:
CANS was strongly represented. The delegation included:
Patrick Wade, Delegation chair; Joseph Chen, CANS President; and Delegates: Javed Siddiqi, Ciara Harraher, Mark Linskey, Anthony DiGiorgio, Brian Gantwerker, and Nicole Moayeri. Additionally, alternate delegates: Kenneth Blumenfeld, Moustapha AbouSamra, and Harminder Singh.
12 of 18 resolutions were authored by CANS members. Most were approved as submitted.Please review the discussion results, vote, adoption, amendment, or rejection separately under CSNS 2013 Spring Resolutions.
It is always educational to attend the CSNS luncheon after the meeting. This year’s speaker was Wes Cleveland, JD, the lead attorney for AMA, who discussed Non-Compete Clauses. We learned that there are significant differences between states and that it is always important to read employment contracts carefully and with a critical eye; having an attorney review such a contract in advance is advisable.
We learned that in this cycle, California Neurosurgeons contributed the most of any state society neurosurgeons to the NeurosurgeryPAC; unfortunately, and for various reasons, donations to the PAC have steadily declined over the past several years. Only 5% of neurosurgeons donate to the PAC, less than many other specialties.
The annual AANS meeting that overlapped with the CSNS meeting was well attended. Dr. Ann Stroink, the second female president, chose “Neurosurgeons as Advocates” for the theme of the meeting. Advocacy for our patients, profession, and neurosurgical colleagues is important and necessary.
AI and its potential application to neurosurgery in the future received much attention; we should learn more about it and watch its evolution carefully, lest we be left behind.
Three late-breaking abstracts were significant and may have significant implications:
There were two highlights:
During the Meeting, the WINS – Women in Neurosurgery – section celebrated its 30th anniversary. It was a beautiful celebration attended by many of our men colleagues also. Sharona Ben Heim, from UC San Diego is the upcoming Chair.
Celebrating this occasion, the JNSPG published a special cover for the April issue of Neurosurgery; it is a mosaic of photos submitted by female neurosurgeons overlaid with the shape of the female symbol. A copy of the issue was provided to all in attendance.
In this issue, the Women in Neurosurgery column was written by former CANS Board member Kim Page, who also served in the past as Chair of WINS. It is honest and very personal. Kim is missed in California.
Adela Wu wrote the Innovators in Neurosurgery column about Sir Victor Horsley. Adela, one of our Board Resident consultants, is a regular and devoted contributor to this newsletter.
Meanwhile, we continue to learn more about Private Equity acquiring medical practices, including neurosurgical practices, a trend California neurosurgeons are encouraged to watch carefully. And the latest is a plan by Kaiser Permanente, with $95 billion in revenue last year, to acquire Geisinger Health. Please see Tidbits.
Dr. DiGiorgio wrote a thoughtful essay about the Social Determinants of Health. Again, he was critical of this “movement” as he felt it “makes every aspect of society a medical issue.” He is also afraid of alienating some legislators we must work with. I disagree with my colleague. More than anything, I value my “First Amendment Right of Expression.” And although we should not take a stand on all social issues, I feel that we should take a stand on some issues. For instance, gun control: I am sure you must have received by now the digital survey from AANS; they need to know what its membership thinks about this issue. Another example is the recent Federal judge in the Amarillo division of the Northern District of Texas’s decision to ban mifepristone; CMA President Donaldo Hernandez felt compelled to issue a statement that might alienate some legislators – please see From CMA Column. If we feel strongly about something like the increased height of the border wall, we should speak up; our legislators need to know what we think.
Also included in this issue are all the regular columns.
As always, my editorial committee and I welcome all suggestions and criticism. Please e-mail me at firstname.lastname@example.org or call me at 805-701-7007 if you prefer to discuss any issue directly with me.
I hope you will enjoy this issue.
Title: Hospital Medical Staff independence, oversight, and due process in hospital medical staff investigations
Action: Adopted Amended Resolution
BE IT RESOLVED, that the CSNS request that the AANS and CNS, working with the Washington Committee and their AMA delegation, introduce AMA resolution(s) that require hospital medical staffs to have independent legal representation, separate from that of the Hospital and/or Health Affairs umbrella organizations; and
BE IT RESOLVED, that the CSNS request that the AANS and CNS, working with the Washington Committee and their AMA delegation, introduce AMA resolution(s) encouraging/requiring wording in hospital medical staff bylaws allowing for an independent, impartial external review of medical staff investigations/proceedings; and
BE IT RESOLVED, that the CSNS request that the AANS and CNS, working with the Washington Committee and the AMA delegation, explore legislative remedies to improve due process in the hospital medical staff peer review, and disruptive physician referral to medical staff professionalism committee and/or physician well-being committee contracting processes, that includes defining circumstances where transparency in the legal discovery process would be allowed.
FISCAL NOTE: None
Title: Regulation and Licensure of Hospital and Payer Administrative Staff
Action: Adopted Amended Resolution
BE IT RESOLVED, that the CSNS request that the AANS and CNS, working with the Washington Committee and our AMA delegation, explore implementation of a hospital and payer professional administrative staff licensure and regulatory process to ensure strict adherence to promotion of the interest of the patient/client and public at large; and
BE IT RESOLVED, that the CSNS request that the AANS and CNS, working with the Washington Committee and our AMA delegation, explore forming a coalition with physician and surgeon organizations along with public interest groups and elected political officials to implement such regulatory processes.
Fiscal Note: None
Title: Measuring and reducing the electronic health record burden in neurosurgery
BE IT RESOLVED, the CSNS survey the neurosurgical community to determine the EHR burden among both attendings and residents, including determining if there are any current institutional initiatives that are taking steps to measure and reduce EHR burden; and
BE IT RESOLVED, the CSNS take the results of this survey and formulate a white paper to provide policy suggestions aimed at reducing the EHR burden to neurosurgeons; and
BE IT RESOLVED, that the results of this white paper be referred to the CNS, AANS and Washington Committee for further action.
FISCAL NOTE: None
Title: Getting spine emergencies to where they need to be: Moving toward a “spine attack” paradigm
Action: Not Adopted
BE IT RESOLVED, the CSNS will form a committee to work with national organizations including the AMA and American College of Emergency Physicians to recommend all patients with new or worsening deficits consistent with spinal cord compression (ie paraparesis, quadriparesis, and symptoms of cauda equina) be transferred without delay to a facility with MRI availability and spine surgery coverage, and
BE IT RESOLVED, such transfers without diagnosis should be to a medical service or ER to ER; and
BE IT RESOLVED, the CSNS will suggest to the parent organizations to push for recognition of the symptoms of spinal cord compression to hospitals and non-neurosurgical providers in a way that is easy to recognize and in a manner similar to how stroke is often presented with a simple pictorial diagram.
Fiscal note: none
Title: Call for Advocacy Efforts Regarding the Neurosurgical Implications of Increasing the US-Mexico Border Wall
Action: Adopted Substitute Resolution
BE IT RESOLVED, that the CSNS study the magnitude of neurosurgical implications as well as the humanitarian and economic costs that have resulted and will result from further expansion of the border wall.
Title: Impact of Travel Nursing and Nursing Staff Shortages on Neurosurgical Patient Quality and Safety Outcomes
BE IT RESOLVED, the CSNS support an institutional based study to correlate nursing staffing and traveling nursing rates to neurosurgical patient quality and safety metrics, in the pre and post pandemic era. Nurse staff ratios and full-time equivalent hours will be used to cross tabulate against patient safety and quality outcomes, that range from adverse patient related events (including falls, pressure ulcers, medication errors, etc.) and operating room metrics.
Fiscal note: none
Title: AANS and CNS should study the impact and educate their membership of upcoming Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP)
Action: Adopted Amended Resolution
BE IT RESOLVED, that CSNS will ask the parent bodies to study the impact of CMS’s change in split-shared billing and educate membership on how this alteration may impact neurosurgical practice; and
BE IT FURTHER RESOLVED, the CSNS request that the AANS and CNS ask the Washington Committee to add to their legislative agenda ensuring that CMS compensate on the basis of medical decision making rather than time-based criteria.
FISCAL NOTE: None
Title: Assessment and validation of neurotrauma and acute care neurosurgery readiness and metrics
Action: Adopted Amended Resolution
BE IT RESOLVED, that CSNS assign a Neurotrauma subcommittee working group to study and define neurosurgeon readiness as well as design and validate readiness metrics for neurotrauma and acute care neurosurgery in the military community; and
BE IT FURTHER RESOLVED, that CSNS develops a white paper describing the results that can be used to advise the military neurosurgery community and improve neurotrauma and acute care neurosurgery outcomes within the military health system.
FISCAL NOTE: None
Title: Assessment of Financial Literacy to Identify Targets for Educational Intervention
Action: Combined into Resolution IV
Title: Online Posting of Research Positions
Action: Not Adopted
BE IT RESOLVED, that the CSNS request the parent bodies to create listings of open research positions by posting on https://www.neurosurgerymatch.org/ .
FISCAL NOTE: None
Title: Publicized and Published Metrics for Hospital Administrators
Action: Adopted Amended Resolution
BE IT RESOLVED, that the CSNS publish a white paper with the following goals: 1) outline the current metric burden placed upon practicing neurosurgeons, both in the clinic and inpatient settings; 2) determine how the metric burden can be measured as well as shifted to assess hospital administrators from the viewpoint of practicing clinicians; 3) identify metrics that would apply to hospital administrators including but not limited to physician retention and physician satisfaction; and
BE IT FURTHER RESOLVED, that the CSNS, under the guidance of its parent organizations, immediately forward this resolution to the Washington Committee’s American Medical Association delegation for development of a resolution to be considered within the AMA House of Delegates for further action.
FISCAL NOTE: None
Title: Transparency and Accountability for Hospital Systems
Action: Adopted Amended Resolution
BE IT RESOLVED, that the CSNS, under the guidance of its parent organizations and through the Washington Committee’s AMA delegation, develop a resolution to the AMA House of Delegates that will include these elements:
1) Transparency of complaints made against a hospital as it relates to the United States Equal Employment Opportunity Commission (EEOC);
2) Transparency of the volume, type, and frequency of reports sent to the NPDB;
3) A mechanism by which physicians can hold hospitals accountable for false or misleading NPDB reports;
4) The Joint Commission’s involvement in reporting, tracking, and monitoring these issues;
5) The Health Quality Improvement Act of 1986, which defines bad-faith peer review, warrants revision to include monetary penalties for institutions performing or encouraging bad-faith or retaliatory peer reviews.
Title: Evaluation of Private Equity in United States Neurosurgical Practice
BE IT RESOLVED, that the CSNS create a study of the private equity acquisitions of neurosurgery and neurosurgery-related services and practices; and
BE IT FURTHER RESOLVED, that the CSNS use the results of the study to explore the trend in private equity investments and whether changes in ownership, economies of scale and new technologies influence patient care.
FISCAL NOTE: None
Title: Assessment of Current Practices in Global and Humanitarian Neurosurgery
BE IT RESOLVED, that the CSNS coordinate with the AANS, CNS and the various State Neurosurgical Societies to conduct a survey of Neurosurgeons about the current state of Global Neurosurgery practices and programs; and
BE IT FURTHER RESOLVED, that the results of this survey be used to describe the current state of Global Neurosurgery; and
BE IT FURTHER RESOLVED, that this description further be utilized to develop strategies and priorities for improved coordination and augmentation of practices and programs in Global Neurosurgery, potentially including but not limited to targeted public health and global surgery education for neurosurgery residents, fellows, and attending surgeons.
FISCAL NOTE: None
EMERGENCY RESOLUTION 2023S
Title: Elimination of Covid-19 Vaccine Mandate at AANS/CNS Meetings
Action: Not Adopted
BE IT RESOLVED, that the CSNS request that the AANS, CNS, and their joint specialty sections eliminate the discriminatory mandate that requires all participants to receive the experimental EUA Covid-19 mRNA injections in order to attend the scientific meetings.
BE IT FURTHER RESOLVED, that the AANS/CNS AMA delegation draft a similar resolution for the AMA HOD.
Dr. Siddiqi served our Association with distinction last year. It was this Editor’s oversight not to have published this profile at the beginning of his tenure. But as the saying goes: it is better late than never.
A Rhodes Scholar with a Doctorate in International Relations from Oxford University, Dr. Siddiqi went on to specialize in Neurosurgery with mentors like Dr. Charles Drake, Dr. Sam Al-Mefty, and Dr. Gazi Yazargil. Dr. Siddiqi has served on the Board of Directors of the American Association of Rhodes Scholars since 1998.
Dr. Siddiqi is the only MD neurosurgeon to have concurrently founded two AOA-accredited neurosurgery residency programs, one of which went on to achieve ACGME accreditation; he also founded an AOA-accredited Neurology residency program, which went on to achieve ACGME accreditation. Indeed, in the 126-year history of the American Osteopathic Association and the 96-year history of the American College of Osteopathic Surgeons, he is the only MD to be honored with the Presidential Citation from both for his contributions to neurosurgery education in the USA.
He graduated more than 50 residents, many of whom hold important academic positions in Californian and throughout the US.
He is a man of many interests in addition to neurosurgery:
He is a multi-engine, instrument-rated pilot as well as a talented photographer. He published a book titled “In Their Hands,” a collection of photographs of the hands of well-known neurosurgeons. The New England Journal of Medicine reviewed the book, and it was subject to three photography exhibits.
In addition to 69 peer-reviewed articles, he published several books that reflect his wide interests. They include Neurosurgical Intensive Care, World Health and World Politics, Multidisciplinary Critique of Phillip Rushton’s Theory on Racial Ranking, and Applied Mathematics Study Guide.
Dr. Siddiqi believes strongly in philanthropy and leads by example. His personal, non-profit research and education philanthropy, Arrowhead Neuroscience Foundation, has received over $8 million in grants in the past two decades. These have been critical for my building neurology and neurosurgery in the Inland Empire and Coachella Valley. The San Bernardino County Medical Society recognized this contribution to “his” region in 2010 when he was awarded the William L. Cover MD Award for Outstanding Contribution to Medicine. This honor recognized Siddiqi’s commitment to public service for the indigent populations of southern California and his “single-minded pursuit of academic and clinical excellence for the benefit of the citizens of San Bernardino County.”
He is married to his better half, Seema, who supports him in all his career activities. They have two beautiful and talented children, Amman and Saira, who attend every CANS meeting. In fact, Javed says that they grew up as “CANS babies.”
Reps. Raul Ruiz, MD (D-Calif.); Larry Bucshon, MD (R-Ind.); Ami Bera, MD (D-Calif.) and Marionette Miller-Meeks, MD (R-Iowa) introduced H.R. 2474, the Strengthening Medicare for Patients and Providers Act. The bill would implement a new annual Medicare physician payment update based on the Medicare Economic Index (the measure of practice cost inflation in Medicare) beginning in 2024.
This is the first part of our multi-part legislative strategy for permanently reforming the broken payment system. Additional elements include modifying Medicare’s budget neutrality requirements and streamlining the quality payment programs.
Another successful meeting has ended; this is always the easiest CANS update to write. As always, the CSNS portion of AANS was informative, entertaining, and productive. The event featured outstanding presentations and lively debates, with several excellent resolutions being passed. I was fortunate enough to co-author three of these resolutions.
These resolutions aimed to address the EHR burden and quality metrics for hospital administrators. I’m proud to say they received overwhelming support. The next steps involve creating a survey and white paper for the EHR burden and a standalone white paper on quality metrics.
Two controversial resolutions addressed the border wall and the COVID vaccine mandate were also discussed. Clearly, the CSNS is not immune to controversy. Many social policies can impact our patients’ health, and they span the entire political spectrum. In fact, the push to address “social determinants of health (SDOH)” essentially makes every aspect of society a medical issue. I have previously criticized this movement for being too broad.
As individuals and researchers, studying and speaking out on these topics are admirable. We should certainly examine how social policies affect our patients’ health and share our findings through op-eds and publications. However, when our representative organization decides to advocate for a specific policy, we signal that our group has taken a stance on a social issue.
Employment, education, crime, climate, nutrition, and the presence of a loving family all influence our patients’ health. Every political topic up for debate can potentially affect their well-being. If the CSNS advocates for one social policy, should we take a stance on every political issue since everything is now considered an SDOH?
Our profession faces clear and imminent threats, and we must remain focused. Legislators are fighting for us against Medicare cuts, prior authorization, and administrative burdens. Through these allies and our focused, persistent advocacy efforts, we can make changes that positively impact our daily practice of medicine and ultimately improve patient care. These legislators likely have passionate stances on other social issues; we must not alienate them. Our organization cannot change the political outcomes of large, contentious social issues.
The barbarians are at the gates. They want us to become docile, compliant hospital employees. They would love nothing more than for us to battle within our advocacy organization on inconsequential debates and larger social issues on which we will never influence change. We must maintain a unified front to reclaim our profession. That should be our focus.
Science and biology were captivating when I was a little girl, but I didn’t dream of becoming a surgeon. When I attended medical school at the University of Reno, Nevada, I became fascinated by the human nervous system. My passion for learning more in this field secured interviews for numerous residency programs.
I observed neurosurgeons in action on a surgical rotation. A posterior fossa meningioma and adeptness in the operating room led me to consider a neurosurgical profession. I secured a clinical rotation in Neurosurgery at Stanford and interviewed for their neurology training program. During that four-week rotation, I decided that neurosurgery was the direction I would pursue.
I trained with Stanford’s first female resident during my residency at Stanford. Frances K. Conley was also the first tenured full professor of neurosurgery in the United States. Neurosurgery, in particular, was a uniquely men’s club. It still is, but it’s evolving. It was an excellent opportunity to work with another woman.
Professor of general surgery James Stone and I married during my second year of residency. We wanted a family and knew it would be challenging with our careers and my having postponed starting a family in favor of my education. One of my miscarriages occurred while I was on the critical care service. I went to the bathroom, flushed that dream, and returned to continue caring for my patients.
My attendings were supportive of my decision to have children. One was there for me when my husband was in Chicago for board recertification exams, and I went into labor. Jim and I lost our first child at 29 weeks gestation during my fourth year of residency. I was in L&D, on medications to stop contractions. Then a sonogram was performed, showing the baby had no kidneys. Dr. Gerald Silverberg, the acting Chairman of my training program, sat with me the entire time. He held my hand until my husband arrived. We delivered a baby that wouldn’t survive. That kindness and support can’t be measured or repaid. Those actions show true heart.
In 1989, at the AANS meeting in Atlanta, I noticed an unusual group of women. They weren’t vendors but neurosurgery trainees. We gathered then for the first time and later formed the nationally recognized Women In Neurosurgery organization. Over the years, I served as secretary-treasurer, president-elect, and president in 2005.
After my pregnancy loss, I trained with another female mentor, and epileptologist, Dr. Martha Morrell. It was a year-long enfolded epilepsy fellowship. The combined training in both neurosurgery and epilepsy was daunting and exhilarating. Deciding to have children when you’re a surgeon is monumental. Residency hours are grueling. But waiting means you could miss your optimum pregnancy years.
My husband and I decided to pursue IVF. We spent ten years from start to finish trying to bring a pregnancy to term. After several more pregnancy mishaps and seven weeks of hospital bed rest, we were finally blessed to bring twins to a healthy delivery during my first year of solo private practice. My male colleagues were very supportive. Although once I overheard one male of them say, “She’s a good surgeon, but…she’s a mother.” Comments like that are expected when breaking into the boys club, but the majority had my back.
My 27 years in solo private practice were demanding. My husband and I relocated to Redding, a small town in Northern California. I took online courses in practice management and opened up an office. I had advanced practitioners fairly consistently and partners for short periods who left for “bigger pastures.” During those years, I served as a member of the Credentials Committee, Chief-elect of Surgery, and Chief of Surgery in 2014 for Mercy (now Dignity)Medical Center. I covered the one private hospital and one level II trauma center, on rotation with 2-4 other
neurosurgeons. Dr. Kym Chandler and I started a Think First chapter to bring brain and spinal cord safety education to our community. Unfortunately, my marriage did not survive amidst the careers of two surgeons and raising twins. After 18 years, we divorced.
I served as a council member for the north state chapter of the American College of Surgeons for two years. In 2000, I joined CANS and became a board member from 2005-2009. I also served as secretary-treasurer, second vice president, first vice president, and president-elect in 2014. In 2014, my ex-husband developed a large rare thoracic tumor. With 15-year-olds at home and a full-time practice, I declined the opportunity to become the first female president of CANS in 2015. I served as a consultant until 2020. Thankfully, Jim has survived his cancer to this day and continues to be an integral part of our children’s lives.
I stayed active in CANS and my private practice until 2017, when I decided to wind down and work as Locums Tenens. I really enjoyed seeing new places, learning how other medical centers worked, and meeting and working with new team members. I traveled to work in Billings, Montana; Urbana, Illinois; Santa Rosa, California; and Coeur D’Alene, Idaho. Coeur D’Alene won my heart. A colleague and long-time friend, Dr. Bill Ganz, encouraged me to join him for our “final years” of practice together. I relocated in 2019 to Kootenai Health in Coeur D’Alene. We became hospital-employed neurosurgeons that year, leaving our private practices behind.
What it has come down to for me is that I love making a positive difference in people’s lives. To me, they aren’t just patients, and I’m not just the provider; I cherish many of the relationships. Several former patients and I stay in touch via social media or email. Yes, I made a difference in their lives, but they have also made a tremendous difference in mine.
Kim Page with one of her patients to the right and his father to the left. Photo provided by Dr. Page and published with permission.
What do a stereotactic frame, hemostatic bone wax, and the transcranial surgical approach to the pituitary gland have in common?
These were all just some of the many inventions and innovations Sir Victor Horsley created and used throughout his illustrious career as a neurosurgeon, neuroscientist, and physiologist. Born in London in 1857, Horsley trained as a surgeon at University College Hospital before becoming appointed as Professor of Clinical Surgery and Pathology. This month’s installment about innovators in neurosurgery will highlight a few of Horsley’s lasting contributions to our field.
One of his collaborations, with Robert Henry Clarke, planted the seed for principles of stereotaxis that neurosurgeons still use today. The Horsley-Clarke apparatus developed in 1906 and first described in 1908, was a metal device that they used to study cerebellar function in monkeys. It was based on the three-coordinate Cartesian system, and Horsley and Clarke were the first to refer to their technique as “stereotactic.” The foundation of the Horsley-Clarke apparatus relied on the three-dimensional relationships between external landmarks, such as the external auditory canal, to internal anatomical sites within the brain. Different arms of the apparatus could be adjusted in each of the x, y, and z planes to direct an electrode that targeted a precise location. While the Horsley-Clarke frame was used primarily in animal experiments by Horsley and Clarke, it served as a blueprint for further stereotactic frames in neurosurgery, such as Aubrey Mussen’s stereotactic apparatus (which also was never used on humans, coincidentally). The first reported use of the Horsley-Clarke apparatus for invasive stereotactic recordings in humans was performed in 1947 by Frederic Gibbs and Robert Hayne, who also utilized air ventriculography to facilitate their procedure.
The origins of hemostatic bone wax were a bit more muddled. Henri-Ferdinand Dolbeau was the first surgeon to use bone wax during frontal osteoma surgery in 1864. Horsley then popularized its use as a hemostatic agent from his experiments on canine cranial bones after modifying the composition of the wax. This new formulation was commonly called Horsley’s wax, although multiple changes have been made since its first use. Currently, the makeup of bone wax is based on beeswax and isopropyl palmitate, while other forms may include soft paraffin wax.
In addition to his contributions to neuroscience and surgical tools, Horsley was also a consummate surgical master, credited as the first neurosurgeon to perform pituitary surgeries. The first recorded operation occurred in 1889. For example, from archives of case logs from the National Hospital for Neurology and Neurosurgery (formerly known as the National Hospital for the Paralyzed and Epileptic during Horsley’s time), four patients with pituitary tumors were operated on by Horsley. Operative notes indicated that Horsley preferred the subtemporal approach, and he and Cushing had correspondence with each other about this surgery for pituitary patients. His contemporaries remarked on Horsley’s technical excellence and anatomical knowledge. Horsley’s skill, knowledge, and boldness in pursuing surgical treatment for pituitary tumors was yet another aspect of his legacy in furthering the field of neurosurgery and advocating for his patients who faced no favorable medical treatment for their syndromes.
Jensen RL, Stone JL, Hayne RA. Introduction of the human Horsley-Clarke stereotactic frame. Neurosurgery. 1996 Mar;38(3):563-7; discussion 567. doi: 10.1097/00006123-199603000-00029. PMID: 8837810.
Das JM. Bone Wax in Neurosurgery: A Review. World Neurosurg. 2018 Aug;116:72-76. doi: 10.1016/j.wneu.2018.04.222. Epub 2018 May 9. PMID: 29753076.
Pollock JR, Akinwunmi J, Scaravilli F, Powell MP. Transcranial surgery for pituitary tumors performed by Sir Victor Horsley. Neurosurgery. 2003 Apr;52(4):914-25; discussion 925-6. doi: 10.1227/01.neu.0000053148.34310.bb. PMID: 12657189.
The photo was taken on February 17, 2023, in Washington DC by Moustapha AbouSamra, MD – iPhone 13 Pro.
Hellebore – Helleborus – is an evergreen perennial flowering plant in the family “Ranunculaceae.” It is sometimes referred to as “winter rose, Christmas rose, or Lenten rose,” even though it is unrelated to the Rose family “Rosaceae.”
BY ALEXANDER TENORIO
Los Angeles Times/ APRIL 13, 2023 3 AM PT
At 2 in the morning and while I was caring for my hospitalized patients, my pager went off. The message was short: “30-year-old male. Unstable spinal fracture after border fall.” I think of all the similar pages I have received in my three years as a resident physician in neurosurgery in San Diego: young individuals with life-changing severe injuries that they sustained falling from the wall that separates the United States from Mexico. The Trump administration raised sections of this wall to 30 feet high rather than 8 to 10 feet, after which more falls caused more serious injuries.
Before seeing the patient, I took a moment to look at the MRI: He had a severe spinal cord injury. I walked over to the trauma unit and saw the terrified young man, lying immobile with a collar supporting his neck. Instead of concerned family, he was surrounded by Border Patrol officers. I sensed his despair and then his relief when I spoke to him in Spanish. I told him that we would care for him as best we could, but that he would need surgery. He started to cry. As I examined him to determine the extent of his injuries, checking whether he could feel my hand or wiggle his toes, I asked him to tell me about himself.
He told me why he came: “Ya era muy peligroso para mi y mi familia en el pueblo.” It was too dangerous for me and my family back home.
This is a story I know all too well. As the son of Mexican immigrants who crossed the same border in the 1980s when fleeing violent threats in their hometown, I know that my patient’s life story could so easily have been mine or my parents’. Raising me in an impoverished migrant community in South Los Angeles, my parents instilled in me the values that I live by, to help the helpless.
When I care for people fleeing similar violence, I know that they are searching for the same things that my parents did and that we all do: safety and a chance for a better life for their children. As a neurosurgeon, I am horrified by the rash of traumatic brain and spinal cord injuries caused by falls from the border wall.
Under Executive Order 13767 in 2017, the Trump administration started raising the height of sections of the border wall in San Diego, Arizona and Texas to as high as 30 feet. The wall in San Diego was completed in 2019. Since then, there have been a record number of traumatic spinal injuries sustained in border falls. The Mexican Consulate recently noted that 646 Mexican nationals were hurt or killed crossing the border from 2020 to 2022, saying the main cause of injury “was wall-related.”
As a neurosurgeon working in San Diego, I can attest that we are seeing not only more but also new types of neurological injuries, including traumatic brain and cerebrovascular injuries that will leave people unable to work and care for their families. The horrors we are seeing now are caused by the height of the wall.
Aside from the humanitarian impact, there are economic costs that few anticipated. The cost of caring for each patient injured while crossing the border has increased by 70% since 2020. Our hospital systems, already strained by the COVID-19 pandemic, are now facing a rash of border-wall injuries.
I fear that this trend will worsen in the coming months. The Biden administration initially signed an executive order to halt all funds directed for border wall construction. However, the administration has now approved continuation of these projects in Arizona and Texas. More recently, plans to erect 30-foot barriers at the historic San Diego Friendship Park were approved.
We are now dealing with an international public health crisis.
To be sure, some will argue that no one should try to cross the border fence in the first place. Consider what would drive someone to take these risks to come to the United States. The patients I care for are not coming here because of trivial circumstances. They are coming because of unlivable political, economic and violent conditions, similar to what my parents endured. They are aware of the dangers the new border walls pose. They just don’t have a better option.
As one of the primary residents taking night call, I can attest to the unnecessary human suffering the higher wall is imposing on people doing what any of us would do if the situation were reversed: seeking safety for themselves and their children.
We must urge political leaders to halt these planned border wall extensions and provide greater resources for hospitals serving border regions. I understand the need for border policies, but increasing the height of a physical barrier is not the answer: We know now that this leads desperate people to risk spinal cord and brain injuries. We must urge both local officials and the Biden administration to recognize these unintended humanitarian and economic consequences of the border walls.
That night with the 30-year-old patient, as I tried to comfort him, he asked: “Cómo voy a cuidar a mi familia?” How will I care for my family?
I think of the line by the Somali British poet Warsan Shire, who wrote: “No one would leave home unless home chased you.” I think of my parents and the sacrifices that they made so that I could become a neurosurgeon. I am grateful that my parents didn’t have to risk these injuries by climbing a 30-foot wall.
However you feel about immigration, ask yourself: Is that risk something you would want for anyone?
Alexander Tenorio is a neurological surgery resident in San Diego. v
CMA-sponsored prior authorization bill clears Senate Health Committee
A California Medical Association (CMA) sponsored bill to reform the prior authorization process passed out of Senate Health Committee on April 12. The bill— Senate Bill 598, authored by Senator Nancy Skinner— would require health plans to institute a one-year “gold card” prior authorization exemption for physicians who are practicing within the plan’s criteria 90% of the time.
CMA urges U.S. Surgeon General to issue report on gun violence epidemic
Following a troubling surge in firearm deaths, CMA is urging U.S. Surgeon General Vivek Murthy to issue a report on gun violence and provide recommendations for how to address this public health epidemic. Against the current backdrop of Congressional gridlock on gun legislation, a Surgeon General’s Report can spur much-needed action.
CMA applauds bipartisan bill to provide annual inflation update for Medicare physicians
CMA applauds the bipartisan introduction of a bill that would require an annual inflation-based update for Medicare physician payments. The bill—H.R. 2474, the “Strengthening Medicare for Patients and Providers Act”—was introduced by California congressional representatives Raul Ruiz, M.D. (D-CA) and Ami Bera, M.D. (D-CA) and their Republican partners Larry Bucshon, M.D. (R-IN) and Mariannette Miller-Meeks, M.D. (R-IA).
CMA statement on Texas judge’s ruling to ban mifepristone, used by millions of Americans
Donaldo Hernandez, M.D., CMA President, issued the following statement in response to the decision made by a judge in the Amarillo division of the Northern District of Texas in the lawsuit against the FDA over its approval of mifepristone: “The judge’s ruling today is yet another violation of patients’ right to evidence-based reproductive health services and represents a further erosion of the individual’s legitimate right to private health choices.”
CMA-sponsored bills protecting abortion access and gender-affirming care progress out of legislative committees
CMA priority bills protecting access to reproductive and gender-affirming health care services have cleared their first legislative committee hearings. Since the U.S. Supreme Court’s overturning of Roe v. Wade, lawmakers across the country have sought new ways to restrict patient access and punish physicians who provide abortion or gender-affirming care. SB 487 and AB 571 aim to protect physicians from out-of-state encroachments and ensure that they can continue to provide these vital services.
CMS will again allow COVID-19 MIPS hardship exception for 2023
Physicians and physician groups affected by the COVID-19 pandemic will again this year be able to apply for a Medicare hardship exception for the 2023 performance year. Merit-based Incentive Payment System (MIPS) eligible clinicians, groups, and virtual groups may apply to reweight any or all MIPS performance categories if they’ve been affected by extreme and uncontrollable circumstances, including the COVID-19 pandemic.
Medical board will no longer accept paper applications after June 1
Effective June 1, 2023, the Medical Board of California will no longer accept or process paper-based applications for a Physician’s and Surgeon’s (P&S) License. The paper application will be removed from the medical board’s website on May 19, 2023. Except under limited circumstances, paper applications submitted on or after June 1, 2023, will not be processed.
APM incentive payment extended through 2023
In December 2022, Congress enacted provisions of the Advanced Alternative Payment Model (APM) Consolidated Appropriations Act, 2023 that extended the availability of an APM Incentive Payment, allowing eligible APM participants for the 2023 performance period to receive a 3.5% APM Incentive Payment in the 2025 payment year. Without this, there would have been a one-year gap with no statutory incentives for Advanced APM participation.
CMS finalizes Medicare Advantage payment rule for 2024
The Centers for Medicare and Medicaid Services (CMS) recently released the final 2024 Medicare Advantage and Part D payment rules. The final payment rule includes a 3.32% payment increase for Medicare Advantage plans, instead of the originally proposed 1.03% increase. This represents an approximate $13.8 billion increase for Medicare Advantage plans next year.
The word “byzantine” has been getting a lot of use in my professional dialogues lately. Having just completed the AANS and the CSNS (I put extra acronyms in there for Mark Linskey), I found myself using to describe two very pertinent and difficult institutions which we as neurosurgeons have to contend.
First, the definition. Byzantium was the capital of the Eastern Roman Empire. It was subsequently known as Constantinople, then Istanbul. Tangentially, the very words conjure the famous-among-my-friends klezmer/novelty song from 1953, written by Jimmy Kennedy and Nat Simon, and covered by the rock band They Might Be Giants in 1990.
“Byzantine” the adjective refers to the reputation of the old Empire for being synonymous with mystics, wars, and political infighting. It became in the daily lexicon in the 1930s in the West when referring to the former Soviet Union’s political machinations.
How fitting then, to use it to describe the souls of our two biggest adversaries in patient care: Medicare and the Insurance Cartel.
Of recent, there have been many bills and actual progress on the specter of prior authorization. This has been mostly relegated to the patients covered by Medicare Advantage plans. Insurers have become increasingly bolder in their use of double-secret guidelines and goalposts in order delay inevitable care to patients.
In their hopes of discouraging patients and doctors from fighting, medical roulette to see if the condition spontaneously improves, and painting the doctors as drivers of cost of care; the mantra taken up by their paid policy wonks or even their representatives on the phone saying the doctors don’t know what they are doing.
Some of the origins of the STARK laws I imagine were borne partly out of the party-line the insurance lobbyists fed Congress. There were and are bad eggs to be sure, as we have all seen pill mills, surgeons driven by profit seeking taskmasters, and general greed corrupt our system. The current PA system was designed in order to control costs in care. As we all know, it has been usurped and corrupted, in order for ostensibly for-profit insurers to make money off the interest in accounts with funds that should be used to pay physicians and hospitals for care. Imagine daily interest on a 100 million dollars which is but a fraction of their holdings.
The question becomes, if this is the worst-kept secret in the medical industry, why are physicians sent the blame check?
Two main reasons are of course: 1) the narrative control, fostered by large amounts of lobbying dollars and likely corrupted bureaucrats; 2) the inability of physicians to get their act together and figure out how to strike back effectively.
Tackling these issues is the subject of much wrangling and oftentimes degenerates into a partisan argument. As recently as this past week, when discussing the subject of some contention, the No Surprises Act (NSA), people, including myself, were arguing back and forth with those placing blame on the current administration. I think the more salient argument is not which party, is WHY. Because we have been pretty much sold down the road by both at one time or another.
How to make the argument more compelling in a favorable way, is to put the concerned parties front and center – the patients. Delaying care results in measurable harm to the patient. It is difficult to quantify this for 2 reasons. First, the overall impression is the book is closed, and that anything we want to do is in our own self-interest. Second, is that we are just CYA’ing in order to avoid civil action.
Starting a conversation from a disadvantaged point is hard. But taking back the narrative as to why we do what we do is crucial. Collectively a method to do this is to take the fight to them directly. There are laws governing insurers.
Here is from one of their lobbying sites:
“The McCarran-Ferguson Act, approved by Congress in 1945, entrusts states with the authority and responsibility for the regulation of the business of insurance.
The McCarran-Ferguson Act does not include a blanket exemption from antitrust laws, but provides a targeted exemption for certain limited insurance activities. The exemption is limited to activities that constitute the “business of insurance,” are “regulated by State law,” and do not constitute “an agreement to boycott, coerce or intimidate or an act of boycott, coercion or intimidation.” Like other exemptions from antitrust laws, this exemption is construed narrowly and has been subject to extensive court interpretation during the past 65 years.
Under the regulatory regime established by the McCarran-Ferguson Act, insurers are subject to a vibrant, comprehensive state-level system of regulation, consumer protections and antitrust enforcement. States regulate virtually every aspect of insurance from licensing to market practices to financial solvency, and all insurance activity is subject to regulatory supervision. In addition, every state has an Unfair Trade Practices Act providing authority to investigate, and if appropriate, correct and punish a variety of unfair practices. “
..and the kicker..
“The McCarran-Ferguson Act has worked well for decades to maintain a vigorous and competitive marketplace for America’s consumers and should be preserved. “
So, the insurers want to keep this. It basically keeps regulation of the insurers with the states. Well, we haven’t had much luck since my grandfather was a buck private in the US Army during World War II.
We can work to repeal it, which was voted in 2010 and was voted to be removed but did not pass the Senate. President Trump did make efforts to remove it, but ultimately it was basically redundant.
Insurers have effectively struck back by painting us as the main drivers of cost, while posting billing dollars of profits while still taking federal subsidies in one of the most beclowning cases of corporate welfare in recorded history. The way to peel back the layers and change the narrative is to enjoin in legal and lobbying action, addressing the second of the two reasons we fail.
There are two main lobbying groups in our bailiwick. I am on the board of one, and a member-at-large in the other. Currently there are some contentious issues between them. Key people are not speaking to one another, and each is preferring to go their own way. The desire to channel Kumbaya is strong, but I know those of use in private practice would say: what the hell do I care? They haven’t done anything for me.
The truth is both committees have work politically to help mitigate the damages wrought by all the payers. Sometimes in concert and other times in antagonistic positions. What must happen is the common goal and undercutting has to be addressed openly, and without people getting their feelings hurt and looking beyond self-interests. Each going their own way will not help us at all. We are being bound to an iron ball and chain and pushed over the side of the rowboat together in very deep water, and we have to share their hacksaw and quick.
Changing the narrative is a Sisyphean task and may be a dead issue. Here, each surgeon has to take 60 seconds and explain what is going on to these patients when they get their surgery denied or their scans pushed back or cancelled. Regardless of whose committee you support, it is up to everyone who touches a patient to generate the change of the narrative. Nearly all of my patients support us in this, and I would encourage everyone to gather their respective fleets and have them call their congresspeople and to complain to the Department of Insurance https://cdiapps.insurance.ca.gov/CP/create-complaint-page/
One thing that will not benefit us or our patients is learned helplessness. The insurers know we are on our heels. But there is also a sense of panic. Recently, one of the insurers pledged to cut their prior authorizations by 20%, and to offer a Gold Card type plan, which many of us are familiar with. Essentially, if a doctor “wins” 90% of their authorizations over a specified period of time, then they will be issued a Gold Card (more like papal bull) that their PAs will get pushed through automatically. As of now, this is not in effect. Texas has implemented something like this.
This show of good faith, more than likely meaning the other 80% of the insurer’s PAs will be even more difficult to get, is a sign of the façade beginning to crack. So, I would encourage all of us to push for this much needed reform and unburden ourselves. If creating loopholes and beartraps are the forte of the insurers, it is high time we learned to stitch and vault. Maybe we will get somewhere before they break the whole thing.
Open Payments Pre-Publication Review and Dispute Open Today!
Pre-publication review and dispute for the Program Year 2022 Open Payments data is available beginning today, April 1, 2023 through May 15, 2023.
Open Payments is a national disclosure program that promotes a transparent and accountable health care system. Open Payments houses a publicly accessible database of payments that reporting entities, including drug and medical device companies, make to certain health care providers, which are referred to as covered recipients .
As a reminder, the definition of a covered recipient includes the following health care providers:
From February 1, 2023 through March 31, 2023 the reporting entities submitted their 2022 data to the Centers for Medicare & Medicaid Services (CMS). CMS will publish the Open Payments Program Year 2022 data and updates to the previous program years’ data in June 2023.
Now is your opportunity to review the data before it is published. Covered recipient review of the data is voluntary, but strongly encouraged as this ensures the accuracy of the data.
Pre-Publication Review & Dispute Actions
The Pre-publication review and dispute period provides covered recipients the opportunity to review data attributed to them prior to the data publication. During this time covered recipients may review and affirm that the data is correct or if necessary they may dispute data that they believe to be incorrect or inaccurate in any way. Please note that simply reviewing the data does not indicate if it is correct. In order to note that you agree with the data attributed to you, you should take the action of affirming.
The Program Year 2022 Pre-publication Review and Dispute period is from April 1, 2023 through May 15, 2023.
Please keep in mind the following reminders:
Detailed information about the Review and Dispute process is available in the Review and Dispute Tutorial for Covered Recipients, located on the Resources for Covered Recipients page.
In order to participate in the Pre-Publication Review and Dispute period, covered recipients must be registered in the CMS Identity Management System (IDM) and have access to the Open Payments System.
Registration is a two-step process:
Registration details are available on the Covered Recipient Registration Page. The Open Payments team recently released two registration videos. These videos provide information for covered recipients about the registration process, including a step-by-step tutorial of the registration process.
There are two versions of the registration video, one for physician and non-physician practitioner (NPP) covered recipients and one for teaching hospital covered recipients. The videos are available at:
We are pleased to share a variety of resources about the program. There is an Open Payments Overview Video which provides details about what the program is, who is involved, and how the program operates. There is also a Natures of Payment video that highlights what the Open Payments Natures of Payments are and how they are reflected in the data.
As mentioned above, there are two new registration video tutorials. Along with the tutorials are quick start guides that provide information for what you should have on hand when you start the registration process. These items are available on the Covered Recipient Registration Page.
Questions – Contact the Help Desk
Need help or have questions? Contact the Open Payments Help Desk at email@example.com or call 1-855-326-8366 (TTY Line: 1-844-649-2766). The Help Desk is available Monday through Friday, from 8:30 a.m. to 7:30 p.m. (ET), excluding Federal holidays.
The Help Desk refers media inquiries to CMS’ Press Office for response.
Published with permission from Elsevier.
Neurosurgical Giants: Feet of Clay and Iron by Paul Bucy – 1985
By Eugene Stern
Howard Christian Naffziger
An erect, commanding figure with a twinkle in his eye (some of the time), white-haired, every inch a fine physician, Howard Naffziger was the West’s neurosurgical giant and had been for many years when he turned over his academic reins as Professor and Chief at the University of California, San
Francisco, in 1952. His beginnings were molded by an intelligent mother in the fascinating, rough-hewn environment of Nevada City in the western goldmine ridden slopes of the California Sierra Nevada. Following graduation in Medicine from the University of California, he was strongly motivated by Dr. Camillus Bush, surgeon, to improve his surgical education at the Johns Hopkins Hospital and, although initially rebuffed by Harvey Cushing’s un-cordial reception, Naffziger convinced the “chief” of his strong motivation by hard work, and his neurosurgical career was launched. Although invited by Cushing to move with him to Harvard, Naffziger returned to the far west, carrying the seeds of surgical education, neurosurgical specialization, and the superior standards of Halsted and of that great man’s colleagues back to the “coast.” These standards he never deserted, and the seeds rooted and flourished.
The years it took for them to blossom encompassed the first World War. Albeit a member of the American Expeditionary Force in France, his primary neurosurgical contribution at that time came from his efforts in
behalf of the excellent military manual of neurosurgery published by the Surgeon General’s office.
It is of interest to review his writings in the early years of his career as he acquainted the medical community with the value of surgical expertise in managing neurological problems. While culturing neurosurgery, he retained a catholic interest in all facets of surgery as a broad discipline, and to his death was a doctor, a surgeon, and a neurosurgical specialist, depending upon the need of the occasion and eschewing a chauvinistic attitude.
As neurological surgery grew from fledgling to eagle status in those great years of the 1920s, Naffziger’s writings reflected his active mind and spanned the entire field of the new specialty. Before the Great War and immediately afterwards, he published works on head and peripheral nerve injuries, intracranial pressure problems, tic douloureux, and spinal cord tumors.
Three major contributions appeared in the mid-1920s. In 1924 he described traumatically induced collections of subdural fluid that acted as mass lesions and emphasized the importance of surgical evacuation of the watery or bloody fluid from the nonabsorbing subdural space. The major work by Putnam on subdural hematoma in 1925 referred to this important paper; and Naffziger’s interest in the general topic was sustained, as evidenced by the 1934 paper with Brown on chronic subdural hematoma in infants.
In that same year (1924), he joined Locke in a splendid anatomical paper defining, by injection and corrosion techniques, the cerebral subarachnoid system, thereby filling in part a void that had existed from the landmark paper of Key and Retzius in the previous century.
The following year, referring to the calcified pineal image in plain roentgenograms, he stated, “It occurred to us that the position of this structure might be of diagnostic value …. ” Naffziger clearly enunciated the value of the “pineal shift” in the anterioposterior projection in diagnosing lateral displacements of the cerebral hemispheres, and who, today, does not look for this valuable sign?
By 1928, his excellent reputation was broad and in that year, the paper, so well illustrated by Ralph Sweet, on surgical exposures was published and continues to receive and deserve study. In it, he described the valuable occipital flap for combined supra- and infratentorial exposure; he contributed a midline cerebellar exposure and noted the importance of a fascial fringe for proper closure along the superior nuchal line. This paper reflected a master surgeon’s work and was echoed in a technical sense when he later described the “California flap” for pituitary tumors, a simplified and more acceptable modification of the Cushing flap then in vogue.
Called from his clinical faculty status to the Professorship and Chairmanship of the Department of Surgery of his University in 1929, he launched the first formal surgical residency training program in the western United States and firmly established his role as a surgical educator. Although neurosurgery was a favored subspecialty in that program through the merits of Naffziger’s leadership and forceful personality, yet it was not until 1947 that he relinquished the reins of the Department of Surgery as a whole to assume those of the first head of a separate department of Neurological Surgery, a prototype the successor of which exists today.
In the two years after his call to the chairmanship, he published two papers of value. The first of these was the fundamental experimental paper on depressed fractures of the skull, work done in conjunction with Glaser. The paper made clear that changes in the brain are caused by the force producing the injury to the skull rather than by the depression of the bone; it dispelled the myth, still abroad, that untreated depressions cause progressive brain damage. The second contribution ( 1931) was the first of a sequence of papers defining the entity of infiltrative endocrinopathic exophthalmos and its vision- saving surgical treatment. The dramatic case report of the first orbital decompression revealed the trail-blazing and innovative nature of the man whose world-renowned work on this problem culminated in his Hunterian Lecture on the subject in 1954 for the Royal College of Surgeons of England of which he was an Honorary Fellow.
Naffziger trained relatively few neurosurgical specialists in the early years; (the tempo was to increase after the second World War), but he had profound influence upon surgical education in the West and upon standards of excellence in the general field of surgery nationally. His influence was appreciated through the American Board of Surgery ( of which he was a founding member), through the American College of Surgeons, of which he was an officer and Regent for so many years, and through the American Board of Neurological Surgery as Chairman for numerous terms. He gave of his energies and canny wisdom and expertise in furthering the standards of surgical care in hospitals; he was instrumental in founding the Northern California Chapter of the College of Surgeons and he strived, diligently,
against a stifling tide to correct deficiencies in nursing education. • Intermingled with his service roles he presented first-rate papers, which continue to command review. His paper with Brown on hour-glass tumors of the spine added a significant chapter to our understanding of neoplasms that are contiguous within and without the spinal canal. His papers on the scalenus anticus syndrome (the Naffziger syndrome) may have been partially discredited, but they placed the structures of the thoracic outlet under scrutiny as important in explaining neurovascular compression problems not accounted for by cervical ribs. With Aird, he presented needed experimental data on the effects of ethyl alcohol on the contents of the subarachnoid space, and with that same esteemed colleague, he established the value of bilateral jugular vein compression in eliciting symptomatology and signs of disease, especially within the spinal canal (Naffziger’s test). An excellent paper on the role of structures other than the intervertebral disk in explaining root-compression findings (with Inman and Saunders) and fine papers on spine injuries, nerve injuries, and on unusual surgical and neurological problems documented a fertile and vigorous scholar. An example of his tenacious ingenuity was the pursuit of a logical solution to the challenge of the syndrome of the jugular foramen for which he, with Davis and Bell, offered a successfully applied procedure in correcting the paralysis of deglutition following a careful functional anatomical analysis of swallowing based on some of the earliest medical radiological cinematography.
Neurosurgeons of the future, as Naffziger generically observed in his 1939 Presidential Address to the American College of Surgeons, will appraise their forebears only as creators. And so with him. They will barely recall his many international honors, his numerous presidencies of senior surgical societies (e.g., The Pacific Coast, The American, The Society of Neurosurgical Surgeons). They are likely to be unaware of his service to the Office of Scientific Research and Development during World War II or to the National Research Council as a member, nor are they likely to have heard of his participation in the medical mission to post-War Poland and the Philippine Republic or of his aid as surgical consultant in the Korean conflict. Nor will they be able, easily, to measure his contribution as Regent of the University of California from his retirement in 1952 to his death in 1961 during which time he gave of his broad knowledge to the master-planning of medical educational expansion in that great institution.
It would be only through his students, family, and friends that so many qualities of a great surgeon and teacher could be communicated; his incisive thinking, his devotion to excellence, his insistence on dedication, hard work, and unimpeachable integrity. Lost to but a few would be his humor, his courtliness, his graciousness, his dignity. A warm physician, he gained much of his own inspiration from those before him and those who taught him. May his honor of medicine be communicated to those who follow him and be
implemented in as many good works.
Of all the neurological surgeons in the United States, Howard Naffziger was certainly the most debonair. A fine figure always immaculately dressed and as one might well expect from such a man, always with a keen eye for the ladies. He was a close personal friend. We worked together closely in the
formation of the American Board of Neurological Surgery and in its operation over a period of several years. Although I was 20 years his junior, he never made me feel my lack of years and experience as compared with his. Two things stand out in Howard Naffziger’s career-his development of neurological surgery on the West Coast of the United States and his position as a statesman in medicine and neurological surgery. His well considered judgement was always highly appreciated and respected by his associates. He was responsible for few innovations. Among those few were the orbital decompression for malignant exophthalmos and the shift of the pineal body resulting from unilateral cerebral expanding lesions. One of Naffziger’s greatest accomplishments was his selection of his wife. She is one of the most remarkable women ( other than my own wife) that I have ever met. She impresses me as a typical daughter of our Far West. She is lovely in appearance; she is vigorous. As of recent dates she still frequently rode horseback in spite of her years. She is a delightful hostess.
April was declared National Arab American Heritage Month by President Biden. He stated, “Today, the achievements of Arab Americans are reflected in the arts and sciences; in businesses and faith communities; in classrooms and hospitals; and police stations, firehouses, and every branch of the military. Arab Americans are also proudly serving throughout my Administration, bringing a diversity of expertise that helps make this country stronger, more prosperous, and more just.”
April 1 – April Fools Day, also known as poisson d’avril (literally “April’s fish”) in many French-speaking countries and others, including Türkiye, where it is called “Nisan Balığı” (April Fish.)
April 2 – One-hundred-and-twenty years ago, in a rare instance of cross-cultural solidarity in U.S labor history, the Japanese Mexican Labor Association of sugar beet workers – betabeleros – achieved victory in a bitter strike against the Western Agricultural Contracting Company in Oxnard, CA; The company had slashed the wages for sugar beet thinning and topping by 50 percent. After the strike, they were able to unionize.
On April 3, 1973, Martin Cooper, an engineer at Motorola, stood on a sidewalk on Sixth Avenue in Manhattan with a device the size of a brick and made the first public call from a cell phone to Joel Engel, head of AT&T-owned Bell Labs, one of the men he’d been competing with to develop the device. “I’m calling you on a cell phone, but a real cell phone, a personal, handheld, portable cell phone.” Cell phones have changed, and the world has changed since.
April 5 – Passover starts at sundown. The Jewish festival celebrates the Israelites’ exodus from Egyptian slavery in the 1200s BC. The story is chronicled in the Old Testament book of Exodus, in which Israelites marked their doorposts with lamb’s blood to protect children from the tenth plague: the slaughter of the firstborn. With the protective mark, the destruction would “pass over” the house.
April 7 – Good Friday. It marks the day Jesus died on the cross. For Christians, it is a day of mourning and penance.
April 9 – Easter. Christians celebrate the resurrection of Jesus Christ on the third day after his crucifixion. It also marks the end of the 40-day period of penance called Lent. It is celebrated on the first Sunday after the first full moon following the first day of spring. Easter is considered the most important Holiday of the Christian year.
April 10 – National Siblings Day. Unofficial holiday to honor the bonds between brothers and sisters.
April 13 – Mary Quant, the British designer known as the mother of the miniskirt, died at her home in Surrey, in southern England. She was 93. She epitomized the style of the Swinging Sixties. She never intended to succeed and eventually said “I grew up not wanting to grow up.” “Growing up seemed terrible. To me, it was awful. Children were free and sane, and grown-ups were hideous.” She predicted that “the miniskirt was here to stay.” She was eventually named an officer of the Order of the British Empire in 1966 for her contribution to British exports.
April 13 – A survey published by the National Council of State Boards of Nursing found that about 100,000 registered nurses in the US left the workplace due to the stresses of the Covid-19 pandemic. Another 610,388 registered nurses, with more than ten years of experience and an average age of 57, said they planned to leave the workforce by 2027 because of stress or burnout. 189,000 nurses with ten or fewer years of experience and an average age of 36 planned to leave nursing.
April 16 – The last performance of Broadway’s longest-running show, “The Phantom of the Opera,” was held at the Majestic Theatre. It was No. 13,981 performance, and it ended with a reprise of “The Music of the Night” performed by the current cast, previous actors in the show – including original star Sarah Brightman – and crew members in street clothes. Andrew Lloyd Webber took to the stage last in a black suit and black tie. This brings back good memories!
April 17 – the 127th running of the Boston Marathon and the 10th anniversary of the terrorist act when two bombs exploded at the finish line, killing two people and injuring 264 others. It is the elite event in the marathon running world; every athlete in the world dreams of running Boston. Eliud Kipchoge, 38-year-old, the two-time Olympic gold medalist, winner of 15 marathons, and the man who became a semi-mythical figure when he broke the two-hour barrier in October 2019 had a bad day coming sixth. His reaction? “As a human, I was disappointed.” “But this is sport.” “Today you are up, tomorrow you are down.” Superhuman in my book!
Eliud Kipchoge finished the Boston Marathon in sixth place. Credit…Brian Snyder/Reuters
Meanwhile, women’s elite marathoning continues to break new records year after year: five women who entered the Boston Marathon ran a marathon under 2:18 and 14 under 2: 21.
April 18 – Apple opened its first store in Mumbai, India, as this amazing country is set to overtake China as the most populous country in the world!
April 19 – The California Supreme Court this week declined to block the rollout of Governor Gavin Newsom’s new plan to compel people with severe mental illness, many of whom are homeless, into treatment. So, the plan remains on track to begin this fall in several counties. Newsom’s plan, known as CARE Court – Community Assistance, Recovery, and Empowerment – was opposed by a coalition of disability and civil rights groups, claiming that it violated due process and equal protection rights. And that it would infringe on personal liberties. They also argued that forced treatment is not effective.
April 21 – Eid-al-Fitr/Breaking of the fast signals the end of Ramadan for the more than two billion world Muslims. There are about 3.5 million Muslims in the US. Also called Eid -al Saghir/Small Holiday is celebrated during the first three days of Shawwāl, the 10th month of the lunar Islamic calendar, so that it may fall in any season. As in Islam’s other holiday Eid-al-Adha/Sacrifice Holiday/Big Holiday, it is started by the performance of communal prayer at daybreak on its first day. Eid al-Fitr is a time of celebration when friends greet one another, presents are given, new clothes are worn, and relatives’ graves are visited.
April 22 – Earth Day. The theme this year is “Invest in our Planet.”
View of the Earth as seen by the Apollo 17 crew — astronaut Eugene A. Cernan, commander; astronaut Ronald E. Evans, command module pilot; and scientist-astronaut Harrison H. Schmitt, lunar module pilot — traveling toward the moon. NASA
April 23 – Sifan Hassan, an Olympic track champion from the Netherlands running her first marathon, staged a stunning comeback to win the London Marathon in one of the most dramatic and unexpected finishes in the race’s history. She finished in 2:18:33. An Ethiopian-born Dutch athlete better known for her middle-distance success, Hassan fell off the pace about an hour into the race, stopped at least once to stretch her aching left hip, and offered a drink to one of her rivals as they ran even after missing a water stop herself. Hassan did it all despite training for the race during Ramadan, a month of fasting that left her unable to complete long runs because she could not eat or drink during the day. Makes me want to run again!
April 24 – Armenian Genocide Remembrance Day is held annually to commemorate the victims of the Armenian genocide of 1915. It was a series of massacres and starvation of 1.5 million Armenians by the Ottomans. It is sad to see that ethnic cleansing continues to happen in various parts of the world.
April 25 – The AHA- American Hospital Association gave former Speaker Nancy Pelosi (D. CA) an award for “her incredible efforts in advancing health care” after she spent the past four years fulfilling the industry’s top legislative priority: blocking consideration of Medicare for All or any other major reforms to the insurance-based health care system. “Throughout her career, Speaker Emerita Pelosi has been a friend to America’s hospitals and health systems,” said Rick Pollack, president, and CEO of the American Hospital Association (AHA), in a press release announcing Pelosi’s award. The AHA is part of a healthcare industry coalition made up of insurers, pharmaceutical firms, and hospital companies that spent $81 million from 2018 to 2021 on a TV and lobbying campaign opposing Medicare for All. Lobbying works!
April 26 – Mattel introduced its first-ever version of the Barbie doll representing a person with Down syndrome. The new doll is part of the Mattel Barbie Fashionistas line, which aims to offer kids more diverse representations of beauty and fight the stigma around physical disabilities. Is she wearing foot drop braces?
April 27 – Kaiser Permanente, with 39 hospitals and 24,000 doctors, and $95 billion in revenue last year, said that it plans to acquire Geisinger Health, a smaller East Coast group, to develop a new company to operate nonprofit community health systems. Geisinger, headquartered in Danville, Pennsylvania, will be folded into Risant Health, a new nonprofit group that will operate independently. Kaiser said it hoped to invest $5 billion in Risant over the next five years; it expects to add five or six health systems to Risant during that period. Wow!
April 28 – Arbor Day. In 1972, former President Richard Nixon declared National Arbor Day to be celebrated on the last Friday in April. Nebraska was the first state in the US to observe it as a formal holiday in 1872; more than one million trees were planted on the first official celebration.
CANS MISSION STATEMENT
To Advocate for the Practice of California Neurosurgery Benefitting our Patients and Profession
The 17th Annual UCSF Spine Symposium will be held June 16-17, 2023 at the Hilton San Franisco Financial District. It would be great to see you there.
It will be an interactive course, with all lectures followed by case discussions.
More information can be found here: https://spinesymposium.ucsf.edu/
Registration link: https://spinesymposium.ucsf.edu/registration
UCSF Spine Symposium June 16-17, 2023
NSA meeting, Chatham, MA, June 18-21, 2023
WNS Meeting Portola Hotel & Spa, Monterey, Sept. 29-Oct. 2, 2023
WFNS Cape Town, December 6-11, 2023
CANS, Annual Meeting, January 12-14, 2024 – San Francisco, CA
Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter. Submit your text to the CANS office by E-mail (firstname.lastname@example.org) or fax (916-457-8202).
The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.
or to the CANS office email@example.com.