Volume 51, Number 8

Inside This Issue

Picture of Joseph Chen, MD

Joseph Chen, MD

CANS President

The Love of The Game

President's Message

I’m writing this after having concluded presiding over the fall board meeting of CANS.  We had a very productive meeting reviewing 24 resolutions being considered by the Council of State Neurosurgical Societies, covering a wide range of issues including physician unionization, preauthorization, physician wellness, accommodations for pregnant neurosurgeons, social media, violence in the workplace, advanced practice providers and other topics.

Your elected board of directors and appointed consultants and fellows engaged in deep discussions regarding these issues and will be representing the interests of the neurosurgeons in the State of California to our national bodies.  A report of the results from the CSNS will be presented next month.

The Love of the Game

Fall is here.  The summer seemed to have passed like the blink of an eye.  Now comes the uneasy coexistence of baseball and football and the fast shortening days.

I have to confess that I’ve never been comfortable as a sports fan.  I’ve always been impressed with my friends and acquaintances who seemed to know every player on every team with excruciatingly precise details on stats, injuries, key plays and the like. I, for one, have problems keeping straight names of people whom I just met a few minutes ago, let alone knowing the life story and stats of a defensive back or a power forward.

Being part of the football obsessed three letter university faction in Los Angeles has long added more responsibilities for the neurosurgery residents and attendings with staffing of home games with sideline concussion evaluations and the like.  My first experience staffing a college game was akin to being exposed to a foreign land with a different set of customs, language and traditions.  A certain quasi and overt religious aspect of the college game is evident with team prayers, pageantry and declarations of loyalty to school and team.

I have not been close to the college game in the last 20 years, but having had some experience with the professional game recently, the differences are striking.  The millionaire filled professional locker room is more akin to a board room.  Every aspect of the product is carefully curated, tested and cleared by the League, its advertisers and mass media conduits.  It has been a singularly successful enterprise.

So for this month’s news topic, we have the demise of the PAC12, a historic college athletic conference.  Most of you know far more about college athletics than I do, so I will dispense with the lead up, only to state the well known conclusion that this is about the business of college athletics and that 80 million dollars a year in the Big10 is better than 25 million dollars a year in the PAC12. At least 55 million dollars better, as it turns out. The playbook of mergers, acquisitions and consolidation has hit college athletics in a big way.  Such is how accumulation of capital is generated in mature markets.

This is a far cry from the origin of college athletics, where loosely organized clubs would play against each other for the “love of the game”.  Young men and women who for no other reason than to engage in sporting camaraderie and competition would beat each other up on the field and then finish it up with drink and song. The last pretense of such love of the game was in my opinion rightfully shattered by allowing college athletes to benefit from name/image/likeness revenues.  So in the end, commerce wins out over everything else as it usually tends to do.  Yet, to be great, as this year’s Yankees have shown, money is never enough.  Greatness always comes from the love of the game.

So what of the love of neurosurgery?  I’m willing to wager that few of us who had gone into neurosurgery had any idea or interest in billing, coding, medical documentation, malpractice risk, hospital staff politics and insurance reimbursements. To the lover of neurosurgery, these things are base affairs, irrelevant to the Art and Science. Yet, it is these things that seem to consume an increasingly

vast amount of our time and effort.  The uncomfortable fact is that these base things make the Art and Science possible.

Yet the love of neurosurgery continues: the making of the difficult diagnosis, the comforting of the patient, the incision and everything leading to the last stitch; the care in the aftermath, and the pride of having a grateful patient.  

Most people, even those who work closely with us will never quite understand the intimate inner experiences of the neurosurgeon.  They will not know the deep fear that sometimes comes when taking the details of the consult and the first look at the imaging, the internal weighing of contingencies . The relief that comes when the plan becomes clear and the final relief of a case that has gone well.  They also will not understand the despair and existential dread of a case gone wrong.  

It can be an object of obsession with the neurosurgeon seeking to control every small detail in the quest for perfection and avoidance of the last bad outcome.

And if those who work with us will never truly understand, the machine of commerce will not only not understand but more importantly has no care to understand either.  The reason is obvious – commerce has different objects of love and desire.

Yet for all the extraneous travails that we must surmount, the love of neurosurgery will always be there, and I, for one, will always love it even after I hang up the bipolars for the last time.

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Corner

Let me take the Editor’s prerogative by sharing that Joanie and I celebrated our 50th Wedding Anniversary this month. The truth is we didn’t think we were this old! Please see “Changing Times.”

The CANS Board of Directors and Consultants to the Board met via Zoom on August 27. It was a productive meeting, expertly led by our President Joseph Chen. It was well attended. It started promptly at 9 AM and was concluded at 3:15 PM with a 30-minute lunch break … Here are some of the highlights:

  • The location for the 2024 annual meeting was finalized. It will be at the Intercontinental Mark Hopkins Hotel on Nob Hill in San Francisco, January 12-14. It is a great location and should be a great meeting you wouldn’t want to miss; President Chen is finalizing the agenda. You should receive a link to make hotel reservations shortly from Emily Schile.
  • We have five new active members, bringing our total numbers to the following:
  • Active Members 173
    • Private Practice 86
    • Academic Practice 94
  • Honorary Members 15
  • Lifetime Senior Members 19
  • Senior Members 32
  • Resident Members 169
  • Total 413
  • Our Association is on a solid financial footing.
  • Plans for the 2025 Annual Meeting are underway. President-Elect Ciara Harraher and her committee are excited about the plans so far.
  • Our President has encouraged us to update the newsletter’s design; it has not been updated in many years. The board agrees. Please look for some changes in this and future issues.
  • A record number of resolutions, 24, that will be debated at the upcoming 2023 Fall CSNS meeting in Washington, DC, were discussed. Our Board took a position on each. Our position will be presented at the CSNS meeting by our delegates. Please see the text of all resolutions, the CANS position, and the name of the delegate who will present CANS views at the end of this newsletter.

In this issue, we are pleased to publish a “Letter to the editor” in response to two thoughtful essays about Single-payer healthcare written by Anthony DiGiorgio in the last two issues of our newsletter. The good news is that our newsletter is read widely, even by neurosurgeons outside California. The writer, George Bohmfalk, and I were co-residents at the University of Texas Health Science in San Antonio. He retired from a private neurosurgical practice in Texarkana, TX, and now lives in North Carolina. His letter would hopefully prompt some spirited discussion. Of course, letters to the editor are always welcome.

Climate disaster struck this month, affecting various places on our planet and here in the Western Hemisphere. The wildfires in Maui were nothing but disastrous; the wildfires in the Canadian West have been vicious; Hurricane Hillary, which caused severe damage in Baja, California, was downgraded to a tropical storm as it caused havoc in Southern California; The stifling heat in the South; water temperature in the Atlantic Ocean around the

Florida Keys reaching 101.1 degrees. It is becoming increasingly obvious that climate change is a reality we have to deal with – there was even a resolution that attempted to deal with this issue. Please see “Tidbits.”

Covid- 19 continues to evolve. Even though it is no longer a pandemic, a new variant has surfaced, causing an increase in the number of infections; we should continue to be vigilant. Please see the report from WHO.

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 or call me at 805-701-7007 if you prefer to discuss any issue directly with me.

I hope you will enjoy this issue.

Photo of the month

Photo of sunset at Faria Beach taken from Solimar Beach in Ventura, CA, at 7:54 PM, on July 30, 2023. Moustapha AbouSamra, MD. I-Phone 13 Pro

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

Wildest of Imaginations

Changing Times

If You Can Dream It You Can Do It -Walt Disney

All Our Dreams Can Come True If We Have The Courage To Pursue Them. – Walt Disney

On August 18, 1973, Joanie and I were married at St. Mary’s Catholic Church in South Amboy, NJ, Joanie’s hometown. Father James McConnell, her Parish Priest, performed the wedding ceremony outside the sanctuary but in the shadow of the statue of the Blessed Mother. Father McConnell, one of the wisest people I met, made it possible for a young Syrian Muslim man to marry a young Irish Catholic woman in a Catholic ceremony; it was important to Joanie.

We were in love and had big dreams. Our imagination was very fertile. I imagined myself a successful neurosurgeon, but first, I had to be accepted into a neurosurgical residency; this was difficult for a Foreign Medical Graduate in 1973. Joanie’s imagination focused more on our immediate family: How many children? Are we going to raise them Catholic? Will they be good citizens? Where were we going to live and raise them? Were we going to stay in the US or return to the Middle East? If we moved to the Middle East, would we return to Damascus? I had ruled out returning to my hometown because of the dictatorship that ruled Syria and, unfortunately, continues to rule that beautiful country and has since destroyed it.

We were determined to enjoy our journey together, and nothing seemed impossible for two idealistic young people in love.

Joanie always dreamed of having many children. Twelve, to be exact. Eventually, as we faced life’s realities, I convinced her that six might be a more realistic number. We stopped at five after Patty was born, a perfect princess who had threatened to come prematurely, requiring Joanie to be on bed rest for the last six weeks of her pregnancy.

We’ve had a charmed life and many, many successes. We have truly been blessed, and as the song says, we keep asking ourselves, “Why me, Lord?” Our children are

all healthy and good citizens of this Country and the World. Our Grandchildren are all healthy and beautiful and smarter than their parents and, yes, you guessed it, smarter than us. One might become the president of the United States of America. However, their dreams now are more in line with ballerinas, astronauts, baseball players, opera singers, and poets … one thing is for sure: they will change the world for the better!


A major tragic event on December 5, 2017, turned our lives upside down. The Thomas Fire, then the largest in the history of wildfires in California, destroyed our home and 575 others in our beloved city of Ventura. Miraculously, no one died in Ventura.

We survived this ordeal with our family and friends’ help, support, and love. We re-imagined our lives after the fire … we dreamed of traveling and spending more time with our family. The Pandemic added another layer of stress, but we survived it too.

This year, after moving back to our house – it took five and a half years to rebuild – we decided to celebrate our Golden Anniversary in style by taking our entire family twenty-two of us – to Disneyland for four days and three nights; it was one of Joanie’s dreams to take our grandchildren to the “Happiest Place on Earth.” Eight of our ten grandchildren and one son-in-law had never been to Disneyland. And what an experience it was!

I always admired Walt Disney and his vision and creativity. This year, Disney is celebrating the centennial of his creation of Mickey Mouse, Minnie Mouse, Disneyland, and the amazing Disney Empire. I had not been to the park in many years; I had forgotten how special it was.

This time, Joanie and I got to experience “The Happiest Place on Earth” through the eyes of our grandchildren. The oldest is thirteen, and the youngest is three. Their imagination is so vivid; their thinking so magical; their dreams so spectacular; their laughter so contagious … We haven’t felt so excited in a long time.

I realized that at 76, I lost some of my grandchildren’s excitement. But I am going to work hard to get it back. I hope it is not too late.

I know that Walt Disney was right on target when he said, “The real trouble with the world is: that too many people grow up.” And I also agree with Walt Disney when he said, “Laughter is timeless, imagination has no age, and dreams are forever.”

Yes, dreams are forever! And “If you can dream it, you can do it!”

Let us give free rein to our imagination. And let us pursue our dreams!

Quote of the Month

Logic will get you from A to B. Imagination will take you everywhere. -Albert Einstein

From CMA

Medical board publishes new guidelines on prescribing opioids for pain
The Medical Board of California recently published a long-awaited update to its opioid prescribing guidelines, which will make it easier for patients to get the care they need while maintaining appropriate safeguards. Importantly, the medical board has clarified that the guidelines are not intended to replace a physician’s clinical judgment and individualized, patient-centered decision-making.

Urgent: AMA practice expense survey officially launched July 31
The American Medical Association (AMA) Physician Practice Information Survey will be administered from July 2023 – April 2024. Physicians will be randomly selected to participate. The California Medical Association (CMA) strongly urges all physicians who are selected for the surveys to respond as soon as possible.

CMA-supported prior authorization reform legislation moves in Congress
 The U.S. House of Representatives Ways and Means Committee has advanced a bill that would reform the Medicare Advantage prior authorization process by streamlining the health plan bureaucracy to help Medicare patients get the care they need – when they need it. The bill was amended to include the prior authorization reforms included in the Improving Seniors Timely Access to Care Act of 2022 (H.R. 3173) and passed with bipartisan support.

Take Action: Urge your legislators to vote yes on CMA-sponsored prior authorization bill
The California Medical Association (CMA)-sponsored bill on prior authorization reform is making its way through the California Assembly. CMA is asking physicians to contact their legislators today and urge them to vote yes on SB 598. The bill — authored by Senator Nancy Skinner— would require health plans to institute a one-year prior authorization exemption for physicians who are practicing within the plan’s criteria 90% of the time

Urge Members of Congress to provide a Medicare inflation updateCMA is strongly supporting the Strengthening Medicare for Patients and Providers

Act (H.R. 2474), a bipartisan measure now pending in Congress, which would provide the crucial link between the Medicare physician payment schedule and the MEI, and finally put physicians on an equal fiscal footing with other entities drawing Medicare payment. Physicians can contact their representatives in Congress through this portal to urge passage of H.R. 2474.

Gain valuable insights at Health Equity Leadership Summit on attracting and retaining a diverse physician workforce  
As California strives to develop a diverse health care workforce, too many underrepresented minorities face unique obstacles to joining and staying in medicine. At the Sept. 14-15 Health Equity Leadership Summit, hosted by Physicians for a Healthy California (PHC), attendees will hear from a panel of experts and practitioners as they discuss how best to attract, retain and develop clinicians of color.

CalMedForce GME grant program application cycle open now
PHC is pleased to announce that the sixth application cycle of CalMedForce application cycle is now open! CalMedForce administers annual grants to fund residency positions at graduate medical education (GME) programs throughout California. CalMedForce dedicates voter-approved, state tobacco tax revenues from Proposition 56 (2016) to train physicians and help California address its growing physician shortage.

Support Prior Authorization Reform!

CMA’s sponsored bill on prior authorization reform, SB 598, is being considered by the Assembly in the coming days. This bill will reform the prior authorization system by providing a one-year prior authorization exemption for providers who consistently prescribe medically necessary care and requiring insurance reviewers to have the same medical expertise as the treating provider.

Doctors have long been documenting insurers’ practice of denying necessary care to patients to boost heath plan profit margins and delay treatment. This is an imbalance that puts profit margins over treating patients and has contributed to delayed patient care, worse health outcomes, administrative burdens on physicians and clinicians and increased health care costs. Contact your legislator TODAY to share your support for SB 598.

Federal court strikes down steep fee hike and batching rules in latest NSA case
A federal court judge in Texas has again sided with the Texas Medical Association (TMA) in its latest lawsuit against the federal government over its misguided implementation of the No Surprises Act, which governs the resolution of payment disputes between out-of-network physicians and insurers. The most recent lawsuit – the fourth lawsuit filed by TMA challenging provisions of the rule — objects to a 600% hike in administrative fees for those seeking dispute resolutions.

Appeals court preserves FDA approval of abortion drug, but subject to restrictions; sets up Supreme Court review
In the latest ruling in an ongoing legal battle on the future of abortion medications, a panel of the U.S. 5th Circuit Court of Appeals in New Orleans recently upheld parts of a Texas District Court ruling that would restrict the use of mifepristone, while still allowing the drug to remain on the market.

CMA-supported pharmacy benefit manager reforms adopted by Senate committeeRecently, the U.S. Senate Committee on Health, Education, Labor and Pensions passed bipartisan legislation to regulate and reform pharmacy benefit manager (PBM) practices. The legislation – S. 1339, the Pharmacy Benefit Manager Reform Act – would require PBMs to pass on all of the rebates they receive from drug manufacturers to employers and policy holders as well as ban spread pricing.

Urge Congress to take action now to protect patient access to care
CMA is urging all physicians to contact their Congressional representatives and urge them to cosponsor the “Strengthening Medicare for Patients and Physicians Act of 2023” (H.R. 2474), a bipartisan bill that provides an automatic annual inflation update based on the Medicare Economic Index – a reasonable market basket of physician practice costs.

Picture of Adela Wu, MD

Adela Wu, MD

Dr. Dorothy Klenke Nash

Women in Neurosurgery

A column about women in neurosurgery would be remiss without including Dr. Dorothy Klenke Nash, the United States’ first female neurosurgeon and the only woman performing neurosurgeries in America from 1928 until 1960.

Born in 1898, Dorothy Klenke Nash graduated from Bryn Mawr College and pursued her medical degree at Columbia College of Physicians and Surgeons. In 1928, she became the first female neurosurgeon in America after completing her neurosurgical training at the Neurologic Institute of New York, eventually establishing a busy clinical practice at three hospitals in the neighborhood. Dr. Nash took on the mantle of senior neurosurgeon at St. Margaret’s Hospital in Pittsburgh and held a position within the University of Pittsburgh Department of Neurological Surgery. She retired from her 23-year tenure at St. Margaret’s Hospital in 1965 before moving on to Mayview Hospital in Bridgeville, Pennsylvania until 1974.

Dr. Nash also contributed to the neurosurgical scientific literature. In collaboration with Dr. Byron Stookey, she investigated the utility of bedside lumbar manometric testing in early diagnosis of spinal cord tumor. Their work influenced clinical decision-making and outcomes for patients receiving surgical intervention for spinal cord disease. Dr. Nash, along with Dr. Bernard Wortis, discovered that seizures did not only originate from a singular area in the brain. From experiments on feline subjects, they ablated a region within the tuber cinereum in some animals and pharmacologically induced seizures in all subjects. Regardless of lesion status, all experimental animals still experienced convulsions, disproving a long-standing theory at the time that all seizure activity had only one source in the brain.

Beyond her commitment to her patients and the field of neurosurgery, Dr. Nash was also incredibly devoted to her family and her community. She encouraged other women to pursue careers in medicine, giving lectures at the University of Pittsburgh. Dr. Nash was also a vocal advocate for improved access to mental health resources and the destigmatization of mental illness. She died in 1976, and Dr. Nash’s beloved granddaughter recalled that the funeral was attended by so many “whose lives she changed with her incredible gift.”

Casillo SM, Venkatesh A, Muthiah N, McDowell MM, Agarwal N. First Female Neurosurgeon in the United States: Dorothy Klenke Nash, MD. Neurosurgery. 2021 Sep 15;89(4):E223-E228. doi: 10.1093/neuros/nyab246. PMID: 34293169.

Picture of Brian Gantwerker, MD

Brian Gantwerker, MD

The Measure of a Person

Learning how to listen - how we are - and how we can stop dismissing female patients’ concerns.

Private Practice Corner

When a woman is talking to you, listen to what she says with her eyes. -Victor Hugo

Medical school taught me a lot of things.  There was the requisite histopathology, anatomy, physiology, and microbiology, but one of my favorite courses was history taking.  In the late ’90s and early ’00s – there was a big push for people in our school to go into family practice and internal medicine.  In fact, we were told by the school faculty that the only people eligible for AOA would be those who designated themselves as going into primary care.  Whether that was legal or ethical is another matter.  But one focus I did enjoy was getting patients to tell us their real issues.  We were taught about verbal cues, body language, and how to write the patient’s story.  At that time, we were really focused on members of the LGBTQ community as this was the near pinnacle of the AIDS epidemic.  We learned how to make the members of that population feel comfortable disclosing touchy topics like sexual partners and so forth.  The majority of this population at the time were men. In fact, HIV/AIDS used to be called “GRID” [ A pejorative term, standing for “Gay Related Immune Deficiency”].  I lost a close relative who was not a member of that community, but she got it from a blood transfusion.  She died; she had been one of the first compassionate trial patients in Chicago who took AZT, the first of the reverse transcriptase inhibitors.

So, at that time, we were not really focused on another very important population of patients – women.  It was always awkward for me, and I am certain other men in my class – as most of us had prolonged adolescence – to ask personal questions of women. So, we never really got to the point where we learned that most women are still dismissed, and their symptoms minimized or attributed to being “hysterical.”  Rotating at the “Old” Cook Country hospital, that old turn-of-the-century hulk of a building, we saw pathology one should not see in a society with modern medicine.  There, amongst the “sun parlors” that were popular for treating tuberculosis patients, when getting “fresh air” was thought to help patients and not spread tuberculum bacilli.  Many of our patients, especially minority women, had extremely advanced pathology. 

And yet, in the 2020s, one of the worst cases of a thoracic metastasis causing cord compression who became paraplegic in the ER, was found to have a fungating breast mass that had been neglected for who knows how long.  Recently, tennis superstar Serena

Williams’s symptoms of chest pain and shortness of breath were dismissed, and she was ultimately diagnosed with a pulmonary embolism.  Here, a rich, athletic, affluent, and celebrated woman was not listened to, which almost cost her her life.

What follows is a patient experience shared with the permission of my wife.

Our marginalized and needful patients are sometimes not just at our county and safety net hospitals but sometimes in our own private elective practices.  My wife’s experience was traumatizing, which happened during her numerous cycles of IVF.  Our first doctor, a vaunted physician in his field, had his fertility lab maturing the unfertilized embryos, and the lab forgot to “feed” the embryos, so they did not survive.  The physician was both dismissive and defensive at the same time.  My wife told me she felt unheard, sad, and empty.  He truly failed on many fronts.  When she was younger, she suffered from endometriosis and was dismissed out of hand, the physician telling her she was “too young” to have it.  She later was found to have it on laparoscopy and had successful surgery.  Later on, she had a hysterosalpingogram; she was told to toughen up while the radiologist, a woman herself, blasted dye into her blocked fallopian tube.  My wife still remembers the agony of the procedure and how vacant and spent she felt after.

Her words:

“As a woman, you are told to ‘suck it up’ and just bear it.  You are told you have a job to do, so you go with it.  You do not want to disappoint anyone and delay anyone’s job.  That is what we are taught – just deal with it.” 

In the Serial Podcast, the latest edition is called “The Retrievals” the story is of the Yale reproductive endocrinology clinic and the numerous women patients seeking to have children or potentially freeze their eggs, and how one of the nurses was siphoning out the Fentanyl and replacing it with saline.  The patients undergoing egg retrieval, which is done via a transvaginal ultrasound and a really big needle, were screaming in pain.  This happened almost a dozen times until someone tested the vials.  Further, post-op patients who were in real physical distress were not phoned back or ignored altogether.  It really is a compelling and sad commentary on how medicine fails our women patients.

In our profession, we deal with patients in pain before or after surgery.  I am sure we have all seen at one time or another a female patient who is seeking another opinion for her symptoms after she has been dismissed as being “upset” or “unusual” – even dismissed totally.  I have diagnosed MS in a woman who was told her symptoms

were in her head.  Another patient I saw came in with potential cervical cord compression; she called me one night saying she was getting worse but was now having trouble swallowing. She was walking around with fulminant Guillain-Barré. Thankfully, I did not operate on her; she was intubated 6 hours after getting to the ER.  None of the male physicians involved were really convinced, even after I found out she had been ill about 6 weeks before.  I had to armbar the neurologist into doing a lumbar puncture; the protein was nearly 600.  Even the pulmonologist was doubtful that she needed to be intubated; it took him six hours to decide.

Besides being better listeners to women patients, we have to be tuned into the very presence of a physician.  Some of the women who come into my clinic are self-effacing or even apologetic when they get upset, telling me about their symptoms.  And perhaps it’s not about becoming a “feminist” – it might be about taking the 5-6 minutes to listen to them.  It might helpful, according to a female colleague, if we just let a brief uncomfortable silence sit. 

We all know from studies we may or may not like, that minority patients feel better cared for by someone of their same race.  It might be the same for women.  The truth is, we still have woefully low women representation in neurosurgery.  Thanks to the efforts of some of our colleagues who represent us so well in organizations such as WINS, hopefully that will change.

But until then, there is a paucity of women representation in our specialty.  And we do not have data that female neurosurgeons listen better than their male counterparts.  Therefore, it is incumbent on use that we all listen and not dismiss.  It’s probably harder to acknowledge this than it is to make a special effort to make sure our women patients are truly heard and not misdiagnosed or quickly hurried out of our clinic with labels such as “hysterical,” “emotional,” or “crazy.”

It should be said aloud that the root hypothesis of this piece is not to assume male neurosurgeons are bad listeners.  Nor, does it presuppose that female neurosurgeons are inherently better listeners.  We do know that all of us do not listen well to our female patients.

It has been borne out in the literature as well.  In a study in the Academy of Emergency Medicine (, they found that “After controlling for age, race, triage class, and pain score, women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes).” 

In  a 2009 article in the Journal of Women’s Health (, they found physicians were significantly less certain of the underlying cause of symptoms among female patients regardless of age (p = 0.006). And in middle-aged women they were significantly less certain of the coronary heart disease diagnosis (p < 0.001). Among middle-aged women, 31.3% received a mental health condition as the most certain diagnosis, compared with 15.6% of their male counterparts (p = 0.03). An interaction effect showed that females with high SES were most likely to receive a mental health diagnosis as the most certain (p = 0.006).”

Lastly, A recent study by the AHA ( showed women being evaluated for myocardial infarction waited 29% longer to see a doctor than men. 

One to the women physicians I interviewed for some background told me she diagnosed a young, postpartum woman who was dismissed after complaint of significant chest pain after delivery, of having a coronary dissection.  Luckily, she was treated and recovered.

I have heard from several women: “we are listened to but dismissed.”

One woman whose husband was complaining of chest discomfort, insisted to his doctors something was wrong, but was dismissed. Later she facilitated a cardiac angiogram for him.  That day, he underwent emergency quadruple bypass.  Even when they are the advocate, women may still be ignored.

As physicians of any gender, we need to pay attention, and give our women patients the benefit of the doubt.  Dismissal of symptoms can lead to disaster, and we need to shift our frame of reference.  Assume all patients that are complaining of something, might actually have something, and care accordingly. We all need to do better. 

Letter to the Editor:

Reading Dr. DiGiorgio’s essays on single-payer healthcare in the previous two issues, I am pleased that he agrees that universal coverage is a worthy goal and that the current system is not praiseworthy. And I’m happy that he knows a prominent spine surgeon who favors a single-payer system. Those are great beginnings!

As a retired (Texas) community neurosurgeon with many patients who struggled to obtain or pay for needed care, I realized many years ago that we desperately need a better system. Over the past several years, I’ve become convinced that the only viable option is single-payer healthcare. We don’t need universal Medicare, as it’s currently designed, for many reasons. The solution is improved Medicare for All, as described in bills currently before Congress (H.R.3421 and S.1655).

Dr. DiGiorgio criticizes the proposal for a state-level single-payer system in California; I agree with many of his points. While states can be the laboratories for many ideas, there are many practical reasons why single-payer systems are likely to fail in individual states. As more and more Americans cannot access or pay for needed healthcare, the issue is approaching a national crisis. Only a national solution will suffice.

Space does not allow me to address every issue that concerns Dr. DiGiorgio, but I’ll touch on a few:

  • Like most critics of single-payer healthcare, he worries that we can’t afford it. In fact, we’re already paying more than a comprehensive, universal system would cost. The silver bullet is that around 34% of every healthcare dollar goes to administrative overhead resulting from our hundreds of insurance companies and thousands of plans. Beyond the multi-million dollar incomes of insurance execs, we waste billions on preauthorizations, denials, appeals, and other paper shuffling that do not exist in countries with rational systems. While there’s little chance of our ever-matching Taiwan’s 1.6% overhead, we should be able to halve ours with single-payer, saving enough to cover everyone comprehensively. We can easily afford this.
  • While several countries he mentions have multi-payer systems with private and competitive insurance companies, those companies are not-for-profit and highly regulated. They must provide identical coverage, similar to our for-profit  “Medigap” supplemental policies. The overhead in these systems is several percent higher than in single-payer systems because of this multi-payer administrative duplication, advertising, and other expenses. Adopting such a system seems to have no advantage, only higher costs.
  • Using the Medicare framework as a basis for single-payer reimbursements does not mean that the dollar amounts would be what they currently are, only that this functional framework is the logical existing system to use rather than creating one from scratch. No one has suggested using current Medicare rates, which everyone understands are artificially low as private payers subsidize them. It’s disingenuous to assume that rates would be set so low as to cause needed physicians to close their practices. While it is likely that specialist incomes may decrease slightly, it’s reliably certain that primary care incomes will increase, as that’s the greatest national need. Specialists need not worry about being able to support their families, even with modest income reductions. The general public is not likely to be very sympathetic to complaints from neurosurgeons who earn over $900,000 annually. I imagine we could all scrape by on just a bit less in exchange for providing healthcare to everyone.
  • Regarding wait times and rationing, DiGiorgio’s mention of Canadians coming to the U.S. for healthcare ignores the hundreds of thousands of Americans who travel to other countries for less expensive and often higher-quality care. We cruelly ration healthcare now based on the ability to pay, with endless wait times and hundreds of thousands of families filing for bankruptcy each year, mostly due to medical expenses, most of whom have some insurance. Wait times and rationing are functions of how well a system is funded. As the wealthiest nation on earth, the U.S. has enough capacity to fund our system to avoid such rationing.
  • Finally, Dr. DiGiorgio worries about who will make the rules in a single-payer system. Does he not worry about who makes the inconsistent rules now – faceless, unaccountable clerks in multiple for-profit insurance companies? A great book, Deadly Spin, gives a chilling look inside Cigna and other insurers’ operations. Single-payer rules will be made by panels of physicians, including surgical specialists, not faceless government bureaucrats. His charming notion that decisions would be best made between a physician and a patient toting a bag of money ignores so much. Namely, the powerful incentive for proceduralists to recommend procedures and that very few patients have a bag of money to offer. Policies and guidelines must be set, and panels of accountable medical experts are preferable to heavy-handed, unaccountable, profit-driven insurance company employees.

I recently heard a young physician say, “I went into medicine to help patients, not drive them into bankruptcy.” That’s what we too often do today in our dysfunctional system. I encourage you to learn more about single-payer than you can through short essays and invite you, once informed, to criticize single-payer proposals. The very readable book Medicare for All: A Citizen’s Guide is a great start. Upon being enlightened, I hope you’ll join me and thousands of other physicians in advocating for Medicare for All by joining PNHP (Physicians for a National Health Program).

George Bohmfalk, MD
Chair, Health Care Justice — NC
The Charlotte NC chapter of PNHP
Physicians for a National Health Program

World Health Organization

EG.5 Initial Risk Evaluation, 9 August 2023

EG.5 is a descendent lineage of XBB.1.9.2, which has the same spike amino acid profile as XBB.1.5. EG.5 was first reported on 17 February 2023, and designated as a variant under monitoring (VUM) on 19 July 2023. With this risk evaluation, we are designating EG.5 and its sub-lineages as a variant of interest (VOI).

EG.5 carries an additional F456L amino acid mutation in the spike protein compared to the parent XBB.1.9.2 subvariant and XBB.1.5. Within the EG.5 lineage, the subvariant EG.5.1 has an additional spike mutation Q52H and represents 88% of the available sequences for EG.5 and its descendent lineages.

As of 7 August 2023, 7354 sequences of EG.5 have been submitted to GISAID from 51 countries. The largest portion of EG.5 sequences are from China (30.6%, 2247 sequences). The other countries with at least 100 sequences are the United States of America (18.4%, 1356 sequences), the Republic of Korea (14.1%, 1040 sequences), Japan (11.1%, 814

sequences), Canada (5.3%, 392 sequences), Australia (2.1%, 158 sequences), Singapore (2.1%, 154 sequences), the United Kingdom (2.0%, 150 sequences), France (1.6%,119 sequences), Portugal (1.6%, 115 sequences), and Spain (1.5%, 107 sequences).

Globally, there has been a steady increase in the proportion of EG.5 reported. During epidemiological week 29 (17 to 23 July 2023), the global prevalence of EG.5 was 17.4%. This is a notable rise from the data reported four weeks prior (week 25, 19 to 25 June 2023), when the global prevalence of EG.5 was 7.6%.

Based on the available evidence, the public health risk posed by EG.5 is evaluated as low at the global level, aligning with the risk associated with XBB.1.16 and the other currently circulating VOIs (see risk evaluation table below). While EG.5 has shown increased prevalence, growth advantage, and immune escape properties, there have been no reported changes in disease severity to date. While concurrent increases in the proportion of EG.5 and COVID-19 hospitalizations (lower than previous waves) have been observed in countries such as Japan and the Republic of Korea, no associations have been made between these hospitalizations and EG.5. However, due to its growth advantage and immune escape characteristics, EG.5 may cause a rise in case incidence and become dominant in some countries or even globally.

WHO and its Technical Advisory Group on SARS-CoV-2 Evolution (TAG-VE) continue to recommend that Member States prioritize specific actions to better address uncertainties relating to antibody escape and severity of EG.5. The suggested timelines are estimates and will vary from one country to another based on national capacities:

  • Share information on the growth advantage of EG.5 in your country and/or provide sequence information (1-4 weeks).
  • Conduct neutralization assays using human sera, representative of the affected community(ies), and EG.5 live virus isolates (2-4 weeks, see table below for the results from previously conducted).
  • Perform a comparative evaluation to detect changes in rolling or ad hoc indicators of severity (4-12 weeks, see table below for the results from previously conducted studies).

The WHO and its Technical Advisory Group on COVID-19 Vaccine Composition (TAG-

CO-VAC) continue to regularly assess the impact of variants on the performance of COVID-19 vaccines to inform decisions on updates to vaccine composition.(2)

The risk evaluation below is based on currently available evidence and will be revised regularly as more evidence and data from additional countries become available.

Amongst the VOIs and VUMs featuring the F456L mutation and for the period 19 June to 23 July 2023, EG.5 is most reported at 49.1%, compared to other VOI and VUM including XBB.1.16.6 (4.88%), FL.1.5.1 (4.41%), XBB.1.5.10 (4.06%), XBB.1.5.72 (3.52%), EG.6.1 (3.26%), FD.1.1 (3.07%), EG.5.2 (3.06%), FE.1.1 (2.58%), FL.15 (2.47%), FE.1.2 (2.09%), XBB.1.5.70 (1.91%), GK.1 (1.83%), FE.1.1.1 (1.68%), XBB.1.5.59 (1.31%), XBB.1.5 (1.27%), GN.1 (1.26%), XBB.1.16.9 (1.15%), FL.1.5 (1.08%), and XBB.1.9.1 (1.07%), among others with reported prevalence less than one percent.

Picture of Anthony M DiGiorgio, DO

Anthony M DiGiorgio, DO

Do American Doctors Make Too Much?

Academic Practice Corner

The Washington Post suggests that doctors in the United States are overcompensated, highlighting that their peak earning years (ages 40-55) yield an average annual income of $405,000. The article notes that the top 1% of doctors can earn up to $4 million per year, although much of this comes from non-wage sources like royalties and other business income. This inflates the overall figures, as a small number of high earners skew the data. Neurosurgeons top the earnings list in the report, averaging over $900,000 annually while working 63 hours a week. These figures stand in sharp contrast to the earnings of doctors in Europe, prompting some progressive groups to advocate for reducing physician pay in the U.S.

But do American doctors really make too much?

It’s worth noting that higher wages are not exclusive to the medical field. All American workers earn approximately 30% more than their British counterparts. This trend holds true across European professions; tech salaries in the U.S. are 40-70% higher,

university professors and lawyers earn more, and even manual laborers like plumbers and electricians make 10-30% more than their European peers. Finance, engineering, marketing, and consulting all pay 20-50% more in the US.  The higher earnings indicate a robust American economy, where a truck driver in Oklahoma can out-earn a doctor in Portugal.

However, this doesn’t mean everything is perfect with physician compensation in the U.S. Our income is largely determined through central planning, as Medicare sets base rates that most private insurers also use as a starting point. Due to this structure, reimbursement rates are more influenced by lobbying efforts than by market forces. In fact, Medicare reimbursement for physicians has decreased by 26% since 2000, while hospital reimbursement rates have risen faster than inflation.

Should public opinion shift toward believing that physicians are indeed overpaid, we may see a rapid decline in reimbursement rates. Besides being demoralizing, a 50% pay cut for doctors would only shave about 4% off total healthcare costs. The consequences could be devastating: early retirements, private practices dropping Medicare, increased hospital consolidation, and reduced quality of care.

Moreover, reduced compensation may drive talented individuals away from the medical field altogether. Why invest decades in education and residency when one could enter tech or engineering and start earning significant income much sooner?

The economics of physician compensation resemble those of other commodities like gasoline prices or freight rail rates: price controls lead to shortages, reduced innovation, and lower quality. Therefore, physicians should advocate for a decentralized market with minimal central planning as the best way to protect the industry from arbitrary price controls.

In conclusion, let critics write all the scathing articles they wish. We should focus on advocating for a compensation system that’s equitable, sustainable, and based on free-market principles.

Theodore Kurze

Historical Vignette

Editor’s Note: in this issue, we publish an article from the LA Times written on the occasion of the passing of Theodore Kurze, one of the giants in our field.

Theodore Kurze, 79; Introduced Use of Microscope to Brain Surgery 
BY ROSIE MESTEL/ MAY 25, 2002, 12 AM PT/ LA Times

Dr. Theodore Kurze, a pioneering neurosurgeon who radically altered the practice of neurosurgery with his introduction of the microscope to brain surgery, has died. He was 79.

Kurze died May 10 at his home in Newport Beach. He had been battling prostate cancer.

Kurze’s introduction of the microscope in the 1950s was an innovation that caused death rates and complications from surgery to plummet.

“To do brain surgery before the microscope … you had to be able to accept the fact that people didn’t do well, that you were hurting and maiming people by trying to help them,” said longtime colleague Dr. Peter J. Jannetta, professor of neurosurgery at Allegheny General Hospital in Pittsburgh. Surgeons in those days could ill afford to become too friendly with their patients, said Jannetta.

Then, in 1957, Kurze–who was in private practice in Los Angeles–and his colleague Dr. Robert Rand of UCLA introduced the microscope to better visualize the neural tissues they were working with. Such methods had already helped change ophthalmology as well as ear, nose and throat surgery.

“Ted had the sense to walk the microscope across the hall from the laboratory to the operating room–it was a simple, fabulous, constructive idea,” said Jannetta, who as a UCLA resident in the 1960s would assist Kurze and Rand at operations around Los Angeles so he could learn their techniques.

Kurze first used the operating microscope in his surgical specialty: removal of tumors on the nerves supplying the ear and balance organs. Operations on these growths, called acoustic neuromas, used to kill 20% to 30% of the patients and cause serious side effects such as hearing loss, facial paralysis and difficulty swallowing in the majority of survivors.

Today, mortality for such surgery is less than 1% and rates of serious complications are below 10%, said friend and colleague Dr. Martin Weiss, chairman of the department of neurological surgery at USC’s

Keck School of Medicine, a department once headed by Kurze.

In the years that followed, the use of the microscope became ubiquitous in neurosurgery.

“It made surgery infinitely safer and really revolutionized what we were able to do,” Weiss said.

Kurze was born in Brooklyn, N.Y., on May 18, 1922, and grew up in Floral Heights, Long Island. He graduated from Washington College in Chestertown, Md., in 1943, and received a doctor of medicine degree from Long Island Medical College (now SUNY Downstate Medical School) in 1947.

Kurze held several academic positions, and was associated with USC in various capacities from 1959 to 1987. From 1963 to 1978 he served as chairman of the department of neurological surgery, and concurrently as director of neurological surgery at the Los Angeles County Medical Center.

He was a member of many distinguished neurosurgical societies and from 1968 to 1974 served on the American Board of Neurological Surgery, the body responsible for the certification of neurosurgeons.

Kurze, said Weiss, was a “chatty, gregarious, outspoken bon vivant” with a love of sailing and cooking.

In a 1981 Times interview, Kurze described unwinding from 10- to 12-hour stints of surgery by whipping up favorites like avocado soup and huevos rancheros. He approached cooking much like surgery, carefully setting out his utensils and ingredients in advance, just as he would do with his surgical instruments.

Kurze also had a long-standing interest in medical ethics, taught courses on the subject and received an honorary degree in that field from Washington College.

He consulted for television programs such as the medical drama “Ben Casey.” In fact, recalled Weiss, “He always claimed that the role of Ben Casey was modeled after him–and like Ben Casey, he was a bit of an independent spirit who spoke his mind.” Kurze is survived by his wife, Joan Kurze; four grown children from a previous marriage, Janet Kurze of Rock Creek, Ore., Peter Kurze of San Luis Obispo, Carol Nicholson of Baltimore, and Heather Kurze of South Pasadena; and eight grandchildren.

The family requests that donations in his memory be sent to the Theodore Kurze ’43 Memorial Fund, c/o Washington College, 300 Washington Ave., Chestertown, MD 21620, or c/o Alumni Fund for Theodore Kurze, Alumni Assn., College of Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave., Box 1204, Brooklyn, NY 11203.

Picture of Deborah Henry, MD

Deborah Henry, MD

Is it all Hype?

Brain Waves

The hype got to me. I broke down and did it. I saw the Barbie movie. And if you are wondering if I dressed in pink for the movie, I did not. But even three weeks after its blockbuster release, there were those in Barbie pink (a new Crayola color?).

Barbie is not quite a kid’s movie but a commentary on the platonic male and female relationship. Barbie, who becomes human or at least humanoid, is joined by Ken (Ryan Gosling), her sidekick in the toy world, who comes along for the ride, literally and figuratively.

The opening scene shows Barbie in a classic black and white swimsuit standing on a 2001 Space Odyssey earth, the iconic theme music swelling, as little girls are smashing their baby dolls. They have discovered something different.

Now, a couple of weeks after seeing the movie, this surprising opening scene affected me the most. I was not into smashing dolls or cutting and dying their hair, as in Weird Barbie, but this scene gave me pause to determine the effect Barbie had on my life. The first realization is that I do not remember having a baby doll. Maybe it was because I had four younger siblings, so I had the real thing. Maybe it was because my family did not have extra money for toys except at the prescribed times of birthdays and Christmas. Or maybe I have no reason to remember.

But Barbie was different. Because I wanted her outside the birthday or Christmas window, I had to earn the money to obtain her. She was my first purchase. I was around 6 years old and worked in our backyard in Wellesley, Massachusetts, helping put pebbles in the pathway my mom was building. Eventually, I made the $3 or $4 dollars and purchased a Barbie with snazzy brown hair, a la Jaqueline Kennedy. To me, my Barbie was forward-looking. It turns out she really was. Barbie owned her first Dreamhouse in 1962, and though I would never own a Dreamhouse, I had a vanity set. When Barbie bought her first house, many women could not even hold a bank account. In fact, it was legal for any bank to refuse women an account, credit, or

mortgage until the 1974 Equal Credit Opportunity Act.

My mom would sew my Barbie dresses. My Barbie did not wear pants. She was like me, who did not wear pants until middle school. (Dresses were likely also easier for my mom to make). I treasure these dresses to this day as a reminder of my mom. By middle school, I had my second Barbie, the classic blonde. My mom made her a wedding dress.

Unlike the baby dolls, which promoted motherhood only (not a bad idea), Barbie promoted careers. She is a teacher, a musician, an Olympian, an astronaut, a veterinarian, and a firefighter. Barbie earned her medical degree in 1973 when women made up 5% of the doctors in the U.S. My Barbie taught me to think about the future me. She did not pigeonhole me to the role of only mother as the baby dolls did. Nothing against motherhood. It is by far my most favorite job. But Barbie gave me a grander version of myself to think about.



In 1989, one of the most distressing times in my junior residency happened when I was rounding with my chief resident. A little girl was playing in the hallway with her baby doll, listening to her heart with a stethoscope. I bent down and asked her if she were going to be a doctor. She said, “No”. When I asked her why not, she said, “Girls cannot be doctors.” Were little girls still thinking this in 1989? That child needed Barbie!

Gazi Yaşargil

Innovators in Neurosurgery

Editor’s Note: In this issue, we continue publishing articles about Innovators in our field whose contributions led to their names being used daily. These articles are published with permission from Elsevier, the publisher of World Neurosurgery, in a chapter titled “Eponyms of Cranial Neurosurgical Instruments: An International Collaboration to Optimize the Field of Neurosurgery,” by Lukasz Strulak 1, Ferda Gronki 2, Kaveh Shariat 1, Daniel Schöni 1, Alex Alfieri 1 3

World Neurosurgery

Volume 153, September 2021, Pages 26-35

Gazi Yaşargil is best known for his self-retaining retractor (Yaşargil-Leyla) microforceps, microscissors, dissecting hooks and probes, angled mirrors, and aneurysm clips of various sizes and shapes.5,42,43 He also improved microscopes, operating stools and described a support device for resting the surgeon’s arms.42,44

During the late 1960s, a limited number of microsurgical tools were available due to the lack of interest in advancing a small field like microneurosurgery.42,43 It wasn’t until 1968 when 3 gentlemen—Mr. Cohn, an American businessman from Los Angeles, C. H. Hollender, a surgical instrument dealer from New York, and Fr. Hilzinger of the Aesculap Company—came to Yaşargil with the wish to start producing microsurgical instruments on an industrial scale.42 Based on Yasargil’s knowledge and the gentlemen’s expertise, they created a complete set of instruments for microsurgical procedures (Figure 9).42, 43, 44

Dissatisfied with the balancing and movements of microscopes, Yasargil previously worked together with the Contraves company from 1963 to enhance the mobility of microscopes. It was during this partnership that a neutralization mechanism of recoiling forces applied in canons by means of parallelogram-levers to facilitate intraoperative use of microscopes was developed. Furthermore, they added lighting, video and still photography, which were introduced in the NC-1 model of the binocular Zeiss microscope (Figure 8C).42,44

The most renowned tool named after him, however, remains the aneurysm clip, which was first introduced in 1968 and quickly became popular due to its mechanical properties. Since its development, more than 2 million clips have been implanted worldwide.5, 44, 45 He is cited to be Neurosurgery‘s man of the century as well as the father of modern microneurosurgery.42,43

Gazi Yaşargil was born in Lice, Turkey, and grew up in Ankara after the Turkish revolution.42 Following his graduation from Ankara Atatürk High School, he moved to Germany in 1944 and attended the Friedrich Schiller University of Jena until 1945, when he was forced to leave due to U.S. and Russian troops entering Germany at the end of the Second World War.42,43 He continued his studies in Basel, Switzerland, and graduated from the University of Basel in 1950. Before specializing in neurosurgery, he worked as a resident in psychiatry and general surgery until 1953 when he began his training in neurosurgery at the University Hospital Zurich under the guidance of Hugo Krayenbühl.42 After completing his training in 1957, he continued working in Zurich until 1965 and made great contributions to the clinic as well as to the field of neurosurgery, especially with respect to thalamotomies for parkinsonism, tremor, and hyperkinesia.5,42,43 From 1965 to 1967, he worked and trained under Pete Donaghy, one of the pioneers of microneurosurgery at the time, at his microvascular laboratory in Burlington, Vermont.46

Upon his return to Zurich in 1967, Yaşargil became professor at the microsurgical laboratory at the University of Zurich and began implementing everything he had developed, publishing his famed 6-volume book Microneurosurgery, and creating his microsurgical instruments.5,42,43 During an almost 20-year reign between 1972 and 1993, Yasargil served as chair of the department of neurosurgery at the University of Zurich. He later continued his work in the United States in Little Rock, Arkansas, until 2013. At the age of 88 years, he moved to Istanbul, where he began teaching at Yeditepe University Hospital and where he works to this day.42,43

Picture of Yagmur Muftuoglu, MD, PhD

Yagmur Muftuoglu, MD, PhD

The July Effect

Residents Corner

We can breathe sighs of relief now that another July transition has come and gone. Some of us steel ourselves in preparation for it, a few “go on vacation,” and others state that such a phenomenon does not significantly apply to our field. I dare to propose that whatever the mysterious July Effect may mean to a given gaggle of neurosurgeons, the start of each academic year offers tremendous opportunity for growth, regardless of our rank. Like the rare hurricane that graced our coast this past month, July suddenly blends fresh energy with time-tested expertise. It gives the more junior among us a glimpse of who we could be and all we have yet to learn. And it also shows the more seasoned among us the kind of leader we have become.

Having listened to an audiobook or two about various leadership theories, I can say that I genuinely care about developing into a solid leader, and I have enjoyed the reciprocal learning moments that I have noticed during my own progression out of junior residency. I welcome the challenges that each July – and the more frequent quarterly rotation of residents – will inevitably offer me over the next few decades in academic neurosurgery.

Being a leader when the workload is small and the team is well-oiled proves easy. But I witness that true leaders are sculpted when everything hangs in the balance, a process accelerated when the situation takes a turn for the worse. In this way, July offers a big dose of such continued education with no specific number of credits assigned. July shows us who we are toward those who underrank us, who we are when no one is looking, and what we become when placed under stress. If we are introspective about it, we might realize how we can be better, and I see now that every piece of feedback, verbal or non-verbal, offers a precious moment to improve. 

So, bring it on, July. We are ready for you.


July 31 – A record string of daily highs over 110 degrees Fahrenheit in Phoenix ended. For 31 straight days, Phoenix hit at least 110 degrees Fahrenheit, breaking its 18-day record in 1974, and setting a significant new one. On Monday, a slight cooling – only 108 degrees – due to rain. The forecast called for 110-plus degree days to return later in the week.

August 1 – Cases of syphilis are rising across the country and in San Luis Obispo County, according to the SLO County Public Health Department. Health officials say there were 99 cases of syphilis diagnosed in San Luis Obispo County in 2022. In 2021, there were 65 cases. Bicillin L-A, a long-acting, injectable form of penicillin and the preferred treatment in women and infants, is in low supply because of surging demand.

SAN Luis Obispo County Public Health Department

August 1 – The credit rating of the United States government was downgraded to AA+ from AAA, the highest possible rating by Fitch Ratings, citing “rising debt at the federal, state, and local levels and a steady deterioration in governance standards” over the past two decades. The new rating is still well into investment grade.

August 2 – The Trust for Public Land (TFPL), a nationwide environmental organization founded in 1972 and based in San Francisco, has purchased the “Deer Creek” parcel for $25 million with plans to soon turn the property over to the National Park Service (NPS). This spectacular property includes over two miles of Ventura County coastline and rugged canyons rising from Pacific Coast Highway. As a result, the Santa Monica Mountains National Recreation Area will grow by 1,241 acres thanks to the purchase. The vacant property on both sides of Deer Creek Road was privately owned and eyed for the development of luxury homes in the past. It is home to mountain Lions, several threatened and endangered species, and around two dozen archaeological sites significant for the Indigenous Chumash community.

The Deer Creek parcel includes canyons and ocean views.

August 3 – A ransomware attack on Prospect Medical Holdings, a California-based healthcare system, forced some locations to close, leaving others to rely on paper records. The system operates 16 hospitals, about 165 clinics, and several outpatient centers in Connecticut, Pennsylvania, Rhode Island, and Southern California.

August 4 – The FDA approved Zuranolone, which will be marketed under Zurzuvae. It is the first pill developed for postpartum depression. This is likely to increase recognition and treatment of a debilitating condition that annually affects about a half-million women in the United States. The pill is supposed to work quickly, beginning to ease depression in as little as three days, significantly faster than general antidepressants. And it is taken for just two weeks, not months,  which may encourage more patients to accept treatment.

August 7 – Zoom, the company that was behind the remote work revolution during the pandemic, decided to enforce a “structured hybrid approach.” In a statement, Zoom indicated that employees who live near an office “need to be onsite two days a week” because it’s “most effective” for the video-conferencing service. I smell a bit of irony.

August 8 – President Biden designated a new national monument near the Grand Canyon. The move protects some sacred lands of indigenous peoples and permanently bans new uranium mining claims in the area. It covers nearly 1 million acres. It will be called Baaj Nwaavjo I’tah Kukveni Ancestral Footprints of the Grand Canyon National Monument.” It sits north and south of the Grand Canyon in Arizona. “Our nation’s history is etched in our people and in our lands,” Biden said. “Today’s action is going to protect and preserve

that history, along with these high plateaus and deep canyons.”

August 9 – Covid-19 variant EG.5 became the dominant variant in the United States, according to the World Health Organization, which classified EG.5 as a “variant of interest.” However, W.H.O. also indicated that based on the available evidence, “the public health risk posed by EG.5 is evaluated as low at the global level.”

August 10 – 115 people were killed due to the catastrophic wildfires raging across the Hawaiian island of Maui. Lahaina, the island’s tourist and economic hub and the capital of the former kingdom under King Kamehameha, has been destroyed, and hundreds of families have been displaced. It is feared that the number of dead could climb further as people remain unaccounted for. Locals and visitors are having difficulties to leave as power and communication services are down in parts of the island. Most of the fires on Maui are now contained. They were partially fueled by violent winds from Hurricane Dora, centered around 800 miles away and to the south. This fire has already taken more lives than a 1960 tsunami that killed 61 on the Big Island of Hawaii. This has been the deadliest US wildfire in more than 100 years.

The hall of the historic Waiola Church in Lahaina and the nearby Lahaina Hongwanji Mission, built in the 1800s, was engulfed in flames. Matthew Thayer/The Maui News via AP.

The 150-year-old famous and beloved Lahaina Banyan tree was damaged tree by the wildfires at Lahaina Banyan Court in Lahaina, Maui. Credit…Philip Cheung for The New York Times

Along the Lahaina shoreline on Maui. Philip Cheung for The New York Times

August 10 – The Centers for Disease Control and Prevention indicated that about 49,500 people committed suicide last year in the U.S., the highest number since the dawn of World War II.

The largest increases were seen in older adults. Deaths rose nearly 7% in people ages 45 to 64 and more than 8% in people 65 and older. White men, in particular, have very high rates, according to the CDC. Experts caution that suicide is a complicated issue.  Various factors, including higher rates of depression and limited availability of mental health services, might have

caused recent increases. But a main culprit is the growing availability of guns, according to Jill Harkavy-Friedman, senior vice president of research at the American Foundation for Suicide Prevention. Please pay attention to your loved ones.

August 17 – The average 30-year fixed-rate mortgage climbed to 7.09 percent, the highest in 21 years.

August 18 – The wildfire near Yellowknife, the capital of the Northwest Territories, caused mass migration as blazes threatened Kelowna, a much larger city in British Columbia. British Columbia was under a state of emergency. Officials called this year’s wildfire season the worst for the province.

A satellite image showing wildfires burning near Yellowknife, the capital of the Northwest Territories.
Credit…Maxar Technologies

August 20 – Spain swept past England, the European champion, the favorite, by a single goal, 1-0, to win the Women’s World Cup Final.

Cameron Spencer/Getty Images

August 20 – Hurricane Hilary reached Southern California. It was a category 4 hurricane over the Pacific Ocean, made land fall over Baja California as Category 1 and was degraded tropical storm as it reached Southern California. It brought significant precipitation and flooding with downed powerlines and power outages . Palm Springs was particularly affected. It continues its course in a north easterly direction threatening Nevada and Idaho. Governor Newsom declared a state of emergency in several Southern California Counties. Southern California has not had to deal with a tropical storm in 84 years. The storm broke several rainfall records: Hilary dumped a year’s worth of rain on Palm Springs, California, and became the rainiest tropical system in Idaho, Oregon and Montana history. 

National Oceanic and Atmospheric Administration

Areal view of Dodgers Stadium at the Chavez Ravine

August 20 – An unusual 5.1 earthquake centered in Ojai hit shortly after noon, rattling nerves. People were preparing for the tropical storm and were surprised by the unrelated quake. No significant damage was reported.

August 21 – The FDA approved the first vaccine that protects newborns from respiratory syncytial virus, known as RSV. The vaccine, made by Pfizer, is given to mothers late in their pregnancies and provides protection to infants  through their first six months of life.

August 21 – Lucy Letby, a nurse, and the most prolific serial killer of babies in modern British history, was sentenced to life without parole. She had been convicted of killing seven newborns and trying to kill six others. The murders and attempted murders occurred between June 2015 and June 2016, when she was a nurse in the neonatal unit of the Countess of Chester Hospital in northwestern England. 

August 22 – Lonnie G. Bunch III, secretary of the Smithsonian Institution, apologized for the institution, having amassed a collection of tens of thousands of body parts, taken largely from Black and Indigenous people, mostly without their consent. The Smithsonian’s National Museum of

Natural History has at least 30,700 human body parts, including 255 brains. Most of the remains were collected in the early 1900s by anthropologist Ales Hrdlicka, who sought to prove his theories that White people were superior to people of color.

August 23 – Chandrayaan-3 spacecraft landed safely on the moon’s south pole. This makes India the fourth country to land a spacecraft on the moon; the landing came a few days after Russia failed to do so when its Luna-25 spacecraft crashed upon landing. The Lunar South Pole region is considered an area of key scientific interest for scientists who believe the region to have water ice deposits.

August 24 – Authorities in Hawaii released the names of 388 people still unaccounted for since the Lahaina wildfires, the deadliest in America in over a century. Meanwhile, Maui County filed a lawsuit against Hawaiian Electric, alleging that the utility company acted negligently by failing to disconnect power lines at risk of toppling in high winds.

August 24 – According to a study published in the journal Communications Earth & Environment, four out of five emperor penguin colonies in Antarctica’s Bellingshausen Sea region lost their chicks late last year because of disappearing sea ice underneath their breeding grounds. 

Emperor penguins brooding on Snow Hill Island in Antarctica. Credit…Danita Delimont/Alamy

August 25 – At 12:27 PM, DFW International Airport, the official weather-keeping station in North Texas, recorded the 44th consecutive day of temperatures of 100 degrees or higher.

August 26 – In 1920, Tennessee ratified the Nineteenth Amendment to the Constitution, making it the 36th state to do so, and the last one necessary to make the amendment the law of the land. The U.S. Secretary of State certified the ratification as soon as he received the notification, making this date the anniversary of the day the Nineteenth Amendment was ratified. Finally, women could vote!

August 27 – Simone Biles won a record eighth U.S. all-around championship. At the U.S. Gymnastics Championships, she won with a margin of 3.9 points over the silver medalist, Shilese Jones. Since 2013, Biles has earned 32 world championships and Olympic medals. Biles’s victory also meant she broke a 90-year record by becoming the first American gymnast, woman or man, to win eight national all-around titles. And, at 26, she’s the oldest woman ever to do so.

Ezra Shaw/Getty Images

August 27 – Nordstrom closed the doors of its five-story department store in San Francisco on Sunday, ending a 35-year run as the city suffers a retail exodus.

August 28 – The 60th anniversary of Martin Luther King Jr.’s speech “ I Have a Dream.”

  1. August 28 – National Bow Ties Day!

    On Tuesday, August 29 – The Biden administration announced the first 10 medications that will be subject to price negotiations with Medicare. Millions of older Americans take the medications on the list, costing Medicare and patients billions of dollars annually. 

    Drugs Selected for Price Negotiations:

    1. Eliquis, for preventing strokes and blood clots, from Bristol Myers Squibb and Pfizer
    2. Jardiance, for diabetes and heart failure, from Boehringer Ingelheim and Eli Lilly
    3. Xarelto,for preventing strokes and blood clots, from Johnson & Johnson
    4. Januvia, for diabetes, from Merck
    5. Farxiga, for chronic kidney disease, from AstraZeneca
    6. Entresto, for heart failure, from Novartis
    7. Enbrel, for arthritis and other autoimmune conditions, from Amgen
    8. Imbruvica, for blood cancers, from AbbVie and Johnson & Johnson
    9. Stelara, for Crohn’s disease, from Johnson & Johnson
    10. Fiasp andNovoLog insulin products for diabetes, from Novo Nordisk
    It is about time!

CANS Board position on the CSNS 2023 Fall Resolutions

The Board of Directors and Consultants to the Board discussed the CSNS Fall 2023 resolutions at length during the Board meeting on August 26, 2023. Some of the resolutions generated very spirited discussion.

Below are the resolutions, and following each, in red, are the CANS positions and the name of the CANS delegate to CSNS who will discuss the CANS position at the upcoming CSNS meeting in Washington, DC.

Resolution I-2023F
Title: Inclusion of Radiation Safety Training for New Neurosurgery Interns

Authors: Arvin Wali, Michael Brandel, David Santiago, Luis Tumialan, Alexander Khalessi

WHEREAS, there is an increasing use of radiation (fluoroscopy, interventional procedures, intraoperative CT imaging) in all neurosurgical procedures (vascular, spine, oncology, interventional pain); and

WHEREAS, radiation dose has a linear non-threshold impact in which radiation can have deleterious effects on the health of patients, surgeons, and staff; and

WHEREAS, the Society of Neurological Surgeons strives to create a culture of safety for surgeons, nursing staff, patients, and additional health care staff; and

WHEREAS, radiation reduction protocols are feasible and can decrease radiation dose during surgery; and

WHEREAS the first year of neurosurgery residency is an ideal time for implementing radiation safety training to ensure proper habits are established early on; therefore

BE IT RESOLVED, that the CSNS revisit and establish standardized guidelines to teach principles of radiation safety in the Society of Neurosurgery bootcamp. This would involve a lecture on the deleterious effects of radiation and simple, practical strategies to reduce radiation dose to the patient and the health care team and encourage safe practices.

Fiscal note: (zero)
Assigned Committee(s): Communication and Education Workforce
Patient Safety
Young Neurosurgeons Rep Section

1. Baeza M. Accident prevention in day-to-day clinical radiation therapy practice. Ann ICRP. 2012;41:179-187
2. Clark JC, Jasmer G, Marciano FF, Tumialan LM. Minimally invasive transforaminal lumbar interbody fusions and fluoroscopy: a low-dose protocol to minimize ionizing radiation. Neurosurg Focus. 2013;35(2):E8
3. Smith-Bindman, R., Miglioretti, D. L., Johnson, E., Lee, C., Feigelson, H. S., Flynn, M., … & Habel, L. A. (2012). Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. Jama, 307(22), 2400-2409. doi: 10.1001/jama.2012.5960 4. Lekovic GP, Kim LJ, Gonzalez LF, Bice A, Albuquerque FC, McDougall CG. Radiation exposure during endovascular procedures. Neurosurgery. 2008 Jul;63(1 Suppl 1):ONS81-5; discussion ONS85-6. doi: 10.1227/01.neu.0000335016.60746.60. PMID: 18728608. 5. Narain AS, Hijji FY, Yom KH, Kudaravalli KT, Haws BE, Singh K. Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery. World J Orthop. 2017 Jul 18;8(7):524-530. doi: 10.5312/wjo.v8.i7.524. PMID: 28808622; PMCID: PMC5534400.

CANS POSITION                   SUPPORT
Spokesperson                      Mark Linskey

Resolution II-2023F
Title: National MSSIC Initiative Promoted by Organized Neurosurgery

Authors: Mick Perez-Cruet, Jason Schwalb, Jad Khalil, Victor Chang, Muwaffak Abdulhak, Teck Soo, David Fernandez, Richard Easton, Ilyas Aleem, Mark Zaki, Jora Dhaliwal, David Nerenz

WHEREAS, spine surgery, the care and evaluation of patients suffering from spinal disorders represents the primary treatment of most neurosurgeons and many orthopedic surgeons; and

WHEREAS, reimbursements for spine care have been dropping and future forecast predict further reductions by the Center for Medicare and Medicaid Services (CMS); and

WHEREAS, Michigan based Michigan Spine Surgery Improvement Collaborative (MSSIC) program working in conjunction with Blue Cross and Blue Shield Michigan (BCBSM) has shown significant cost savings for spine care by reducing post- operative lumbar surgical site infection (SSI), urinary retention (UR), and readmission rates; and

WHEREAS, each lumbar SSI and UR event are estimated to cost $15,000 and $10,000, respectively; and

WHEREAS, the MSSIC program engaging multiple academic and private practices across the State of Michigan have achieved significant reductions in SSI, UR, and readmissions after spine surgery, resulting in an estimated cost savings in the tens of millions of dollars; and

WHEREAS, these cost reductions have provided physician opportunity for incentive payment for quality improvement of as much as 5% offered by BCBSM; and

WHEREAS, CMS might be encouraged to support a multiple state-level initiatives with overall coordination and support so states can learn from each other and thus provide a trusted datasharing environment as illustrated with the current MSSIC program; and

WHEREAS, national implementation of this program could result in significant National cost savings for spine care; therefore

BE IT RESOLVED, that our National organizations (the AANS and CNS) work with the Washington committee to seek federal and CMS support for a National program mirroring that of MSSIC to reduce spine care cost and improve patient outcomes; and

BE IT FURTHER RESOLVED, that this program promote physician incentive payment for quality improvement.

Financial cost: 0
Assigned Committee(s): Workforce
Coding & Reimbursement
Medical Practices
Ambulation on Postoperative Day #0 Is Associated With Decreased Morbidity and Adverse Events After Elective Lumbar

Spine Surgery: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

Zakaria HM, Bazydlo M, Schultz L, Abdulhak M, Nerenz DR, Chang V, Schwalb JM.Neurosurgery. 2020 Aug 1;87(2):320-328. doi: 10.1093/neuros/nyz501.PMID: 31832659

The Preoperative Risks and Two-Year Sequelae of Postoperative Urinary Retention: Analysis of the Michigan Spine Surgery
Improvement Collaborative (MSSIC).

Zakaria HM, Lipphardt M, Bazydlo M, Xiao S, Schultz L, Chedid M, Abdulhak M, Schwalb JM, Nerenz D, Easton R, Chang V; MSSIC Investigators.World Neurosurg. 2020 Jan;133:e619 e626. doi: 10.1016/j.wneu.2019.09.107. Epub 2019 Sep 27.PMID: 31568914

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery
Improvement Collaborative.
Zakaria HM, Bazydlo M, Schultz L, Pahuta MA, Schwalb JM, Park P, Aleem I, Nerenz DR, Chang V; MSSIC Investigators.J
Neurosurg Spine. 2019 Feb 15:1-13. doi: 10.3171/2018.10.SPINE18666. Online ahead of print.PMID: 30771759

CANS position      OPPOSE
Spokesperson       Brian Gantwerker

Resolution III-2023F
Title: A Call to Study the Neurosurgical Residency Application Arms Race

Authors: Gary Simonds MD MS, Cara Rogers DO

WHEREAS, burnout and psychological distress is rife in neurosurgical residents and faculty; and

WHEREAS, seeds for neurosurgeon burnout and psychological distress are potentially sewn in the intense competition for training positions in medical school and residencies; and

WHEREAS, competition for all residency positions in America is intensifying, creating an “arms race” in extracurricular efforts such as research production, “leadership activities,” and “community service;”; and

WHEREAS, the knowledge base expected to be assimilated in medical school is vast and everexpanding leaving students little time for in-depth extracurricular activities; and

WHEREAS, medical student focus on the generation of investigational citations and participation in “extracurricular activities” may compromise development of valuable medical acumen and

depth: and

WHEREAS, evidence has not been established that intense participation in any realm of extracurricular activity in medical school is a predictor of better performance in a neurosurgery residency or career; and

WHEREAS, medical students interested in neurosurgery are feeling pressure to engage in “gap years” during their medical school educations (to bolster their neurosurgical bona fides), adding further time to their already lengthy journeys to viable incomes and professional standing; and

WHEREAS, escalating forces and pressures on neurosurgical residency applicants may contribute to greater financial hardship and stress; and

WHEREAS, escalating forces and pressures on neurosurgical residency applicants may contribute to greater overall anxiety and psychological stress, which may echo throughout a their careers; and

WHEREAS, escalating forces and pressures on neurosurgical residency applicants may contribute to increased maladaptive behaviors and potentially skew applicant pools to less desirable individuals; therefore

BE IT RESOLVED, that the CSNS studies and creates a white paper on the nature and effects of extracurricular achievement pressures on applicants to neurosurgical residencies.

Assigned Committee(s): Communication and Education Workforce
Medical Practices
Young Neurosurgeons Rep Section

CANS position                     NEUTRAL
Spokesperson                      Nicole Moayeri                  

Resolution IV-2023F
Title: A Call for a New Position Statement From Organized Neurosurgery on Gun Violence

Authors: Gary Simonds MD MS, Cara Rogers DO

WHEREAS, gun violence in the United States threatens the fabric of our society; and

WHEREAS, neurosurgeons are acutely aware of the lethality of firearms and of the appalling nervous system injury inflicted by gunshot wounds to the head and spine; and

WHEREAS, neurosurgeons are the societal “stewards” of the nervous system and should proactively seek to protect said system rather than solely respond to its illness or injury; and

WHEREAS, the pro and anti-firearm debate is so polarized that rational compromise is unlikely to occur without pressure exerted by the most respected people and institutions of the society; and

WHEREAS, Neurosurgery is a respected representative of the field of medicine, and its “weighingin” on the subject of mitigation of gun-violence might carry some positive impact; and

WHEREAS, the AMA, the ACS, the ATS, and other medical organizations have taken stands supporting significant reforms in gun laws; and

WHEREAS, the 10 year old CNS/AANS position statement on gun violence offers minimal suggested legislative solutions to the problem; and

WHEREAS, the current AANS/CNS Washington Committee Firearms Task Force Survey holds little hope of rapidly advancing a definitive position statement from organized neurosurgery; and

WHEREAS, gun violence has become the leading cause of death amongst our children; and

WHEREAS, since a similar resolution was defeated in this body in 2018, almost 200,000 Americans have lost their lives to gun violence, making gun violence a definitive public health threat; therefore

BE IT RESOLVED, that the CSNS urges the CNS and AANS to prepare a joint position statement, with policy recommendations, on the toll of gun violence and in support of gun control laws at least in keeping with and/or exceeding those of the ACS, the AMA, and the ATS.

Assigned Committee(s): All Standing Committees and Representational Sections
The Most Agony-Filled Scream I’ve Ever Heard Came in the Wake of a Shooting
— We cannot stand idly by as the death toll grows by Jesse M. Ehrenfeld, MD, MPH April 8, 2023*/relevant/1/PolicyTopic:%22Firearms%22

AMA statement on Texas school shooting

Recommendations from the American College of Surgeons Committee on Trauma’s Firearm

Strategy Team (FAST) Workgroup: Chicago Consensus I can_College_of.7.aspx Statement-on-Firearm-Safety513.ashx

CANS position                     NEUTRAL
Spokesperson                      Joe Chen                                                         

Resolution V-2023F
Title: A Call to Relocate Certain Neurosurgical Meetings and Courses

Authors: Gary Simonds MD MS, Cara Rogers DO

WHEREAS, the country has become increasingly polarized over certain societal issues, some of which having significant impact on public health effort (mental and physical); and

WHEREAS, neurosurgeons are “stewards” of the nervous system and should proactively seek to protect said system rather than solely respond to its injury and illness; and

WHEREAS, Neurosurgery is a deeply respected representative of the field of medicine, and its “weighing-in” on issues affecting public health might carry positive impact; and

WHEREAS, a major healthcare organization’s “voting with its feet” is a potentially effective method of drawing public and elected official attention to concerns over public health policies and legislation; and

WHEREAS, the withdraw of one national medical organization from the utilization of specific venues may precipitate a wave of similar behavior form other medical and non-medical organizations; therefore

BE IT RESOLVED, that the CSNS calls on its parent bodies to consider refraining from holding any meeting or course in states that are legislating policies antithetical to accepted public health conduct and principles.

Assigned Committee(s): All Standing Committees and Representational Sections

CANS position                     OPPOSE
Spokesperson                      Mark Linskey


Resolution VI-2023F
Title: Unions in Neurosurgery

Authors: Jose “Tito” Porras, MD, Scott Simon, MD, and Omar Zalatimo, MD

WHEREAS, more and more US physicians are being employed by large organizations; and

WHEREAS, more and more US physicians are joining unions; and

WHEREAS, the house staff of many hospitals are forming unions; and

WHEREAS, some CSNS members are part of a union; therefore

BE IT RESOLVED, that the CSNS surveys neurosurgeons to determine their understanding and interest in unionization at both the residency and attending level; and

BE IT FURTHER RESOLVED, that the CSNS contact established union leadership to understand the details of their arrangement with and impact on neurosurgeons; and

BE IT FURTHER RESOLVED, that a white paper be written describing the reality of how unionization affects and could affect neurosurgery practice in the future.

Assigned Committee(s): Communication and Education
Coding & Reimbursement
Medical Practices

CANS                     SUPPORT with clarifications
Spokesperson       Mark Linskey                                      

Resolution VII-2023F
Title: Naming of CSNS Resident Fellowship in Memory of Dr. David Jimenez

Authors: Mateo Ziu, MD, MBA; Jennifer Gentry-Savage, MD; George Galvan, MD

WHEREAS, CSNS resident fellowship since its establishment has been an excellent medium for education of many Neurosurgical residents in socio-economic matters and the fellowship has helped many of these residents become leaders in organized neurosurgery and in their own work places; and

WHEREAS, Dr. David Jimenez who suddenly passed away in May 2023 has played a pivotal role in establishment of CSNS Resident Fellowship Program; and

WHEREAS, Dr. David Jimenez who dedicated his life to teaching neurosurgical residents the craft of neurosurgery and who has been a mentor to many CSNS members was a champion through his work as a CSNS delegate and Chairman of CSNS in 2001-2003 to establish CSNS Resident Fellowship to advance socio-economic teaching of neurosurgical residents; therefore

BE IT RESOLVED, the CSNS Resident Fellowship be called, “David Jimenez CSNS Resident Leadership Fellowship” in his memory.

Assigned Committee(s): All Standing Committees and Representational Sections

CANS position                     APPROVE with modification.
Spokesperson                      Nicole Moayeri

Resolution VIII-2023F
Title: Improving Communication on CSNS Resolutions

Authors: Jason D. Stacy Sr, M.D., Cathy Mazzola, M.D.

WHEREAS, resolutions for the CSNS can be submitted by a member(s) or fellow(s) who may or may not be known to all members of the body or a State Society, Caucus, Committee, Representative Section, or Quadrant without a specified individuals; and

WHEREAS, each resolution may be submitted by a large number of authors; and

WHEREAS, communication with the author(s) can be difficult by members of the body without a personal connection, especially to assigned committees when

either the committee itself or its members weren’t authors; therefore

BE IT RESOLVED, that the CSNS changes the format of resolutions to include a separate section titled “Corresponding Author(s)” that must include at least one but not more than two of the authors so as to facilitate ease of communication; and

BE IT FURTHER RESOLVED, that the email address/addresses for the Corresponding Author(s) are listed immediately after their name(s) so that correspondence regarding any resolution can be easily and appropriately routed by all members/committees to facilitate future work on the resolutions.

Assigned Committee(s): All Standing Committees and Representational Sections

CANS position                     APPROVE
Spokesperson                      Joe Chen

Resolution IX-2023F
Title: AANS and CNS should support the NERVES Society to increase and maintain membership productive to Neurosurgical success

Authors: Andrew Wakefield, NERVES

WHEREAS, NERVES was established by the CSNS at the spring meeting in 2003; and

WHEREAS, NERVES has provided socioeconomic data as it relates to financial operation since 2005 based on 2004 data; and

WHEREAS, the NERVES survey data is directly related to the participation in completing the annual survey; and

WHEREAS, the participation in the survey has been decreasing in large part due to the decline in private practices; and

WHEREAS, there is a need to recruit and support the participation to also include large healthcare systems and academic practices; therefore

BE IT RESOLVED, the CSNS ask the boards of the AANS and CNS to participate in broadcasting the value of the NERVES Society; and

BE IT FURTHER RESOLVED, the CSNS assist the AANS and CNS membership to gain a better understanding in the value and encourage neurosurgical practices of all varieties to join and participate in NERVES; and

BE IT FURTHER RESOLVED, the fiscal value gained by the annual NERVES survey with increased

participation will generate data which will positively influence the course of Neurosurgery in the socioeconomic sphere nationally.
Fiscal note: 0
Assigned Committee(s): Communication and Education
Coding & Reimbursement
Medical Practices

CANS position                     SUPPORT
Spokesperson                      Mark Linskey

Resolution X-2023F
Title: Best practices for ergonomic and continuity of neurosurgery practice for the peri- partum neurosurgeon

Authors: Helen Shi, MD, Meena Vessell, MD, Akshay Sharma, MD, George Yang, MD, MPH, Satish Krishnamurthy, MD, Karin Swartz, MD, Owoicho Adogwa, MD, MPH

This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS more women are entering the neurosurgical workforce than before, making up 13.8% of young neurosurgeons versus 3.8% of senior neurosurgeons [1]; and

WHEREAS, the workplace environment for pregnant neurosurgeons lacks standardized ergonomic policies to facilitate delivery of care and efficiency of training; and

WHEREAS, 39% of female neurosurgeons experienced difficulty conceiving versus 25% of their male counterparts, and pregnant female surgeons experience much higher rates of complications compared to the general population, including nearly twice the rate of pregnancy loss [2, 3, 4]; and

WHEREAS, there are currently no official guidelines detailing ergonomics and continuinty of practice for pregnant neurosurgeons; therefore

BE IT RESOLVED, the CSNS distribute a survey to assess what challenges are encountered by peripartum neurosurgeons and institutionally-based steps that have been taken to ensure ergonomic and continued practice; and

BE IT FURTHER RESOLVED, the results of prior survey be presented to CSNS to inform the creation of a best practices resource; and

BE IT THEREFORE RESOLVED, the CSNS ask its parent bodies (AANS/CNS) to collaborate with the SNS and the ACGME to publish best practices regarding ergonomics and continuity of neurosurgical practice and for peri-partum neurosurgeons in training and clinical practice.

Fiscal Note: $100
Assigned Committee(s): Workforce Medical Practices
Patient Safety
Medical Directors Rep Section
1. De La Peña NM, Richter KR, Haglin JM, Pollock JR, Richter RA, Kouloumberis PE. Differences by Practice Year in Numbers of U.S. Female Neurosurgeons. World Neurosurg. 2021;145:363- 367.
2. Thum JA, Chang D, Tata N, Liau LM. Neurosurgeons in 2020: the impact of gender on neurosurgical training, family planning, and workplace culture. Neurosurg Focus. 2021;50(3):E11.
3. Tomei KL, Hodges TR, Ragsdale E, Katz T, Greenfield M, Sweet JA. Best practices for the pregnant neurosurgical resident: balancing safety and education [published online ahead of print, 2022 Nov 8]. J Neurosurg. 2022;1-8
4. Gupta M, Reichl A, Diaz-Aguilar LD, et al. Pregnancy and parental leave among neurosurgeons and neurosurgical trainees. J Neurosurg. 2020;134(3):1325-1333. Published 2020 May 29

CANS position                     SUPPORT
Spokesperson                      Joe Chen

Resolution XI-2023F
Title: Adding an option on the CSNS website to post ideas and encourage collaboration

Authors: Jeremy Amps, Scott Simon, Nitin Agarwal, Omar Zalatimo

WHEREAS, the submission of resolutions is a core function of the CSNS; and

WHEREAS, collaboration between members on the resolutions will help improve resolutions by talking through the details and potential points of concern; and

WHEREAS, the CSNS website is available to all members and could likely be modified to include a section in which members could post ideas for resolutions; therefore

BE IT RESOLVED, the CSNS will discuss with the website directors to discuss feasible options to allow members to post ideas-in-process with contact information for those who wish to contribute. At this point, we would suggest not allowing active debate on the website itself.

Assigned Committee(s): Communication and Education
Young Neurosurgeons Rep Section

CANS position                     NEUTRAL
Spokesperson                      Nicole Moayeri

Resolution XII-2023F
Title: Collective Bargaining Efforts of Resident Physicians and Effects on Neurosurgical Residency Training

Authors: Prateek Agarwal, MD, MBA, William Shuman, MD, Mark Zaki, MD, MBA

WHEREAS, there has been increased organized effort across medical residency training programs to achieve shared aims through collective bargaining, particularly in the wake of COVID-19 pandemic1,2; and

WHEREAS, the intensive training of neurosurgical residency involves substantial demands with associated risks of work-related burnout3; and

WHEREAS, the attrition rates of neurosurgical residents are historically significantly higher than those of residents in other specialties4,5; and

WHEREAS, recent high rates of inflation and cost of living increases pose a challenge for resident physicians, who often carry significant education-related debt with limited income potential during lengthy training6; and

WHEREAS, healthcare employees such as nurses and advanced practice providers whom residents work alongside have historically benefited from collective bargaining, though residents have generally not had the opportunity to join such organized efforts7,8; therefore

BE IT RESOLVED, the CSNS survey neurosurgical residents and faculty on their perspectives on the potential effects of collective bargaining efforts on resident education quality, wellbeing, and productivity to identify the benefits and drawbacks of such efforts; and

BE IT FURTHER RESOLVED, the CSNS investigate neurosurgical training programs at academic institutions where resident unions have already been established to assess their overall impact; and

BE IT FURTHER RESOLVED, that the CNS and AANS publish position statements on their commitment to quality resident physician training and the value of collective bargaining efforts based on the findings of the aforementioned survey and investigation.

Assigned Committee(s): Medical Practices
Coding & Reimbursement Workforce
Young Neurosurgeons Rep Section
Medical Directors Rep Section


  1. Weiner S, By, Weiner S, Writer SS, 7 J. Thousands of medical residents are unionizing. here’s what that means for doctors, hospitals, and the patients they serve. AAMC. June 7, 2022. Accessed July 27, 2023.
  2. Murphy B. Why more resident physicians are looking to unionize. American Medical Association.
    June 28, 2022. Accessed July 27, 2023.
  3. Couldwell WT, Harbaugh RE, Rutka JT. Editorial. pitfalls in the practice of neurosurgery: Identifying those at Greatest Risk. jns. January 27, 2023. Accessed July 27, 2023.
  4. JT; CWR. Editorial. pitfalls in the practice of neurosurgery: Identifying those at Greatest Risk. Journal of neurosurgery. Accessed July 27, 2023.
  5. Agarwal N, White MD, Pannullo SC, Chambless LB. Analysis of national trends in neurosurgical resident attrition. JNS. November 23, 2018. Accessed July 27, 2023.
  6. Brewster RCL, Butler A, Michelson CD, Kesselheim J. Evaluation of Housing Affordability Among US Resident Physicians. JAMA Network Open. June 27, 2023. Accessed July 27, 2023.
  7. Philbrick IP, Abelson R. Health Care Unions find a voice in the pandemic. The New York Times.
    January 28, 2021. Accessed July 27, 2023.
  8. Taylor M. Geisinger nurse practitioners, physician assistants vote to unionize. Becker’s Hospital Review. December 27, 2022. Accessed July 27, 2023.

CANS position                     SUPPORT
Spokesperson                      Joe Chen

Resolution XIII-2023F
Title: Understanding and Re-Evaluating the Urgency to Board Certification

Authors: Meena Vessell, Arvind Mohan, Akshay Sharma, Catherine Mazzola, Chesney Oravec, Owoicho Adogwa

This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS, ABNS requires to pursue board certification by 3 years after graduation[1]; and

WHEREAS, Life or work-related circumstances may make pursuance of board certification by 3 years difficult and difficult to justify to the board but may be known well in advance. Such circumstances may include but are not limited to competitive practice environment with low case volumes, low-volume subspecialties, time split between academics and research, or personal or family leave [2]; and

WHEREAS, Board Certification is a variable metric as practice patterns, particularly in certain subspecialties are changing with economic environment[3]; and

WHEREAS, neurosurgeons entering and leaving the workforce face unique challenges with regards to board certification and upkeep of abilities[3]; therefore

BE IT RESOLVED the CSNS, alongside parental bodies, partner with the ABNS to study number of neurosurgeons and the circumstances under which applying for deferred board certification beyond 3 years has occurred.

Fiscal note: None
Assigned Committee(s): Workforce Medical Practices
Young Neurosurgeons Rep Section
1. ABNS Board Certification Timeline. Accessed July 27, 2023.
2. Rose SH, Burkle CM, Elliott BA, Koenig LF. The impact of parental leave on extending training and entering the board certification examination process: a specialty-based comparison. Mayo Clin Proc. 2006;81(11):1449-1453. doi:10.4065/81.11.1449
3. Nadel JL, Scott RM, Durham SR, Maher CO. Recent trends in North American pediatric neurosurgical fellowship training [published online ahead of print, 2019 Jan 4]. J Neurosurg Pediatr. 2019;1-6. doi:10.3171/2018.10.PEDS18106
4. Maehara T, Kamiya K, Fujimaki T, et al. A Questionnaire to Assess the Challenges Faced by Women Who Quit Working as Full-Time Neurosurgeons. World Neurosurg. 2020;133:331-342.doi:10.1016/j.wneu.2019.08.045

CANS position                     SUPPORT
Spokesperson                      Anthony DiGiorgio                                           

Resolution XIV-2023F
Title: Assessment of Regulatory Obstacles for Neurosurgical Training Programs in the United States

Submitted by: Akshay Sharma, MD, Meena Vessell, MD, Helen Shi, MD, George Yang, MD, Brandon Lucke-Wold Satish Krishnamurthy, MD, Catherine Mazzola, MD, John Ratliff, MD, Deborah Benzil, MD, Karin Swartz, MD, Owoicho Adogwa, MD, MPH
This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS, the neurosurgical workforce size is determined by the number of trainees graduating and the number of neurosurgeons retiring at any given time and current workforce projections reveal 64% of the neurosurgical workforce intends to retire within the next 5-10 years [1]; and

WHEREAS, there will be a severe neurosurgical workforce shortage by 2030 and the current number of neurosurgical trainees is not sufficient to fill this need. [2]; and

WHEREAS, the Accreditation Council for Graduate Medical Education (ACGME) is the primary regulatory body that assesses the quality of neurosurgical training programs and has the ability to censure or close training programs for severe violations. This also includes limiting the expansion of training programs to accommodate increasing neurosurgical volume and increasing demand for training spots [3]; and

WHEREAS, the ACGME collects yearly data on residency programs and issues citations or notes need for improvement based on assessment of designated milestones, information which is released to individual programs each year, and limited analysis of trends over time has been completed; therefore

BE IT RESOLVED, the CSNS ask its parent bodies (AANS/CNS) to collaborate with SNS and request the ACGME provide CSNS detailed but de-identified results of ACGME evaluations for all neurosurgical residency programs that it accredits in the United States, including all citations, designated areas for improvement, available residency positions, and program closures for the last 20 years.

BE IT FURTHER RESOLVED, the CSNS distribute a survey to residency program coordinators of all neurosurgical residency programs in the United States to assess what challenges are present in maintaining accreditation with the ACGME; and

BE IT FURTHER RESOLVED, the results of the report and survey be presented to CSNS and offered

for presentation to the SNS detailing commonalities amongst programs in challenges achieving accreditation and develop solutions and curriculum to address these challenges at a national level, in an effort to support workforce training maintenance and expansion.

Fiscal Note: $100
Assigned Committee(s): Medical Practices Workforce
Young Neurosurgeons Rep Section
1. Sharma, A, Tenny, S, Yang, G, Steinmetz, M, Cheng, J, Ratliff, J, Krishnamurthy, S, Adogwa, O, and Swartz, K. Factors Affecting Retirement and Workforce Attrition in Neurosurgery: Results of a Council of State Neurosurgical Societies National Survey. In Press. Journal of Neurosurgery
2. Williams, Thomas E. Jr MD, PhD, FACS*; Satiani, Bhagwan MD, MBA, FACS*; Thomas, Andrew MD, MBA†; Ellison, E Christopher MD, FACS*. The Impending Shortage and the Estimated Cost of Training the Future Surgical Workforce. Annals of Surgery 250(4):p 590-597, October 2009. | DOI: 10.1097/SLA.0b013e3181b6c90b
3. Overview. (n.d.).

CANS position                     OPPOSE
Spokesperson                      Brian Gantwerker

Resolution XV-2023F
Title: Neurosurgery’s Commitment to Climate Change Mitigation

Authors: Akshay Sharma, MD, Rebecca Achey, MD, Meena Vessell, MD, Helen Shi, MD, George Yang, MD, Brandon Lucke-Wold, Satish Krishnamurthy, MD, Deborah Benzil, MD, Karin Swartz, MD, Catherine Mazzola, MD, John Ratliff, MD, Owoicho Adogwa, MD, MPH,
This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS, climate change is the one of largest global public health threat this generation is facing and has significant impacts on human health. [1, 2]; and

WHEREAS, there is expert consensus within the scientific community that climate change is driven by anthropogenic greenhouse gas emissions from fossil fuel combustion, and healthcare sector as a whole is responsible for 8-10% of total US GHG emissions per year [4,5]; and

WHEREAS, the operating room and surgical care are large contributors to the healthcare sector’s overall carbon footprint, requiring 3-6 times more fossil-fuel generated energy than the rest of the hospital, producing more waste, and releasing anesthetic gases that are GHGs

themselves. In particular, single-use sterile medical devices contribute disproportionately to medical waste [6, 7]; and

WHEREAS, in recognition of climate change’s threat to human health, and the healthcare sector’s significant contribution, the American Medical Association adopted a position statement in November 2022 encouraging physicians to engage in climate and health action [8], and similar measures are being created by national surgical societies, such as the American College of Surgeons [9]; therefore

BE IT RESOLVED, the CSNS request that its parent bodies (AANS/CNS) adopt a formal position statement or endorse that of the AMA/ACS, recognizing the effect of climate change on neurosurgical care quality and access in the United States, recognizing climate change as a public health emergency, and further encouraging research and committing resources to the study of climate change’s effect on neurosurgical care, the economic impact of climate change on neurosurgical care, the provision of neurosurgical care through climate crises, and supporting the discussion, research, and publication of these topics; and

BE IT FURTHER RESOLVED, the CSNS develop and distribute a survey of currently practicing neurosurgeons and current neurosurgical trainees to assess their opinion on current efforts to minimize the impact of surgical services on climate change and their overall opinions on the impact of medicine on climate change; and

BE IT FURTHER RESOLVED, the results of this survey be presented to the CSNS and compiled for publication to better define the priorities of our members in relation to climate change mitigation; and

BE IT FURTHER RESOLVED, CSNS ask its parent bodies, AANS and CNS, to instruct the Washington committee to include sustainable neurosurgery in its biennial pulse survey, including advocacy for the use of sustainable and reusable medical devices, and to consider its addition to the legislative agenda priority list for 2024.

Fiscal Note: $50
Assigned Committee(s): All Standing Committees and Representational Sections
References:Romanello M, McGushin A, Napoli CD, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. The Lancet. 2021;398(10311):1619-1662.doi:10.1016/S0140-6736(21)01787-6
Romanello M, Napoli CD, Drummond P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. The Lancet. 2022;400(10363):1619-1654. doi:10.1016/S0140-6736(22)01540-9

Louis S, Carlson AK, Suresh A, et al. Impacts of Climate Change and Air Pollution on Neurologic

Health, Disease, and Practice: A Scoping Review. Neurology. Published online November 16, 2022:10.1212/WNL.0000000000201630.doi:10.1212/WNL.0000000000201630
Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLOS ONE. 2016;11(6):e0157014.doi:10.1371/journal.pone.0157014
Talibi SS, Scott T, Hussain RA. The Environmental Footprint of Neurosurgery Operations: An Assessment of Waste Streams and the Carbon Footprint. Int J Environ Res Public Health. 2022;19(10):5995. doi:10.3390/ijerph19105995

What Otolaryngologists Can Do to Lessen Their Carbon Footprint. ENTtoday. Accessed November 6, 2022.

American Medical Association Policy Statement. Global Climate Change and Human Health H-135.938.

Accessed 6/26/2023. Moloo, Husein, Clifford Y. Ko, and FASCRS Bruce L. Hall. “Surgeons Have a Duty to Improve Planetary Health.” New Trends in Hernia Repair: 42.

CANS position                     OPPOSE
Spokesperson                      Anthony DiGiorgio

Resolution XVI-2023F
Title: Assessing the Value of Mid-Level Providers in Neurosurgery Care and Productivity

Authors: Meena Vessell, Brandon Lucke-Wold, Akshay Sharma, Deborah Benzil, Prateek Agarwal, Catherine Mazzola, Chesney Oravec, Owoicho Adogwa
This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS, many private, academic, and hospital-based neurosurgical practices are heavily reliant on Advanced Practice Providers (APPs)1; and

WHEREAS, improved patient outcomes have been shown amongst teams with APPs2; and

WHEREAS, the contribution of APPS to patient outcomes, practice efficiency and throughput, team dynamics, and burn out reduction has not been well defined3; and

WHEREAS, other specialties, such as oncology, have established guidelines to measure APP productivity4 ; and

WHEREAS, neurosurgeons may experience administrative hurdles in creating approved positions to hire APPs due to a lack of data characterizing their value to patient care, practice efficiency and throughput5; therefore

BE IT RESOLVED, that the CSNS recognize and support the development of an inclusive neurosurgical workforce which consists of attending neurosurgeons, APPs, and resident/fellow trainees; and

BE IT FURTHER RESOLVED, that the CSNS survey current practice environments regarding the utilization of APPs and impact on neurosurgical care and productivity, as well as, billing methods and salary models. Additionally, survey of relative impacts of APPs on team dynamics and physician burn out reduction should be assessed; and

BE IT FURTHER RESOLVED, that the CSNS encourage the AANS and CNS to establish guidelines for the APP role in improving access to care, delivering improved outcomes, and increasing provider satisfaction

Fiscal note: None
Assigned Committee(s): Coding & Reimbursement
Medical Practices Workforce
Neurotrauma & Emergency Neurosurgery
Medical Directors Rep Section

1. Khan M, Harper J, Hunsaker JC, et al. Letter: Evaluating the Role of Advanced Practice Providers in Neurosurgery. Neurosurgery. 2021;88(3):E285-E287.
2. Ch’ang JH, Ford J, Cifrese L, et al. Preparing Neurology Residents and Advanced Practice Providers for the COVID-19 ICU-A Neurocritical Care Led Intervention. Neurohospitalist. 2021;11(4):342-347.

  1. Richards AE, Curley KL, Zhang N, et al. Burnout and Emotional Intelligence in Neurosurgical Advanced Practice Providers Across the United States: A Cross-Sectional Analysis. World Neurosurg. 2021;155:e335-e344. 4. Krause D, Sharrah K, Gross A, et al. Measuring Advanced Practice Provider Productivity at the National Comprehensive Cancer Network’s Member Institutions. J Adv Pract Oncol. 2022;13(5):507-513.
    5. Burger R, Bolton WS, Mathew RK. Challenges and opportunities in academic neurosurgery. Br J Hosp Med (Lond). 2021;82(10):1-7.
    Prior CSNS Resolutions: Studying the changing training environment: Are we eroding the neurosurgical residency?
    (original submission)

Author: Robert Heary, MD, Brian Nahed, MD, Maya Babu, MD, MBA

Committees: Communications and Education, Young Neurosurgeons, Workforce
Final product: Assigned to the CSNS Workforce Committee for completion of a white paper to be presented at the spring 2012 CSNS meeting.
Final outcome:
Amended Resolution Passed

Final Resolved Text:

BE IT RESOLVED, that the CSNS study the impact of mid-level providers on resident education;

and BE IT FURTHER RESOLVED, that the CSNS better understand the institutional financial impact of hiring mid-levels versus investing in a training program; and

BE IT FURTHER RESOLVED, that the CSNS systematically identify methods programs utilize, or may consider, to compensate for the 80 hour rule and the consequent diminished exposure of trainees to patient volume. Advanced practitioners in neurosurgical practice (original submission) Author: Eric S Sussman,

M.D., John K Ratliff, M.D., Lawrence Shuer, M.D. Committees: Medico-legal, CEC, Workforce
Keywords: Advanced practictioners
Final outcome: Adopted Amended Resolution
Final Resolved Text:

BE IT RESOLVED, that the CSNS conducts a study of the background education and current job requirements of neurosurgical advanced practitioners in practice; and

BE IT FURTHER RESOLVED, that the CSNS develop a whitepaper on the role of advanced practitioners in neurosurgery training programs and practices.

CANS position                     OPPOSE
Spokesperson                      Brian Gantwerker

Resolution XVII-2023F
Title: The Hoover Resolution: Evaluating and Addressing Physical Threats to Neurosurgeon Safety & Mortality

Authors: Meena Vessell, Chesney Oravec, Akshay Sharma, Brandon Lucke-Wold, William Bingaman, Karin Swartz, Owoicho Adogwa
This resolution was reviewed and approved for submission by the CSNS Workforce Committee

WHEREAS, the loss or interruption of even a single surgeon’s practice can have a significant impact on patient care;

WHEREAS, there is a disproportionate incidence of workplace violence in healthcare compared
to other industries. This prompted the new Joint Commission Hospital accreditation requirements

addressing workplace violence prevention which went into effect in January 2022;[1]; and

WHEREAS, at least one study published in 2010 identified homicide as a leading cause of death amongst female neurosurgeons [2] and there have been several recent shootings at clinics, including at least two instances in which patients murdered their surgeon;[3-6]; and

WHEREAS, although some hospital locations have described increased security measures, [7] it is not clear what hospitals and clinics ought to be doing to address the risk of physician violence; and

WHEREAS, the American Academy of Orthopedic Surgeons released a position statement condemning violence against healthcare workers and surgeons after the murder of Dr. Benjamin Mauck and released a Workplace Violence Toolkit[8-9]; and

WHEREAS, the recent homicide of neurosurgeon, Dr. Devon Hoover, by gunshot wound to the head is cause for concern; therefore

BE IT RESOLVED, the CSNS, alongside parental bodies, recognize that neurosurgeons face an increasingly hostile practice environment from a surgeon safety perspective; and

BE IT FURTHER RESOLVED, the CSNS, alongside parental bodies, publish a review of neurosurgeons affected by workplace violence or homicide; and

BE IT FURTHER RESOLVED, the CSNS encourage parental bodies to help develop a best practices guideline for hospitals to protect neurosurgeons’ safety from physical threats.

Fiscal note: $200 for legal review

Assigned Committee(s): All Standing Committees and Representational Sections


  1. The Joint Commission. R3 report issue 30: Workplace violence prevention standards. December 2022. Accessed July 26, 2023. issue-30-workplaceviolence-prevention-standards/
  2. Lollis SS, Valdes PA, Li Z, Ball PA, Roberts DW. Cause-specific mortality among neurosurgeons. J Neurosurg. 2010 Sep;113(3):474-8. doi: 10.3171/2010.1.JNS091740. PMID: 20170305.
  3. Smart, S. Police chief: 5 women were shot in medical center waiting room. May 3, 2023. Accessed July 26, 2023.
  4. Levenson, E. One dead and four wounded in shooting at Minnesota health care clinic. February 10, 2021. Accessed July 26, 2023. minnesota-shooting/index.html
  5. CBS/AP. Surgeon shot to death in suburban Memphis clinic. July 12, 2023. Accessed July 26, 2023. suburb-collierville/
  6. Unger, T. Violence against doctors: Causes, effects and solutions with Ramin Davidoff, MD. May 25, 2023. Accessed July 27, 2023.,massive%20discrepancy%20in%20 health%20care
  7. Killackey D, Riley L. AAOS President: Workplace Violence in Healthcare Settings Must be Addressed Through Changes in Policy and Practice. July 12, 2023. Accessed July 27, 2023. healthcare-settings-must-be-addressed–through-changes-in-policy-andpractice/
  8. Rodriguez J, Balch Samora J. AAOS Prioritizes Safety with New Online Toolkit Focused on Workplace Violence. June 12, 2023. Accessed July 27, 2023.

CANS position                     SUPPORT
Spokesperson                      Brian Gantwerker

Title: Expansion of the CSNS Diversity Task Force, creation of an ad hoc committee, and formal evaluation of the relationship between diversity and patient safety

Authors: Ashkaun Razmara, MD; Aladine Elsamadicy, MD; Prateek Agarwal, MD; Mark Zaki, MD; Laura Stone McGuire, MD; Ann Parr, MD; Jeremy Amps, MD; D. Ryan Ormond, MD, PhD

WHEREAS, not only do minority groups experience inequity in the safety of care and are at higher risk of patient safety events,1 but diversity in health organizations has been shown to improve performance and patient care quality;2 ; and

WHEREAS, despite initiatives made by national organizations to improve equity, Neurosurgery still ranks among the lowest in medicine for diversity when compared with both surgical and nonsurgical subspecialties;3 ; and

WHEREAS, the CSNS has formalized a Diversity Task Force with the purpose of identifying areas of DEI within the CSNS and Neurosurgery that may warrant attention, but actionable goals have not yet been clearly delineated; and

WHEREAS, more targeted efforts to improve DEI in regards to race, gender, religion, and socioeconomic status would be beneficial and improve the applicant pool to neurosurgery residencies; therefore

BE IT RESOLVED, that the CSNS work to develop a white paper on the potential adverse effects of a lack of provider diversity on surgical patient safety; and

BE IT FURTHER RESOLVED, that the CSNS request an update from the CSNS Diversity Task-Force resolution authors as well as its five assigned committees with reports of specific ongoing DEI initiatives and upcoming efforts; and

BE IT FURTHER RESOLVED, that the CSNS establish an ad hoc committee to improve efforts for future DEI resolutions and initiatives while interfacing with the AANS Diversity Task Force, CNS DEI Committee, WINS, ABNS, and Neurosurgery residency training programs to identify opportunities to bolster pre-existing efforts and to establish new growth in DEI.
Fiscal note: None
Assigned Committee(s): All Standing Committees and Representational Sections
1. Wade C, Malhotra AM, McGuire P, Vincent C, Fowler A. Action on patient safety can reduce health inequalities. BMJ.2022;376:e067090. Published 2022 Mar 29.

  1. Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392.
  2. Selden NR, Barbaro NM, Barrow DL, et al. Neurosurgery residency and fellowship education in the United States: 2 decades of system development by the One Neurosurgery Summit organizations. J Neurosurg. 2021;136(2):565-574.
    Published 2021 Aug 6.

CANS position                     SUPPORT 2nd Resolve only
Spokesperson                      Mark Linskey                                                     

Title: Assessing the impact on patient safety from delays and denials in prior authorization for surgical procedures

Authors: Ashkaun Razmara, MD, MPH; Jeremy Amps, MD; D. Ryan Ormond, MD, PhD

WHEREAS, a large majority of physicians believe that prior authorization is costly, inefficient, and responsible for patient care delays;1 ; and

WHEREAS, previous literature has demonstrated that prior authorization requirements are associated with treatment delays in receiving necessary medication, and these delays can negatively affect patients; 2 ; and

WHEREAS, there is scarce data about the effect of prior authorization requirements for surgical procedures on patient-oriented outcomes; and

WHEREAS, the CSNS has a task force dedicated to understanding the financial losses in delays in authorization, but no efforts have been formalized to understand the impact on patient safety; therefore

BE IT RESOLVED, that the CSNS work to identify the volume and percentage of neurosurgical cases that are delayed or denied by prior authorization requirements, in order to evaluate the impact on patient outcomes; and

BE IT FURTHER RESOLVED that the CSNS release a white paper to publicize these findings and support collaborative efforts in influencing the conduct of commercial payers in the context of prior authorization for neurosurgical procedures.

Fiscal Note: None
Committee Assignment: None
Assigned Committee(s): Patient Safety
Medico-Legal Medical Practices
Coding & Reimbursement
1. AHIP 2022 Survey on Prior Authorization Practices and Gold Carding Experiences available at

  1. Wallace ZS, Harkness T, Fu X, Stone JH, Choi HK, Walensky RP. Treatment Delays Associated With Prior Authorization for Infusible Medications: A Cohort Study. Arthritis Care Res (Hoboken). 2020;72(11):1543-1549.

CANS position                     SUPPORT
Spokesperson                      Joe Chen

Resolution XX-2023F
Title: Assessment of the social media utilization of neurosurgical practitioners

Authors: Chesney S. Oravec, Daniel E. Couture, John A Wilson

WHEREAS, social media platforms are valuable communication tools and have become a daily activity for social interaction as well as an increasingly prominent source of news and healthrelated information for many Americans;[1,2]; and

WHEREAS, health care professionals utilize social media for the benefit of patients as well as for practice development, which can create both opportunities for education as well as pose risks to the patient-physician relationship;[2]; and

WHEREAS, physicians are ethically and legally obligated, specifically under HIPAA, to maintain the confidentiality of protected health information (PHI), and even an inadvertent or seemingly innocuous disclosure of patient-related information through social media can be problematic;[3,4]; and

WHEREAS, sophisticated search engines and the ability to search for unique characteristics make it increasingly difficult to comply with the de-identification standards under HIPAA; and

WHEREAS, neurosurgeons may have a poor understanding of the laws regarding PHI release in social media as well as the immeasurable reputational harm associated with an inappropriate post on social media, especially in light of the availability of information on the internet; and

WHEREAS, there is some commentary in the medical literature[4,5] but little formalized guidance from professional societies about the ethics and professional boundaries associated with the use of social media in the patient physician relationship;[6,7] and

WHEREAS, state medical boards are often asked to offer judgement on professional boundary issues and privacy violations which could include penalties such as suspension or termination of medical licensure;[7] therefore

BE IT RESOLVED that the CSNS research neurosurgery-related content on social media platforms, via systematic review of the most popular neurosurgery content found on the top social media platforms in order to characterize current utilization, as well as research the relevant laws and ethical perspectives of sharing patient- and health-related information in such a forum; and

BE IT FURTHER RESOLVED that based on that research, the CSNS, along with the help of parent organizations and legal counsel, generate a white paper to help inform neurosurgeons regarding legal and ethical concerns related to use of patient information and neurosurgical practice on social media.

Fiscal note: review of white paper by parent organization legal counsel
Assigned Committee(s): Communication and Education Workforce
Medical Directors Rep Section
Young Neurosurgeons Rep Section
1. Social media use in 2021. Updated April 7, 2021. Accessed July 21, 2023.

  1. More Americans are getting news on TikTok. Updated April 7, 2021. Accessed July 21, 2023.
  2. Iserson KV, Derse AR, Delpier M. Navigating the Hazards of Social Media. Fam Pract Manag. 2022 May-Jun;29(3):15-20.PMID: 35536299.
  3. Linzey JR, Graffeo CS, Wang JZ, Haider AS, Alotaibi NM. Neurosurgery and the rise of academic social media: whatneurosurgeons should know. J Neurosurg. 2018 Oct;129(4):1-5. doi: 10.3171/2018.2.JNS172817. Epub 2018 Jul 6. PMID:29979122.
  4. Neurosurgeons and Social Media. Updated December 16, 2017. Accessed July 24, 2023.
  5. Social Media and Electronic Communications. Updated April 28, 2019. Accessed July 28, 2023.
  6. AMA Code of Medical Ethics 2.3.2 Professionalism in the Use of Social Media. Updated 2019. Accessed July 28, 2023.

CANS position                     SUPPORT
Spokesperson                      Brian Gantwerker

Resolution XXI-2023F
Title: Observerships for Medical Students without a Home Program

Authors: Prateek Agarwal, M.D., M.B.A., Raj Swaroop Lavadi, M.B.B.S., Scott Simon, M.D., Jeremy T. Phelps, M.D., M.B.A., Alexander A. Khalessi, M.D., M.B.A., Elad I. Levy, M.D., M.B.A., Nitin Agarwal, M.D.

WHEREAS, medical students without a home neurosurgery program are disadvantaged in the Match; and

WHEREAS, these students lack adequate mentorship and clinical exposure to neurosurgery; and

WHEREAS, summer research programs offer a good opportunity for initial engagement,1 clinical exposure within the constraints of the institute may be more conducive for garnering a more thorough exposure to neurosurgery;2 ; therefore

BE IT RESOLVED, that the CSNS collaborates with the CNS Foundation to develop a funded clinical observership exclusive for these disadvantaged medical students to prepare them for sub- internships.

Assigned Committee(s): Communication and Education
Young Neurosurgeons Rep Section
1. Medical Student Summer Research Fellowships. Neurosurgery Research & Education Foundation. fellowships. Accessed [7/19/2023]

  1. Dallas J, Mummareddy N, Yengo-Kahn AM, et al. Neurosurgery Elective for Preclinical Medical Students with and without a Home Neurosurgery Program. World Neurosurg. 2019;131:e201-e210.

CANS position                     SUPPORT
Spokesperson                      Anthony DiGiorgio

Resolution XXII-2023F
Title: Current State of Ambulatory Spine Centers

Authors: Raj Swaroop Lavadi, M.B.B.S., Ryan Hess, M.D., Justin Im, B.S., Nitin Agarwal, M.D., Jeffery Mullin, M.D., M.B.A., Elad Levy, M.D., M.B.A.

WHEREAS, the incidence of outpatient and ambulatory spine surgery services have risen in parallel with patient interest in minimally invasive spine surgery;1,2 and

WHEREAS, the ambulatory spine center provides cost benefits to both the patient and surgeon in private settings;3 and

WHEREAS, the relevance of ambulatory spine centers have yet to be defined under academic circumstances; and

WHEREAS, a similar gap lies within other ambulatory neurosurgical services; therefore

BE IT RESOLVED, that the CSNS circulates a survey to institutions with AANS and/or CNS chapters to understand the current landscape of ambulatory spine centers; and

BE IT FURTHER RESOLVED, that results of this survey be used to determine resident involvement and training curricula in ambulatory neurosurgery centers.

Assigned Committee(s): Coding & Reimbursement Medical Practices
Young Neurosurgeons Rep Section
1. White CA, Patel AV, Butler LR, et al. Comparison of Patient Preference, Understanding, and Sentiment for Minimally Invasive Versus Open Spine Surgery. Spine (Phila Pa 1976). 2022;47(4):309-316.

  1. Sivaganesan A, Hirsch B, Phillips FM, McGirt MJ. Spine Surgery in the Ambulatory Surgery Center Setting: Value-Based Advancement or Safety Liability?. Neurosurgery. 2018;83(2):159-165.
  2. Badlani N. Ambulatory surgery center ownership models. J Spine Surg. 2019;5(Suppl 2):S195-S203.

CANS position                     SUPPORT
Spokesperson                      Nicole Moayeri

Resolution XXIII-2023F
Title: Neurosurgical Medical Director Survey

Authors: Mateo Ziu, MD, MBA; N. Nicole Moayeri, MD

WHEREAS, Medical Director is a leadership position that neurosurgeons hold in varied practice settings, and

WHEREAS, Neurosurgical Medical Directors play an important role in implementing and promoting the most advanced neurosurgical care in health care systems and communities throughout the US, and

WHEREAS, the responsibilities, duties, and rights of a Neurosurgical Medical Director differ depending on the healthcare system and practice setting, and

WHEREAS, formal education for neurosurgeons to fulfill the responsibilities of a Neurosurgical Medical Director is sparse, and

WHEREAS, methods of compensation for Neurosurgical Medical Directors are largely unknown; therefore

BE IT RESOLVED, the CSNS survey the neurosurgical community for better understanding of : 1. the population of Neurosurgical Medical Directors in the US currently, 2. the differences in the responsibilities and job descriptions in various practice settings (e.g. employed, academic and private, physician groups and healthcare systems), 3. contracting and compensation, and 4. The educational needs of Neurosurgical Medical Directors, and

BE IT FURTHER RESOLVED, the survey results be distributed to the participants to provide information that can support their negotiations with hospitals and development of their programs, and

BE IT FURTHER RESOLVED, the results of this survey guide CSNS and the Medical Directors Representation Section to address the needs of the Neurosurgical Medical Directors community in terms of providing educational material and support.
Assigned Committee(s): Communication & Education Medical Practices Workforce
Senior Neurosurgeons Rep Section
Young Neurosurgeons Rep Section
Medical Directors Rep Section

CANS position                     SUPPORT
Spokesperson                      Mark Linskey                       

Resolution XXIV-2023F
Title: Ongoing Collaboration Between The Council of State Neurosurgical Societies and Respective State Societies to Understand and Improve Neurosurgeon Wellness Across All Professional Stages

Authors: Arvin R. Wali, Akshay Sharma, Bryan Ryba, Anthony DiGiorgio, Joseph Cheng, John Ratliff, David R. Santiago-Dieppa

WHEREAS, the vocation of neurosurgery is both intellectually rewarding and physically and emotionally demanding, requiring years of education, training, and continuous practice, and may come at the expense of personal health and wellbeing; and

WHEREAS, stress, burnout, and mental health challenges are significant issues impacting neurosurgeons at every stage of their careers, from medical student to retiree; and

WHEREAS, the wellness and self-actualization of neurosurgeons across all life stages are integral to the provision of high-quality patient care, advancing medical science, and ensuring the longevity of our profession; therefore

BE IT RESOLVED, that the Council of State Neurosurgical Societies have an ongoing partnership with the many neurosurgical state societies to spearhead a collaborative initiative to examine, promote, and support the wellbeing and self-actualization of neurosurgeons at all stages of their careers; This would include the formation of a White Paper to describe the state of well being for neurosurgeon’s and opportunities to improve specific to each stage within a neurosurgeon’s career; and

BE IT FURTHER RESOLVED, that this initiative will encompass, but is not limited to, the development and implementation of:
1. Regular self-reported wellness assessments for neurosurgeons in training (medical students, junior residents, senior residents, and chief residents/fellows) and practicing neurosurgeons (junior attending, mid-career attending, and senior attending) and post retirement that can be compiled on the CSNS website; This will allow for creating a body of dialogue to define and capture opportunities to improve wellness and eventually develop instruments to utilize resources at the national and state level to improve wellbeing;
2. Career stage-specific resources, educational programs, and mentorship opportunities that foster personal and professional growth, facilitate work-life balance, and encourage selfactualization;
3. Policies and practices that promote a positive, inclusive, and supportive working environment, and that recognize and respect the personal needs and aspirations of neurosurgeons in retirement;
4. Direct partnership between the CSNS fellows and their respective regional state society resident fellows to foster ongoing dialogue and partnership to address wellbeing and wellness across all life stages of the neurosurgeon’s career.
Fiscal Impact Minimal – updating the CSNS website to include a repository for wellness issues raised at the state level Assigned Committee(s): Patient Safety
Coding & Reimbursement Workforce; Young Neurosurgeons Rep Section
1) Berardo, Laura, et al. “Assessment of burnout prevention and wellness programs for US-based neurosurgical faculty and residents: a systematic review of the literature.” Journal of neurosurgery 1.aop (2020): 1-9.
2) Hamade, Youssef J., et al. “The modern neurosurgical leader as a cure for team burnout.” Neurosurgery 77.2 (2015):N13.
3) Klimo P Jr, DeCuypere M, Ragel BT, McCartney S, Couldwell WT, Boop FA. Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg. 2013 Nov;80(5):e59-68. doi: 10.1016/j.wneu.2012.09.009. Epub 2012 Sep 25. PMID: 23022641.
CANS position                     SUPPORT
Spokesperson                      Nicole Moayeri



CSNS Fall Meeting, Washington, DC                             September 8-9
CNS Annual Meeting, Washington DC                         September 9-13
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 – Intercontinental Mark Hopkins
San Francisco, CA
CSNS Spring Meeting, Chicago                                     May 2-3, 2024
AANS Annual Meeting, Chicago                                  May 3-6, 2024 
NSA Annual Meeting Penha Longa Resort, Portugal  June 16-019, 2024

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 ( or fax (916-457-8202).

The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.

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This newsletter is published monthly from the Executive Office:

California Association of
Neurological Surgeons

5380 Elvas Avenue
Suite 215
Sacramento, CA 95819
Tel 916 457-2267
Fax 916 457-8202

Editorial Committee


Moustapha AbouSamra, M.D.

Contributing Editors
Austin Colohan, M.D.
Anthony DiGiorgio, D.O.
Deborah C. Henry, M.D.
Brian Gantwerker, M.D.
Ian Ross, M.D.

CANS Board of Directors

CANS Board of Directors

CANS Board of Directors

President             Joseph Chen , MD            Bakersfield
President-Elect   Ciara Harraher, MD          Santa Cruz
Vice-Pres            Samer Ghostine, MD        Los Angeles
Secretary            Brian Gantwerker, MD     SantaMonica
             Sanjay Dhall, MD               Los Angeles
Imed Past Pres    Javed Siddiqi, MD            Beverly Hills
Past President     Mark Linskey, MD              Irvine
Northern CA
Anthony DiGiorgio, DO                                  San Francisco
Marco Lee, MD                                               Stanford
Odette Harris, MD                                           Stanford
Harminder Singh, MD                                     Stanford

Southern CA
Omid Hariri, DO                                               Orange Co
Namath Hussain, MD                                     Loma Linda
Ian Ross, MD                                                    Pasadena
N. Nicole Moayeri, MD                    Santa Barbara

Resident Board Consultants
John Choi, MD                                                Stanford
Yagmur Muftuoglu, MD, PhD                        UCLA
Paras Savla, DO                                              Arrowhead
John Yue, MD                                                  UCSF

Past President Kenneth Blumenfeld, MD    San Jose Past President Deborah C. Henry, MD Newport Beach Past President Theodore Kaczmar, Jr, MD  Salinas
Past President     Phillip Kissel, MD  San Luis Obispo
Past President     Praveen Mummaneni      San Francisco
Past President Langston Holly                       Los Angeles
Past President John K. Ratliff, MD Stanford               Past President     Patrick Wade                     Glendale

Newsletter           Moustapha AbouSamra, MD Ventura                     
              Austin Colohan, MD         Temecula
Website Chair     Anthony DiGiorgio, DO    San Francisco

Executive Secretary         Emily Schile          Sacramento