Volume 50, Number 8

Inside This Issue

Picture of Javed Siddiqi, MD, DPhil (Oxon), FRCSC, FACS, FAANS

Javed Siddiqi, MD, DPhil (Oxon), FRCSC, FACS, FAANS

CANS President

President's Message - The Importance of Our Nurses

American hospitals are having another crisis: nursing shortages. One of my hospitals has over 500 traveling nurses working there, while another has nearly 100. The “great resignation” has hit public hospitals the hardest, with their inability to pivot quickly and be competitive by raising wages as rapidly and as much as non-public hospitals can do. Southern California public hospital nurses are being offered as much as a $20/hour raise to change jobs, so it is not hard to imagine what they see in their best interest. Those hospitals lucky enough to have nursing training programs can hire some of their own graduates, but these new graduates can also write their own tickets as soon as they get some experience under their belts, causing a revolving door. In one of my tertiary care hospitals, we have declared an “internal disaster,” the worst consequences of which include shutting down elective surgery and outpatient clinics so those nurses can be reassigned to inpatient responsibilities and stopping the acceptance of outside hospital transfers (with exception of trauma and stroke). I can’t remember a time in my 25-year career when nursing shortages were so acute, and there were so many negative consequences for our tertiary care hospitals, on which so many smaller hospitals depend for subspecialty support. Of course, the smaller hospitals are also facing this nationwide nursing shortage.

What can our hospital and medical staff leaders do to address the nursing shortage in an economy with full employment? Will this be a short-term problem, or is this the new normal? This may be the time for our leadership to consider new and swift international collaborations to address our nursing shortages. Can California import nurses from countries with a surplus or expand collaborations with countries like the Philippines that specialize in training nurses for the entire world? Can we expedite nursing recruitment from our neighbors: Canada and Mexico? Apparently, there are mechanisms in place for a fast track for international nurses, but the logistics are still daunting, and we are clearly behind the curve and falling fast.

While our nursing shortage is not new, it is at crisis levels now and will most likely deteriorate for years to come. Neurosurgery is not an island, and the nursing limitations affect us in the ER, the OR, the ICU, the clinic, the angio suite, and the wards. While we may not be able to influence their choices, I do want to take this opportunity to personally thank all the nurses that played a critical role in serving our patients (sometimes at high personal risk, such as during COVID-19 and even before), in advancing my education, in assisting our residents, in rescuing me from poor clinical judgments while a junior physician, and as the most enduring co-champions for our patients. We hate to see you go–we have been in the trenches together, and your absence is being felt both professionally and personally; thanks for everything. For those nurses who continue on their jobs and continue to fight the good fight, we appreciate you.

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Corner

In this issue, we have a first … “Letters to the Editor.”

The editorial committee and I always ask for and welcome comments about and critiques of our publication. Well, this month, we received two “letters to the editor.” They are listed in the order they were received. The first is complimentary, but the second is critical. Both came from admired and respected colleagues. The editorial committee and I appreciate and encourage all of you to express your opinion in the form of letters to the editor. We will publish them.

Our colleagues Praveen Mummaneni and Anthony DiGiorgio wrote about some concerns regarding AB 35, a bill that was signed by the Governor; it is called the MICRA Modernization Act and is said to stabilize the malpractice market and introduce a Collaborative Just Culture approach.

The ”Women in Neurosurgery” column is written by our own Deborah Henry; she recalls her experiences during her residency days thirty years ago. Attitudes have since changed, but gender equity remains a concern. She offers a practical and common sense approach to resolving gender discrimination.

We are grateful to Katie Orrico, Senior Vice President of Health Policy and Advocacy, AANS, and CNS, for updating up on the latest ruling regarding Surprise Billing issued on August 19.

Included in this issue is the list of board members of the NeurosurgeryPAC for the calendar 2022-2023. You will note that California is well represented. Kenneth S. Blumenfeld, MD, Vice Chair, Mark E. Linskey, MD, Anthony DiGiorgio, DO, MHA, Brian R. Gantwerker, MD, Praveen V. Mummaneni, MD, Anand Veeravagu, MD, John K. Ratliff, MD are excellent ambassadors. The NeurosurgeryPAC, as you know, is our nonpartisan advocacy group. Led by Katie O. Orrico and Adrienne Mortimer from the Washington Office, it is at once an effective and respected group in the halls of Congress. We are all encouraged to lend your financial support.

The usual columns are included. Additionally, there is an important article from Medscape News titled “Physicians’ Medicare Pay Keeps Dwindling ― How Bad Will It Get?” In it, John Ratliff and many others are quoted. I encourage you to read it.

The photo of the month was taken by Deborah Henry during a recent trip to the Europe. It is of Drop Zone Y, where the British 4th Brigade landed near Arnhem, the Netherlands, on September 18, 1944.

Please note that in addition to the newsletter, you will receive in a separate attachment a call for nominations for next year’s CANS board. Please address your responses to the chair of the nominating committee, Mark Linskey. Your voice is important.

As always, we welcome your comments and critiques. Please contact me directly at, or call me on my cell phone: 805-701-7007.

Picture of Praveen V Mummaneni, MD, MBA

Praveen V Mummaneni, MD, MBA

Picture of Anthony M DiGiorgio, DO, MHA

Anthony M DiGiorgio, DO, MHA

AB 35 – MICRA Modernization

On May 23, 2022, Governor Newsom signed AB 35. This legislation aimed to modernize the Medical Injury Compensation Reform Act (MICRA). California physicians are familiar with MICRA and its protections against egregious non-economic damage claims in malpractice tort cases. AB 35 increases the existing $250,000 cap incrementally until it reaches $750,000 (or $1,000,000 if wrongful death is involved). It does introduce some new protections, however: for example, when the bill becomes effective pre-litigations expressions of sympathy or regret by a physician are protected.

AB 35 was a compromise, as the “Fairness for Injured Patients Act” was set to be on the November 2022 ballot. This would have eliminated the MICRA caps altogether, and California physicians faced an expensive campaign to defeat it. AB 35 was passed with the support of the California Medical Association as a compromise measure, stopping the ballot initiative in exchange for a more moderate legislative proposal.
While this compromise saves that legal fight, the effects of AB 35 are yet to be determined. Work by our group, which was presented at the 2021 AANS national meeting,1 shows the effects of various tort reform laws on the malpractice insurance premium rates, malpractice claims rates, and per capita neurosurgeon compensation across states. The only reform that had a statistically significant effect was the presence of a cap on non-economic damages. This lowered malpractice premiums.
Further work by our research group examined the effects of the malpractice environment on outcomes after spine surgery.2 We found that environments with a higher risk of malpractice claims correlated with longer length of stay, increased chances of a non-home discharge, and higher overall charges. Despite this, there were no differences in mortality rates in the more high-risk states.
California neurosurgeons are right to be concerned about AB 35. As the specialty with the highest malpractice claim rate, we are likely to feel any ill effects of this bill most acutely. Malpractice premiums will undoubtedly rise. Increasing claims will also lead to more defensive medicine, with an increasing cost of providing care. It could lead to less access to care for patients, especially if neurosurgeons do not feel that covering emergency calls will be offset by the increased liability exposure.
The effects of this bill must be monitored closely. We know CANS will continue to do so and to continue advocating for California neurosurgeons.

  1. DiGiorgio AM, Shen-Sempas J, Mahmood B, Chan AK, Burke JF, Dhall SS, Chou D, Orrico KO, Mummaneni PV. The Effects of Various Medical Malpractice Reform Laws on Malpractice Rates, Payoutes & Premiums. Oral Presentations 2021 AANS Annual Scientific Meeting. Journal of Neurosurgery. 2021;135(2):1-73.
  2. Chan AK, Santacatterina M, Pennicooke B, Shahrestani S, Ballatori AM, Orrico KO, Burke JF, Manley GT, Tarapore PE, Huang MC, Dhall SS, Chou D, Mummaneni PV, DiGiorgio AM. Does state malpractice environment affect outcomes following spinal fusions? A robust statistical and machine learning analysis of 549,775 discharges following spinal fusion surgery in the United States. Neurosurg Focus. 2020;49(5):E18.
Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD


Changing Times - Free Will/ Predestination

I believe in free will, but with some … limitations.

OK, let me admit that I was born and raised in a culture where most people strongly believe in predestination. This is not something inherent to the Middle East; it has been addressed by several Christians and western philosophers. And without making this a religious essay, I’d like to be clear: I do not agree with John Calvin’s Doctrine on predestination, or as some describe it, double predestination. Just to refresh your memory, Calvin believed that “it is God’s sovereign decision to determine whether an individual is saved or damned.” This clearly takes “free will” out of the equation.

I firmly believe I can choose right from wrong and am responsible for my choices. If I do something wrong, I should face the consequences. But I still believe that, in general terms, my life was predestined.

Some say that if you believe in predestination, you become lazy. Why work hard? Que sera, sera!

I don’t believe this to be correct. I have been retired for five years but still wake up at five in the morning as if I had to start surgery at 7:30. I am always looking for things to do, and I manage to stay busy. My genetic make-up does not include laziness.

In addition to genetic make-up, social upbringing, educational background, and occupational exposure work together to determine who we are and how we behave. Is our choice a major factor in any of these influencers?

I propose that if you look back at your own life, you will find that you had a minor say in all the major milestones in your life.

In my case, consider this:
  • I was born into a highly educated family. My maternal grandfather had a Ph.D. in education from the Collège de Sorbonne in Paris. He established the secondary educational system in Syria after its independence from France. My mother was the first woman to graduate from college in Syria. Her major? Mathematics. My father had a law degree, and after practicing law for a couple of years in Damascus, Syria, he decided to get an additional degree in economics in France. His studies were cut short when WWII started. He returned home and took over the family’s export business. He spoke several languages and was an avid reader.
  • I was taught in the French educational system in Damascus, where I read Voltaire and Rousseau, among other philosophers, and where I learned about tolerance. My family and school environments encouraged me to accept others as equals regardless of their religious, ethnic, or racial backgrounds
  • I was thirteen years old when my mother was diagnosed with breast cancer. Her American-trained surgeon saved her life by performing a radical Halstedian mastectomy; Dr. Zakai’i Haqqi was revered in my family, and to me, he was a hero. It was then that I decided not only to become a surgeon but also to do my training in the US.
  • Syria was under a dictatorship for almost all my formative years, and my education led me to think that I could not tolerate an environment where personal freedom is not respected. So, I added to my decision: not only will I train in the US but will also stay in America
  • I spent my clerkship as a senior in Medical School at the Hôpital du Sacré Coeur in Beirut, Lebanon, where I met an idealistic and charismatic neurosurgeon, Salim Ghostine. I was hooked. Neurosurgery became my future.
  • Because I was not able to converse fluently in English, my young maternal uncle, who was finishing his training as a pediatric pulmonologist at Tulane University in Louisiana, gave me a piece of good advice: choose a community hospital rather than a university hospital to start my rotating internship and to use the first year in the US to improve my language skills and adjust to the American lifestyle; this way I would be better prepared for a competitive university residency training program.
  • I chose Perth Amboy General Hospital in Perth Amboy, NJ, where within three weeks I met and fell in love with a young cardiac technician. We were engaged about six months later and married less than a year later. Joanie and I will celebrate our fiftieth anniversary next August, Inshallah!
  • This marriage represented an improbable and some would say difficult union. A French-educated Syrian Arab Muslim marrying an Irish Catholic educated by nuns in a parochial school was not destined to be easy. This union, however, was founded on common respect for all religions and cultures and a strong desire to raise a family that celebrated diverse ideas, tolerance, and openness. We hoped and planned to raise good people and good citizens of this country, the world, and our planet.
  • As I applied for a residency position in neurosurgery in 1973, I faced rejection after rejection: American-born and in particular veterans were justifiably given preferential treatment. So, I extended my surgical residency, in which I was successful, but did not give up on my plan to become a neurosurgeon. Additional general surgical training was helpful in my neurosurgical career.
  • During my PGY 3 in general surgery in NJ, I met Joel Singer, an MD., Ph.D. student rotating in general surgery with me. He introduced me to his Ph.D. advisor, Jim Story, at the University of Texas Health Science Center in San Antonio. Jim accepted me to train in his young neurosurgery program. Jim and his colleagues Jack Wissinger and Willis Brown became not only the men who taught me neurosurgery but also my mentors in life and dear friends. Jim is like a father to me.
  • While happily starting my academic career as an assistant professor in San Antonio and while attending a national neurosurgical meeting, I found myself striking up a conversation with Mel Cheatham the man behind me in one of the lunch lines. His name tag said: Ventura, CA. Not knowing where Ventura was, I said flippantly – not my nature – where the hell is Ventura? Mel, being the proper gentleman was scandalized. But at the end of the conversation, he invited me to come out to Ventura and interview with his partners for a position in private practice; the man who started the group was retiring. He did say that Ventura was the best place to practice neurosurgery and to raise a family. He was correct.
  • The Ventura Neurosurgery group was interesting and also an improbable collection of individuals. Bill James was a retired rear admiral in the Navy and a practicing Irish Catholic; Paul Karlsberg was the president of the local Jewish Temple, Beth Torah, and served in the Army reserve; Mel Cheatham was an elder in Community Presbyterian Church; Dan Murphy a dedicated Catholic. The fact that I was Muslim and born in Syria did not seem to matter. However, my upbringing and education helped me fit in easily.

I think I should stop here …

I hope that you can clearly see that in my case, when it came to the major milestones of my life, I had a minor role in the decision-making: I simply chose what was put in front of me. The late Archbishop Desmond Tutu essentially agreed when he said: “There are no self-made men. People helped to shape me.”

Yes, our genetic make-up, our family upbringing, our social encounters, our education, and sometimes pure Providence act collectively, like the proverbial rose-colored glasses: they help us see things from our own perspective and influence the way we exercise our “free will!”

Picture of Deborah C. Henry, M.D.

Deborah C. Henry, M.D.

Women in Neurosurgery

June was my 30th graduation anniversary from my neurosurgery residency. Hard to believe that in three years, it will be my 30th anniversary of becoming the 35th female Diplomate of the American Board of Neurological Surgeons. A lot has changed for women in that time. A lot still needs to change.

As a minority in residency, I stuck out like the proverbial sore thumb. When things went right, no one was recognized. If I was even remotely related to something that went wrong, I was the one people remembered. After all, I looked nothing like the other male residents who blurred together in the eyes of the hospital staff. My saving grace was passing my ABNS written boards in my junior year of residency. Immediately, I went from a female oddity to validation as a female intelligent enough to become a neurosurgeon.

My residency was in the days of the 100+ hour workweek, where the adage was that if you were at home every other night, you were missing half of the good cases. The detriment of making medical errors because of sleep deprivation or nodding off in the OR as the second assistant was balanced with the education from the continuity of patient care. Patients were admitted the night before surgery, giving all residents the crucial experiences in history-taking and neurological examinations and the review of X-rays, CT scans, and the relatively new MRI with attending physicians. I am old enough to remember those UBO’s-unidentified bright objects-as a common MRI interpretation.

Six years ago, I attended my 30th anniversary of graduation from Baylor College of Medicine. Our class was 1/3 female students. Several of us went into surgical fields, including general surgery, otolaryngology, and urology. The general surgeon who was at the reunion had left her field and was practicing emergency medicine. The ENT surgeon, who was an academic physician, commented on her findings showing that women residents finished with significantly fewer cases than their male counterparts. The urologist….well, I think she had a harder time than I did. I sensed bitterness as they discussed their 30-year careers. There was a want for respect for who they were and what they had accomplished.

Being a trailblazer is never easy. Many constantly doubt your abilities. Others never change their opinion that neurosurgeons must have XY chromosomes to be competent.

How do we curb gender discrimination? The simple answer is to treat women and men equally. Same pay, the same family leave, same opportunities-starting with caseloads and names on research papers during residency. Promote women in leadership positions. As of this year, the AANS has elected its second woman neurosurgeon president (Louise Eisenhardt, neuropathologist, also served when the AANS was the Harvey Cushing Society). The Western Neurosurgical Society and CANS each have had one woman president, and the Congress of Neurological Surgeons has none to date. Encourage capable women neurosurgeons to become department chairs (currently 5) and program directors.

Embrace change. Be a mentor. Don’t make assumptions. Ask questions. But don’t ask the sole woman in the room to make the coffee, hotel reservations, or take secretarial notes unless she offers. I’ve been there.

Interesting reads:

Gender Equality in Neurosurgery and Strategic Goals Toward a More Balanced Workforce
Neurosurgery: May 2022 – Volume 90 – Issue 5 – p 642-647

One hundred years of neurosurgery: contributions of American women
Journal of Neurosurgery Volume 134: Issue 2, 2008

Picture of Katie O. Orrico, Senior Vice President

Katie O. Orrico, Senior Vice President

Health Policy and Advocacy
American Association of Neurological Surgeons/
Congress of Neurological Surgeons

Washington Office report

On Aug. 19, 2022, the U.S. Departments of Health and Human Services, Labor, and Treasury (the Departments) issued a highly anticipated final rule implementing parts of the No Surprises Act (NSA). Included in the Consolidated Appropriations Act, 2021 (P.L. 116-260), the NSA protects patients from surprise medical bills and outlines the rules providers must follow when delivering out-of-network care, including the process for resolving payment disputes. The final rule reflects the Feb. 23 decision of the U.S. District Court for the Eastern District of Texas, which vacated parts of the Departments’ interim final rule (IFR) implementing the NSA. Filed by the Texas Medical Association (TMA), this lawsuit challenged the independent dispute resolution (IDR) process outlined in the IFR.

The IFR required arbiters to select the offer closest to the insurer’s median contracted rate when considering payment disputes between health plans and providers for outof-network care. Provider organizations were concerned that this provision would lead to lower payments and unduly favored insurers, upsetting a careful balance established by Congress when it crafted the NSA. According to the Texas court, the NSA is unambiguous regarding the IDR process in stating that the qualifying payment amount (QPA) — or median in-network rate — is only one of several factors to consider when resolving a billing dispute between an out-ofnetwork provider and an insurer.

The American Medical Association (AMA) and American Hospital Association (AHA) filed a similar lawsuit in federal court in the District of Columbia. Like the TMA, the AMA and AHA argued that the statute requires the arbitrator to consider many factors, not just the QPA, in determining fair payments. These factors include the doctor’s experience and level of training, the complexity of the service, and prior contract history between the plan and the provider. The American Association of Neurological Surgeons and Congress of Neurological Surgeons, along with the Physician Advocacy Institute, spearheaded a physician-led amicus brief supporting the AMA/AHA lawsuit. The court has yet to issue a ruling in this lawsuit and, in light of the new rules, has scheduled a status conference on Sept. 21 to determine the next steps.

In the meantime, the Departments’ newly issued rules are a vast improvement over the original IFR. The QPA will no longer be the “presumptive” factor in final payment determinations, and arbiters “should select the offer that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.” The new regulation also requires health plans to submit additional information to the arbiter when they have “down coded” a claim, i.e., altered the service code or a modifier to reduce the QPA to an amount less than that billed by the provider. However, the Departments clarified that arbiters should carefully evaluate payment offers to avoid “double counting” information that may already be incorporated into the QPA.

Additional information about the NSA and its requirements is available on the Centers for Medicare & Medicaid Services No Surprises Act webpage. The California Medical Association also has additional resources related to out-ofnetwork billing on its website.
Picture of Justin Dye, MD, FAANS

Justin Dye, MD, FAANS

Assistant Professor of Neurosurgery at LLU

Picture of Dinesh Ramanathan, MD

Dinesh Ramanathan, MD

PGY-4 Neurosurgery Resident at LLU

Historical Vignette

Loma Linda University, the oldest academic medical center in the inland empire region of California, started as a missionary hospital. The medical school was opened in the early 1910s, as envisioned by the prophet Ellen G. White. The medical institution’s mission of providing whole-person care is based on the guiding principles of the Seventh-day Adventist faith. Since its foundation, over the last 100 years, the University’s history has been marked by several renowned medical high points. In 1984, Baby Fae, an infant born with a congenital cardiac abnormality, received a baboon heart transplant, the world’s first successful xenotransplant in an infant. In 1990, LLU pioneered the building and use of the first proton beam accelerator on the west coast, which has been instrumental in delivering advanced cancer care and furthering research in radiation treatment globally.

The neurosurgery program at LLU was started by Dr. George Austin, who after training with Wilder Penfield at the Montreal Neurological Institute (MNI) moved to the inland empire region to create an academic practice. Dr. Austin transferred the neurosurgery practice at the Hospital of Medical Evangelists, in downtown Los Angeles, to where it is today in Loma Linda. He recruited several other neurosurgeons including Dr. Robert Knighton and a medical student Dr. Lloyd Dayes. Dr. Dayes, a graduate of the LLU School of Medicine, was one of the first African American board- certified neurosurgeons in the country. He also did his neurosurgical training at the MNI and eventually returned to LLU where he practiced for the following three decades. The department has a storied history of providing advanced neurosurgical care in Southern California. In the early 1970s, Dr. Austin invited neuroscientists from all over the world to LLU to research and refine cerebral bypass techniques. Following Dr. Austin, the department was successively led by Dr. Knighton, Dr. Dayes, Dr. David Knierim, Dr. Shokei Yamada, Dr. Wolff Kirsch, and Dr. Austin Colohan.

In line with the academic mission of the institution, the neurosurgical residency program at LLU received its initial approval in 1969 and has since graduated several dozen neurosurgeons. The academic mission of LLU is also reflected in its commitment to research accomplishments. The institution historically has secured numerous NIH grants and continues to work actively on nationally funded projects in cerebrovascular research led by Dr. John Zhang and Alzheimer’s disease research directed by Dr. Kirsch.

The current chairman, Dr. Warren Boling, took over the leadership of the department in 2015. The department has since grown to its current status of a premier quaternary care and referral center for neurosurgical care in the inland empire. The department provides its services at LLU, which opened a new state-of-the-art medical center in 2021, Riverside Community Hospital, Loma Linda VA Medical Center, and Desert Regional Medical Center in Palm Springs. More than 3000 operations are performed annually across all neurosurgical subspecialties, serving the diverse populations of both San Bernardino and Riverside counties.

From the AMA​

AMA applauds House committee passage of prior authorization bill ►
“For years, the American Medical Association has sounded the alarm about burdensome prior authorization processes and their negative impact on patient outcomes.” A statement from AMA President Jack Resneck Jr., MD, applauding the House Ways and Means Committee for passing legislation to improve the onerous prior authorization processes. The AMA remains committed to fixing prior authorization, one of the five key pillars of the Recovery Plan for America’s Physicians.

Physicians sound the alarm on lawsuit threatening preventive care ►
Led by the AMA, a coalition of medical organizations that represent physicians expressed concern that a federal court case could cause millions of Americans with private insurance to lose access to preventive services.

Keeping politics out of the exam room ►
The exam room is too crowded. Insurers, politicians and even law enforcement are squeezing into medical decision-making. Physician speakers and audience members voiced these concerns during the 2022 AMA Annual Meeting in Chicago. See how the AMA is working to protect physician autonomy.

What COVID-19 vaccination means for next AMA president’s family ►
In an episode of “AMA COVID-19 Update,” AMA President-Elect Dr. Ehrenfeld discusses the importance of children under 5 getting vaccinated against COVID-19, sharing his family’s personal experience.

How doctors can quickly boost their practices’ efficiency ►
Life in practice has become progressively more challenging. The AMA Private Practice Simple Solutions program provides rapid-learning courses designed to provide actionable changes to immediately increase efficiencies in your practice.

What will drive the new editor-in-chief’s approach at JAMA® ►
JAMA® is a revered source of peer-reviewed medical research and discussion of critical health issues, but to keep its leadership, it must continue to build trust and emphasize diversity, according to the journal’s new editor-in-chief, Kirsten Bibbins-Domingo, MD, PhD, MAS.

Physician authors explore what the rise of NPs, PAs means for patients ►
Alexus Ochoa-Dockins, a 19-year-old college athlete, was rushed to the hospital where she was treated by an NP instead of a qualified physician. See the effect that scope creep had on Alexus and what many patients unwittingly face. Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.
Picture of Brian R. Gantwerker, MD, FAANS, FACS

Brian R. Gantwerker, MD, FAANS, FACS

Private Practice Corner

“Our fear of death is like our fear that summer will be short, but when we have had our swing of pleasure, our fill of fruit, and our swelter of heat, we say we have had our day.”
-Ralph Waldo Emerson
When I was young, growing up in Chicago, my father worked as a schoolteacher on the West side of Chicago. He would work nine grueling months per year, and then have to scramble to get a summer job each and every summer he taught. He would apply to teach summer school, mostly in a one-hundred-year-old non-air-conditioned building. As he was not “in the crowd” he was turned down year after year. So, he has odd jobs each summer.

For years, he would manage a summer-only country club in the swanky suburb of Highland Park (the same city where the mass shooting took place on July 4), as a night watchman, and most famously as a taxi driver. My father became so familiar with the gridded layout of the city, he could localize virtually any address by the cross streets coordinates in his head and plot the fastest way there. He was our family GPS.

We did have small vacations here and there, one of which was an exciting circle tour of Lake Michigan, and even going to San Diego and Phoenix – in the pitch of summer. But Dad had to work to support the family, no matter what. If he took the summer off, we wouldn’t be able to pay the power bill, even with Mom’s salary as a benefits administrator. He worked because he had no choice.

As neurosurgeons, we are taught the highest commitment to patients and our work. Many of us defer trips and times with family due to workload. Many of us even cancel planned trips when patients’ issues come up. Our specialty reports a 21% divorce rate in post-residency from a 2005 analysis at a single institution (Harms et Al., Ann Surg 2005; 242:520-6). A colleague once told me that my wife had to “live with my mistress of neurosurgery.” One of our attendings spoke at my graduation, and also his retirement (total coincidence- I think,) and thanked his wife for raising their children.

My wife turned to my mother and said, “No. Way.”
Suffice it to say, our work is consuming. I got home at 3 AM last week from an all-day marathon of cases. Our patients are sometimes very sick, their issues complex, and sometimes the surgeries we do can be physically very demanding. That being said, the desire to work, build our brands and reputations, and thirst for success should be held in check by the stark reality of the inexorable passage of time.

Time with our children, parents, siblings, and friends is the stuff that those closest to us will remember. We all pray for successful surgeries and grateful patients, and to be pillars of our community. How many of us, though, neglect those closest to us – those who raised us, looked to us for comfort and love, and to whom they entrusted their most precious memories?

We all have obvious obligations to our patients in need. A patient of mine developed a postop complication that just could not sit in to fix, and I missed a national recognition award. My patient was actually more upset than I was.

But the things we can afford to put off – administrative duties, recruiting dinners, zoom calls, or missing a day of a national meeting – we all should give very careful consideration to what is the real thing we would be missing: a child’s first single, a dance recital, our parents’ anniversary, or the funeral of your best friend’s dad – and to its ultimate cost.

Our legacy is not just all patients we helped, but also those whom we love and who love us back.

From the CMA

U.S. Education Dept. needs to hear from physicians re: loan forgiveness NOW
The California Medical Association (CMA) urgently needs all physicians, residents and medical students to send a letter to the U.S. Department of Education before August 12, 2022, urging them to allow qualified California and Texas physicians who provide care in private non-profit hospitals/clinics to receive federal student loan forgiveness.

The Dept. of Education recently released draft regulations to reform the national Public Service Loan Forgiveness (PSLF) program. Despite the department’s stated interest in fixing its existing PSLF regulation—which inadvertently excludes many California and Texas physicians from participating—the draft regulatory language inexplicably still fails to fix the problem.

The Dept. of Education is accepting comments on its draft regulations through Friday, August 12, and we need as many of you as possible to submit a letter to show the urgency of this matter. CMA has prepared asample letter and instructions for sending the letter via the regulatory comment submission portal. It only takes 3 minutes.

It is critically important that the Dept. of Education resolve the problem once and for all to ensure that physicians in all 50 states can equally participate in this important program to encourage students to pursue careers in medicine and to help our neediest, most vulnerable patients in underserved communities. If the regulations are not fixed to allow physicians in California and Texas to participate, physicians will choose to practice in other states where they can receive loan forgiveness, accelerating our worsening physician shortages and harming our ability to care for the patients who need us most. Reform Prior Authorization: Support SB 250!

Please join the California Medical Association (CMA) in supporting SB 250 by Senator Richard Pan, M.D., which reduces administrative burdens in physician practices so physicians can spend more time dedicated to patient care. SB 250 will comprehensively reform the prior authorization process, resulting in less time spent on administrative work, increased access to necessary carefor patients and a restoration of the physician-patient relationship in medical decision-making. SB 250 will be heard soon in the Assembly Appropriations Committee. It is important that Assemblymembers know that SB 250 will allow physicians to spend more time coordinating care with patients with chronic and complex conditions and increase access to care by seeing more patients. Contact your Assemblymember today to ask for their AYE vote on SB 250.

UnitedHealthcare begins update of commercial fee schedule
UnitedHealthcare (UHC) will begin migrating some physicians to an updated commercial fee schedule beginning in October 2022. The fee schedule update, slated to occur in several phases between October 2022 and January 2023, will move physicians on older fee schedules dating back to 2008 to a new 2020 UHC commercial fee schedule based on 2020 CMS RVU values.

Cigna to reevaluate burdensome modifier 25 policy
CMA has learned that Cigna will delay implementation of its recently announced policy to require the submission of medical records with all Evaluation and Management (E/M) claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed.

Please Act on CMA Priority Bills
AB 1278, by Assemblymember Nazarian, would increase administrative burdens on physician practices and divert time physicians could spend with patients to administrative tasks. AB 2236, by Assemblymember Low, authorizes optometrists to perform surgical procedures (defined as “minor procedures” that require use of a scalpel or an injection, and “anterior segment lasers”) on a patient’s eye if they meet specified education and training conditions.
CMA appreciates your voice in opposing these measures.

Legislature passes CMA bill to protect patients and the sanctity of the physician-patient relationship The California Legislature unanimously passed, on August 23, an important California Medical Association (CMA) sponsored bill (AB 1636) that will ensure physicians who have committed sexual misconduct with a patient or client are prohibited from acquiring or reinstating their license. This bill is now on the Governor’s desk awaiting his signature.
Picture of Anthony DiGiorgio, D.O., MHA

Anthony DiGiorgio, D.O., MHA

My Grand Rounds Adventure

Academic Practice Corner

I was fortunate to give the first-ever community grand rounds for the UCSF department of neurosurgery. This session invited community members to an online forum where they could ask questions and participate in polling. Dr. Praveen Mummaneni moderated, and I spoke about spinal neurotrauma, covering both spinal cord injury and minimally invasive approaches to spinal trauma. The video is available on YouTube here.

This was a huge honor. I am proud of the research into spinal cord injury and novel surgical management of spinal trauma being undertaken at UCSF. I hope that people found the grand rounds informative. Of course, there was not ample time to discuss my other passion: CANS (and policy, socioeconomics, etc.) In planning the grand rounds, we discussed a combined policy & spinal cord injury discussion. Alas, that would not have done justice to either topic.

Readers of the column hopefully know the extent of my love for socioeconomic and policy research. I have no doubt I can fill an hour-long grand rounds on policy as well. Thankfully, I have many outlets for my work in that field: this column, my work on the CSNS newsletter (check that out here), and a smattering of invited commentaries. Please forgive the continual humblebrag in this column. (I will admit I was quite nervous regarding the grand rounds, and this piece is rather cathartic.)

I consider myself lucky to have such research passions. Even more than that, I am privileged to work at an institution that fosters both.

The resources available for my interests at UCSF are unparalleled. I have ample assistance navigating IRB protocols and device regulations. There is data analysts and statistics support. I am humbled by the cadre of incredibly intelligent and hard-working residents, medical students, and pre-med students who share my interests. I can only hope to mentor those students much as my mentors have guided me.

So, this just makes for a long-winded footnote to my grand rounds; a thank you to the institution which has provided me with such resources and support, gratitude to the tireless medical students who make the research seem easy, and appreciation to institutions like CANS and CSNS that let me have a voice in policy.

Leigh Page, Independent Freelance Healthcare Writer

Physicians' Medicare Pay Keeps Dwindling ― How Bad Will It Get?

From Medscape Medical News

John Ratliff, MD, a neurosurgeon at Stanford University, is tired of the way the Medicare program keeps paying physicians less and less.

Physicians are facing a planned 8.42% cut in Medicare reimbursements in 2023, which would be on top of a 2.75% cut in the second half of this year and a 3.3% cut in 2021.

“This constant cutting of Medicare rates, which has been going on for years, makes it hard for practices to make ends meet,” said Ratliff, who chairs the Washington committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

Uncertainty about what the actual 2023 cut will be makes it hard for practices to plan ahead. At the end of this year, just before the cut is scheduled to go into effect, Congress might pare it back significantly, as it did the past 2 years. “These last-minute changes create a lack of stability and a lack of clarity for our practice environment,” Ratliff said.

Will Congress step in again? The past last-minute fixes by Congress were seen as ways to protect physicians from the financial impact of the COVID-19 pandemic. But some policymakers think practices have now recovered and don’t need another financial rescue.

“Medicare’s payments for clinician services are adequate,” stated the Medicare Payment Advisory Commission (MedPAC) in its March report content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf. “We expect volume and revenue to rebound to pre-pandemic levels (or higher) by 2023.”

A coalition of some 120 physicians’ groups, including the American Medical Association (AMA), disputes that view and is calling for an overhaul of the way Medicare adjusts physician pay.

“The constant yearly fixes are ridiculous. It reminds me of the SGR,” Ratliff said, referring to the sustainable growth rate, an automatic adjustment that menaced Medicare physician payments for the first one and a half decades of the 21st century. In all but 1 year, Congress stepped in to undo the yearly SGR cut, often weeks before it was due. The SGR was abolished in 2015, but the annual scenario seems to be back.

Hyperinflation in the economy will make Medicare pay cuts seem even steeper. In June forecasts, the general inflation rate stood at 9.1%, the highest level in more than 40 years, according to the US Department of Labor. In late spring through-to-the-health-sector/, gas prices were up 43.6%, while prices for medical care rose just 3.2% over past year.

Although gas prices have recently been dropping, the rising gas prices have taken a toll on practices. “The gas price forced one person on my staff to quit,” said David L. Holden, MD, an orthopedic surgeon in Oklahoma City. “She needed child care to come to work, and the cost of gas was so high she couldn’t afford the child care anymore,” added Holden, who is president of the Oklahoma State Medical Association.

According to Holden, continued Medicare payment cuts could lead to access problems for patients. “If reimbursements continue to drop, more doctors will have to cut back on Medicare or even drop it,” he said.

A Long-Term Slide in Medicare Payments

“The problems physicians are having with Medicare cuts are not new. We have been experiencing them for more than two decades,” said Parag D. Parekh, MD, an ophthalmologist in State College, Pennsylvania, and chair of government relations at the American Society of Cataract and Refractive Surgery.

From 2001 to 2020, the cost of running a practice rose 39%, but Medicare payments, adjusted for inflation, fell by 50%, according to the Surgical Care Coalition, a group of surgical societies that opposes the Medicare cuts.

Even without accounting for inflation, Medicare reimbursements for doctors are at the same level as two decades ago. The Medicare conversion factor, a multiplier used to convert relative value units (RVUs) into the reimbursement amount, stood at $36.69 in 1998, and this year it stands at $34.60, the coalition reports

“Medicare payments to hospitals have a 2% yearly increase built in, but doctors don’t have that,” said Ezequiel Silva III, MD, a San Antonio, Texas, radiologist who chairs the Relative Value Scale Update Committee, operated by the AMA.

This may also be due to the unique position the SGR put physicians in. The SGR was supposed to regulate physician fees. When Congress abolished it in 2015, it transitioned physicians to value-based payments, which basically reward them for saving money for Medicare. This is done either through the Merit-Based Incentive Payment System or Advanced Alternative Payment Models (APMs).

After the SGR was abolished, physicians received modest yearly increases of 0.5% or less for 5 years, but, owing to other factors, actual reimbursement was lower than that amount. Since 2020, physicians have received no updates at all. In 2026, an even more modest increase of 0.25% is scheduled to begin physician-payment-on-the-decline-its-not-your-imagination/.

Working Harder to Compensate for Lower Payment

“As physicians saw the real payment for their work decline, the answer often was, ‘All right, I’m going to work harder,’ but you can only work so much harder,” said Brian Larkin, MD, a hip and knee surgeon at Orthopedic Centers of Colorado in Denver.

Larkin added that doctors have had to become more efficient, but they are often not rewarded for that by Medicare. “I have been doing hip and knee replacements in a very efficient, cost-effective way,” he said. He has been participating in Medicare’s Comprehensive Care for Joint Replacement Model, which has been rewarding hospitals for improved cost efficiency. But Larkin said the program did not reward doctors for using markedly less expensive ambulatory surgery centers rather than hospitals.

Through his value-based activities, Larkin had hoped to qualify for Medicare’s APM program, which would have rewarded him a 5% bonus. To qualify, however, he would have needed to have received at least 50% of his Medicare payments or to have 35% of his Medicare patients on a qualifying APM, but Larkin said not enough Medicare programs are available to reach that level.

“APMs sound good on paper, but they don’t have practical meaning in terms of benefiting providers,” Larkin said. His concerns about getting the 5% bonus will soon be moot, however, because 2022 is the final year to qualify for it.

When Payment Rises in One Area, It Must Fall Everywhere ElseOne major problem with Medicare physician payments is the principle of “budget neutrality,” which basically means that whenever reimbursement is raised for one service, payment for other services must be reduced. Specifically, when the rate of an RVU is raised by a certain amount, the overall conversion factor has to be reduced to account for that extra spending.

In 2021, primary care groups won concessions in their long-standing campaign to raise their reimbursements. The RVUs assigned to key evaluation and management (E/M) codes were raised significantly. For example, the work RVU for a visit by an established patient rose 34% 2021-e-m-changes-and-the-elephan.

“The E/M changes gave more money to primary care,” Parekh said. “But due to budget neutrality, money had to be taken away from the proceduralists.”

Parekh said the Centers for Medicare & Medicaid Services (CMS) could have softened the blow to surgeons by raising the value of the E/M component of their global surgery codes, but it did not do so.

“Budget neutrality can have the effect of pitting physicians against each other,” Parekh said. “But all doctors’ groups are united in their belief that budget neutrality must end.”

The Perils of More Congressional Cuts

CMS sets Medicare reimbursement each year, but Congress has been adding reductions to the CMS cuts. CMS has proposed a 4.42% cut for physicians in 2023, but the expected cut is actually 8.42% because an automatic 4% cut goes into effect when federal spending reaches a certain level. This cut is directed by Congress through the Statutory Pay-As-You-Go (PAYGO) Act of 2010.

PAYGO cuts were triggered by the American Rescue Plan Act of 2021, a $1.9 trillion package to offset the effects of the COVID-19 pandemic. If allowed to go through, the 4% PAYGO cut would affect all discretionary spending by the federal government, not just Medicare. These cuts were supposed to start in 2021, but Congress set them aside for 2021 and 2022.

Will Congress set PAYGO aside for 2023? Interest groups on Capitol Hill, including physicians’ groups, are asking for another year’s deferral, but PAYGO cuts will probably occur sometime in the future.

Another congressionally mandated cut is not counted in the 2023 cuts because it went into effect in 2022 and therefore is not considered a new cut. The Medicare sequestration is a 2% cut on all Medicare payments, not just those for physicians.

The 2% Medicare sequestration cut was in effect from 2012 to 2019, but Congress set it aside in 2020 and 2021 because of the pandemic. It phased it back in for this year. Is the Medicare sequestration here to stay, or can Congress be convinced to set it aside again?

“Now is a bad time for cuts, when inflation is so high and we just came out of a pandemic,” said Issada Thongtrangan, MD, a solo orthopedic spine surgeon in Scottsdale, Arizona. “Practice costs are going up and they keep cutting reimbursements.”

What Lies Ahead

Physician groups want Congress to go beyond simply overriding planned cuts every year. “Unless there is a fundamental change in the payment system, Medicare physician pay will likely be cut every year into the foreseeable future,” said George Williams, MD, an ophthalmologist in Royal Oak, Michigan, who is a spokesperson for the American Academy of Ophthalmology.

Budget neutrality, as it exists now, produces cuts whenever the value of services is significantly changed. The AMA is calling on Congress medicare-s-unsustainable-physician-pay to “eliminate, replace, or revise budget-neutrality requirements to allow for appropriate changes in spending growth.”

The AMA also wants physicians to have a reliable payment update. “The physician payment system needs to provide predictable and dependable annual increases that take into account inflation and rising practice costs,” said Jack Resneck, Jr, MD, a San Francisco dermatologist who is the 2022-2023 AMA president.

Furthermore, the AMA wants physicians to be able to participate in Medicare payment models that “recognize physicians’ contributions in providing savings and quality improvements, such as preventing hospitalizations,” according to an AMA report medicare-s-unsustainable-physician-pay.

In Resnick’s words, “Physicians are extraordinarily dissatisfied with the way Medicare pays them.”

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Council on Ethics Legal and Judicial Affairs

The CMA Board of Trustees took the following action on the Recommendations in the report from the Council on Ethical, Legal and Judicial Affairs

RECOMMENDATION 1: 501-21: Resolution to Condemn State-Sanctioned Torture of Detained Migrant Children

RESOLVED: That the CMA also publicly recognize that the treatment of these children is consistent with internationally recognized definitions of torture and as such cannot be tolerated in the United States, and,

RESOLVED: That the CMA recognizes that the detention of migrant children may threaten their short- and long-term health; and be it further

RESOLVED: That the CMA call for opposes an immediate end to the practice of separating migrant children from their families; and.

RESOLVED: That CMA call for immediate closure of all all migrant child detention centers and the release of these children to relatives or appropriate community foster care as stipulated by the Flores Agreement, and,

NEW RESOLVED: That the CMA supports the preferential use of alternatives to detention programs that respect the human dignity of immigrants, migrants, and asylum seekers who are in the custody of federal agencies.

RESOLVED: That this be referred for national action.

Board action: Approved recommendation as amended


Chair (term ending in April 2024)
Vice Chair (term ending in April 2024)
Treasurer; AANS Treasurer (term ending in April 2025)
Assistant Treasurer; AANS Chief Financial Officer
AANS President
AANS President-elect
AANS Past President
AANS Vice President
AANS Secretary
Stephen S. Scibelli, MD
Kenneth S. Blumenfeld, MD
Sepideh Amin-Hanjani, MD
Ann R. Stroink, MD
Anthony L. Asher, MD
Regis W. Haid, Jr., MD
E. Sander Connolly, Jr., MD
E. Antonio Chiocca, MD, PhD
Members, at large, term ending in spring 2023
Hooman Azmi-Ghadimi, MD
Maya A. Babu, MD
Nicholas C. Bambakidis, MD
Mark E. Linskey, MD
Catherine A. Mazzola, MD
Ian E. McCutcheon, MD
Jean-Pierre Mobasser, MD
Benjamin J. Remington, MD
Mark E. Shaffrey, MD
Jason D. Stacy, MD
Michael P. Steinmetz, MD
Frederick D. Todd II, MD
Members, at large, term ending in spring 2024
Nitin Agarwal, MD
Byron C. Branch, MD
Anthony DiGiorgio, DO, MHA
Kevin T. Foley, MD
Brian R. Gantwerker, MD
Elad I. Levy, MD
Praveen V. Mummaneni, MD
Peter Nakaji, MD
Anand Veeravagu, MD
Andrew E. Wakefield, MD
Henry H. Woo, MD
Laura Stone McGuire, MD
Meena Thatikunta Vessell, MD
Ex Officio:
Laura Stone McGuire, MD
Meena Thatikunta Vessell, MD
Chair, Washington Committee
SVP, Health Policy & Advocacy
Chair, CSNS
John K. Ratliff, MD
Kathleen T. Craig
Katie O. Orrico, Esq.
Joseph S. Cheng, MD

Photo of the Month

Photo of the Month

The photo was taken by Deborah Henry, MD, on August 6, 2022, on iPhone 11

Tidbits August

Tidbits August

August 1 – California’s governor Gavin Newsom declared a state of emergency to speed efforts to combat the monkeypox outbreak, becoming the second state in three days – after New York State – to take the step. Nearly 800 cases of monkeypox have been reported in California, according to state public health officials. California is usually in the lead.

August 2 – Vin Scully the voice of the LA Dodgers for 67 wonderful years, a legendary broadcaster, a poet, a gifted storyteller, a wonderful human, a role model, a friend, and a father and grandfather figure to millions of fans, dies at age 94. Ace pitcher Clayton Kershaw said it best: “Vin Scully was the best there ever was.”

August 3 – From FP – French mayor Jean-Marc Peillex—whose town of Saint-Gervais-les-Bains is a favored launch point for mountain climbers looking to climb France’s highest peak, Mont Blanc—has called for future adventurers to first pay a 15,000-euro deposit to cover the costs of rescue (or their demise). Peillex has decried the rise of “pseudo- mountaineers” who he says are putting too much strain on local authorities. “People want to climb with death in their backpacks,” Peillex wrote on Twitter. “So, let’s anticipate the cost of having to rescue them, and for their burial, because it’s unacceptable that French taxpayers should foot the bill.” A man driven by common sense.

August 3 – Richard Damadian, creator of the first M.R.I. scanner, dies at 86. Dr. Damadian and his research assistants finished building the first M.R.I. scanner more than 40 years ago. Originally known as a nuclear magnetic resonance scanner, or N.M.R., its first scan, on July 3, 1977, was of Lawrence Minkoff, one of Dr. Damadian’s assistants — a vivid and colorful image of his heart, lungs, aorta, cardiac chamber, and chest wall. We can’t even imagine Medicine, Surgery, Neurosurgery, Neurosciences, and scientific research without this technology.

August 4 – The Biden administration declared the growing monkeypox outbreak a national health emergency, a rare designation marking just the fifth such national emergency since 2001. The declaration by Xavier Becerra comes as the country remains in a state of emergency over the coronavirus pandemic. The World Health Organization declared a global health emergency over the outbreak late last month.

August 5 – To help fund the United States government during the Civil War, President Abraham Lincoln signed a new tax law on this day in 1861. With the help of Republicans in Congress, the nation’s first income tax was born. Congress levied a 3% tax on annual income over $800. Back then, laborers worked 10 hours a day, six days a week, and were off on Sunday. They were paid 10 cents an hour or 300 dollars a year.

August 6 – Fifty-seven years ago, President Lyndon B. Johnson signed the Voting Rights Act. The full title was: “An Act to enforce the fifteenth amendment to the Constitution, and for other purposes.” The title explained the need for this law. Although this law may not be needed here in California because we honor it, it remains to be necessary for many other states.

August 10- Seven years after its debut in Italy, Domino’s American Pizza Company has formally shut its stores after it failed to win over locals. I guess Italians did not like pineapple pizza and preferred the homegrown variety.

August 11 – The Centers for Disease Control and Prevention loosened Covid-19 guidelines on Thursday, freeing schools, and businesses from requiring unvaccinated people exposed to the virus to quarantine at home. In addition to eliminating quarantines, the new guidelines put less emphasis on social distancing, routine surveillance testing, and contact tracing. As the numbers stabilize and start going down, hopefully, this means that this pandemic is becoming more of an endemic and less of a concern.

August 15 – CNN – Thousands of mental health therapists are set to strike in California today. The unionized psychologists, therapists, chemical dependency counselors, and social workers are demanding that Kaiser Permanente – the country’s largest nonprofit HMO – provide “desperately needed” services to its patients, claiming that some wait months for needed therapy sessions. According to the National Union of Healthcare Workers, Kaiser staffs about one full-time mental health clinician for every 2,600 members, leading to therapists leaving Kaiser at a record rate. Please read “The Rise and Potential of Physicians Unions” in JAMA online, published July 28, 2022.

August 16 – The United Kingdom became the first country to approve a new COVID-19 booster shot designed to combat the Omicron variant BA.1 and will begin rolling it out this fall. The so-called bivalent vaccine, developed by Moderna, is not expected to produce high protection from the currently prevalent BA.5 variant. It seems we are still a step behind this virus.

August 16 – The F.D.A. will allow hearing aids to be sold over the counter, removing a barrier for millions of Americans who have not previously sought help. What did you say?

August 16 – President Biden signed into law the Inflation Reduction Act. It is a substantial piece of legislation that will make big investments in the environment and health care, increase taxes on some top earners and corporations, and … reduce the deficit. Why were insulin prices not capped at $35 for private insurers?

August 17 – A federal judge ruled that Walmart, CVS, and Walgreens must pay a combined $650.6 million to Lake and Trumbull Counties in Ohio for damages related to the opioid crisis. Opioids have become synonymous with EVIL. Is it any wonder that physicians are afraid to prescribe opioids even when necessary?

August 19 – California’s unemployment rate fell to 3.9% in July, the lowest since 1976. Employers in the nation’s most populous state continued to defy expectations by adding 84,800 new jobs. We can use good news here in the Golden State!

August 22 – Governor Gavin Newsom vetoed a measure that would have allowed the creation of safe drug- consumption sites in three major California cities as part of an effort to cut the surging number of fatal overdoses. Newsom suggested the clinics might actually encourage illegal drug use. The measure passed California’s state legislature in early August after nearly two years of debate.

August 22 – CNN – Dinosaur tracks from around 113 million years ago have been revealed at Dinosaur Valley State Park in Texas due to severe drought conditions that dried up a river. “Most tracks that have recently been uncovered and discovered at different parts of the river in the park belong to Acrocanthosaurus. This was a dinosaur that would stand, as an adult, about 15 feet tall and (weigh) close to seven tons,” park spokesperson Stephanie Salinas Garcia said in an email. This is a definite silver lining in an otherwise sad drought condition.

August 23 – The San Diego Zoo Safari Park on Monday announced the arrival of a male white rhino born to a first-time mother, Livia, at the Nikita Rhino Resource Center. Happy news for a change.

August 24 – Germany is starting hydrogen-powered trains in Lower Saxony. The trains are emissions-free and low-noise, with only steam and condensed water issuing from the exhaust. They have a range of 1,000 kilometers (621 miles), meaning they can run for an entire day on the network on a single tank of hydrogen. Such a piece of good news for the environment.

August 24 – California Air Resources Board issued a rule requiring that all new cars sold in the state by 2035 be free of greenhouse gas emissions like carbon dioxide. The new policy may accelerate the global transition toward electric vehicles. California is the largest auto market in the United States. A very ambitious goal.

August 24 – Mack Rutherford, 17, landed in Sofia, Bulgaria, on Wednesday, ending a 30-country, 30,000-mile journey and becoming the youngest pilot to circle the globe alone in a small plane. Impressive young man.

August 25 – Governor Gavin Newsom announced the appointment of Dr. Diana Ramos as California Surgeon General. Dr. Ramos has expertise in health equity and reproductive health. She currently serves at the California Department of Public Health’s Center for Healthy Communities, overseeing the state’s public health and prevention programs. The Governor created the role of Surgeon General in 2019 on his first day in office. His latest health-related action was the signing of AB 35.

August 28 – A Mickey Mantle baseball card from 1952, his rookie year with the Yankees, was sold at auction for $12.6 million. This is record-breaking, making this card the most valuable sports collectible in the world. Mantle, born in Spavinaw, Oklahoma, spent 17 years playing for the New York Yankees and was inducted into the Baseball Hall of Fame in 1974.

August 29 – NASA called off the scheduled launch of Artemis I, the first NASA trip to the moon in 50 years, because of an engine issue. I was very disappointed that the launch was postponed, but I am glad we are resuming our moon exploration. Artemis, the daughter of Zeus and the twin sister of Apollo, is the goddess of the hunt!

August 30 – The International Day of the Disappeared. It is a good idea to reflect on the hundreds of thousands of people who are missing worldwide due to armed conflict, violence, disasters, and migration.

August 31 – The Food and Drug Administration authorized the first redesign of coronavirus vaccines since they were rolled out in late 2020, setting up millions of Americans to receive new booster doses targeting Omicron subvariants as soon as next week. I plan to get it as soon as it becomes available to me.

Letters to the Editor

Letters to the Editor

August 14, 2022
Dear Dr. Abousamra,

It has now been seven months since you took over as the full-time new CANS newsletter and I wanted to take a moment to thank you for your hard work and efforts and a terrific job so far. Taking over from a true neurosurgery newsletter icon such as Dr. Randy Smith is never an easy task, but I think that you have made an excellent start. The newsletter is expanded in scope and content reflecting your new ideas, vision, and input. In terms of new editions, the historical vignettes are very interesting and will serve as archival resources for CA neurosurgery and CANS. The Private Practice, Academic Practice, and Large Group Practice Corners are excellent new additions bringing the full range of perspectives on issues important to CA neurosurgeons. The Resident’s Corner, Medical Student essays, and Women in Neurosurgery sections broaden readership interest in the CANS newsletter and provide new and differing perspectives on issues important to CA neurosurgeons. At the same time, California and national legislative and health policy issues important to CA neurosurgeons continue to be brought to our attention in a timely manner. Personally, I read the newsletter cover-to-cover as soon as it comes out each month. All-in-all I think you have expanded and improved an already excellent society newsletter. I wanted you to know that your hard work and efforts are noticed and certainly appreciated. Thank you for all you are doing.
Mark E. Linskey, MD, FAANS
Professor of Neurological Surgery
Department of Neurological Surgery
University of California Irvine

August 19, 2022
We were disappointed to read Moustapha AbouSamra’s editorial on “Changing Times” in the June 2022 issue of the CANS newsletter. He describes how physicians have lost control of Medicine to Hospital Administrators and the government, the decline in physicians’ reimbursement, while the hospital administrators’ salaries have increased significantly. He states that many physicians are employed by hospitals or large medical groups and laments that physicians have lost control of the patient. Any attempt to object by them will be met with the dismissal of the physician, labeled as “disruptive”, implying that their reputations would be damaged. He indicates that physicians can no longer determine the patients’ treatments, which are now controlled by insurance companies or governmental regulators. Moustapha states, “When we accept the care of a patient, we enter into a sacrosanct contractual relationship with the patient in which we are bound to choose the best course for that patient.” He says Doctors no longer have the power to provide care for the patient. What has happened to that unwritten contract to do everything possible to help the patient by the doctor? What Moustapha does not address is how did all of this happen … Moustapha offered no solution to his colleagues …

James I. Ausman, MD, PhD
Miguel A. Faria, MD

Editor’s note: Drs. Ausman and Faria’s letter is appreciated, and their criticism noted. They included in their response an essay 13 pages long with detailed references that I cannot publish here due to space limitations. However, this essay titled “American Medicine: Central Control and Corruption, The Patient Comes Last” will be Published in Surgical Neurology International in the next month or two. Here is the link:



Western Neurosurgical Society: Annual Meeting, September 9-12, 2022, Kona, Hawai’i, HI
CSNS Fall Meeting October 7-9, 2022 San Francisco, CA
CNS Annual Meeting October, 9-15, 2022 San Francisco
CANS, Annual Meeting, January 13-15, 2023 – Riverside, CA The Mission Inn
CSNS Spring Meeting Los Angeles, April 19-21, 2023
AANS, Los Angeles, April 21-24, 2023
NSA meeting, Chatham, MA, June 18-21, 2023
WNS Meeting Portola Hotel & Spa, Monterey, Sept. 29-Oct. 2, 2023
WFNS Cape Town, December 6-11, 2023

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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• Comments can be sent to the editor, Moustapha AbouSamra, M.D., at
or to the CANS office

• Past newsletter issues are available on the CANS website at

• If you do not wish to receive this newsletter in the future, please E-mail, phone or fax Emily Schile (, 916-457-2267 t, 916-457-8202 f) with the word “unsubscribe” in the subject line



CANS Board of Directors

CANS Board of Directors