Volume 51, Number 12

Inside This Issue

Picture of Joseph Chen, MD

Joseph Chen, MD

CANS President

Cause and Effect

President's Message

The practice of medicine continues to change apace with increasing automation and industrialization made possible by a combination of powerful information technology, governmental incentives and large capital investments from the financial industry.  

As the era of the artisanal practice of medicine comes ever closer to a close, organized advocacy on behalf of doctors will be of increasing importance.

Your California Association of Neurological Surgeons serves a vital role in representing the interests of all our members at the state and national levels.  Your participation in this organization is critical to ensure that your voice is heard, your experiences are shared and the interests of the physician-patient relationship are served.  We can only do this by coming together in a unified manner in an organization dedicated to the highest levels of integrity.

This is my last editorial as your President of the California Association of Neurological Surgeons.  It has been a tremendous honor to serve in this position and I will look back fondly over this last year far into the future.  Yet, this time to serve is necessarily limited so as to preserve the health of our organization through a constant renewal of our leadership.  Only in such a way can this organization, year in and year out, preserve its vigor and focus on the things that matter most to our membership and to our patients.

I’m excited to be turning over the gavel to my esteemed colleague, Dr. Ciara Harraher –  a dynamic and trusted advocate for neurosurgeons in California – at our next annual meeting in San Francisco, CA at the historic Intercontinental Mark Hopkins Hotel, January 12-14, 2024.  I hope to see you there and share important insights into this critical time in neurosurgical practice.

As always, my best wishes to you and your cherished ones.


Annual Meeting Info

There is still time to register.  Please do so at this link:

Byron Cone Pevehouse Distinguished Service award recipient: Lawrence Shuer, MD

CANS Lifetime Exceptional Service Award recipient: Moustapha AbouSamra, MD

These awards will be given during the Saturday night banquet. There is an option to sign up for this banquet on the registration page.

Quote of the Month

“Celebrate endings–for they precede new beginnings” — Jonathan Lockwood Huie

Author picture

Private Practice Column

Episode 23: Crossing the Junction: how to work with people who want to see you fail

“Nothing is permanent in this wicked world – not even our troubles” -Charlie Chaplin

This past November I got a particularly bad flu that had been going around.  I was feeling particularly crappy just being sick but also some very difficult times with events around the world.  I got better, of course, just in time to leave town for Thanksgiving.  We tried to work my schedule so that I don’t do anything major before I leave town.  Which is akin to telling a cat to do a crossword puzzle, but I do try.

Even with that, patients have a tendency to have issues right before or right after one leaves town. If I have someone or some issue on the bubble, I am able to call on colleagues and frankly, competitors, who are willing to be there to back me up.  I’m fortunate that I can call on these surgeons to lend a hand. It took years, getting to know these other surgeons, both ortho and neuro, and for them to get to know me. If I have a spine case, I can call either, and obviously a neurosurgeon in another group has been great backing me up for cranial cases.  I am fortunate that I have to pull the favor card rarely, but I have help if I have to go out of town.

When I first started at my hospital, I came in like a bull in a China shop and should have been a little more subtle. It ruffled some feathers – and I ticked one or two people off just my showing up.  Instead of hanging out and meeting some of the other surgeons, I jumped at the chance to start taking call and introduce myself to the ER docs.  I figured it was easier to ask for forgiveness than permission.  Getting fairly busy in a reasonable amount of time, I took a lot of call and saw a lot of cases.  There were better ways, looking back to show up than just come crashing in.

While I did make the effort, introducing myself to the chief of the service.  It was a rocky start, as when he did ask me to come on one night for him (there was no formal call schedule and it was catch as catch can) I couldn’t as my father-in-law was hospitalized having just undergone an emergency cardiac bypass and was on a ventricular pump. It was touch and go for him. 

I kept working, really without much break, for about 5 years.  Relations with the other people on staff got better as I got settled in and folks got to know I tried to work hard, show up when called, behaved as a mensch in the operating room, and offered advice if colleagues ever hit me up.  I covered other colleagues if they left town and their partner could not, or if one of the mid-levels needed some oversight and they were stuck in the operating room and I was around. 

Goodwill is a really good way to build interpersonal capital. During M and M I don’t really chime in on someone else case unless someone asks me.  I present my own cases when they come up with a sense of humility, straightforward, and definitely with a sense of the gravitas. 


For me, things settled down but it took a significant amount of time and change.  New surgeons come on and some go, and I keep my head down and grind on.  12 years on, and I’ve been through my share of crap, but I have also showed my ability to not get into trouble most importantly, but also how to fight my way out of the den of bears when I step in it.  Working alongside other surgeons who do the same thing, and we compete for some of the same patients, I have learned to not take it personally (for the most part), but also to work hard to be better and to build trust and a good reputation out in the community. 

My personal experiences being solo for most of my professional career have been critical life lessons. When others see how you handle not just the easy stuff but when stuff goes left instead of right, either passing in the hall, chatting with the OR front desk staff, or even M and M, your modesty and competence can help you not only mature, but also create a sense of community with your fellow surgeons.

Personal enmity can always get in the way of building relationships with people you need to back you up, but also share patients with. And sometimes, help you out when everyone has been doing fine, and you are on that

plane to visit your mom and suddenly someone’s leg pain came back gangbusters or clear fluid is leaking from their scalp.

Showing your colleagues personal accountability on your own cases but also if you see their patients in clinic, not needing to shove your colleagues under the bus even given the opportunity. Part of being a mature surgeon, and frankly and adult, is being able to express your opinion without putting someone else down or out is one of those Maslow achievements we should all get to.

There is a certain dance we do with people we compete with but also paradoxically rely on.   Abiding respect and basic understanding that we are all good surgeons and decent people is a good start. While we may count on partners, people outside our own practices offer a unique perspective on our own selves. Many times, external colleagues are gracious and even helpful. While you may never “date,” certainly there are good opportunities for collaboration or even helping out in a jam. 

In neurosurgery, we are bred to be fiercely independent and that we are the smartest people in the room. We have to realize that although that may be true, that at one time or another, we may need a friend or two.

And at the end of the day, don’t be a putz. We are all in the same boat, more or less.

Happy Holidays to all, and to all, a good month. And, as my dad used to say: “good luck and good bowling.”

Take care and be well.

Picture of Anthony M DiGiorgio, DO, MHA, FAANS

Anthony M DiGiorgio, DO, MHA, FAANS

Academic Corner

Ah, the pager: often the subject of jokes about healthcare being stuck in the past. NPR’s Planet Money podcast attempted to explain the widespread use of pagers in healthcare and, in typical NPR fashion, completely missed the point.

They discuss a California hospital that tried to replace pagers with a HIPAA-compliant text messaging system, aiming to simplify contact between the ER and consultants. The podcast hosts and ER doctors who implemented the program were shocked when consultants resisted the change. This reduced friction in contacting consultants, which meant consultants became inundated with “curbside” consultations, adding to an already overwhelming deluge of messages.

Low-friction communication isn’t inherently bad. In fact, many consultants openly share their cell phone numbers in the ER and at every nurse’s station in the hospital. In other hospitals, physicians are insulated by layers of residents and/or APPs.

The crux of the issue lies with autonomy.

Corporate America has understood the importance of this for years. Well-run companies maintain hierarchies but encourage autonomy among lower tiers. The upper levels of the hierarchy aren’t bogged down with minutiae because their subordinates have enough autonomy to handle those decisions. Only big-picture issues make it up the chain, fostering dynamic, adaptable systems that encourage creativity.

In contrast, healthcare often structures hierarchies so that every minor detail is escalated up the chain of command, leading to sclerotic and paralyzed decision-making processes. This is what healthcare has become: inundated with mundane inquiries, while significant, big-picture questions (and much quality patient care) go unaddressed.

Various factors contribute to this situation. Top-down controls have stripped nurses of much of their independence. Seemingly minor practices, such as allowing verbal orders or dosing ranges for pain medications, are deemed “dangerous” by certain authorities. ER physicians feel compelled to consult, even in situations where they know the consultant will not intervene, “just to get them on board.” This cult of safetyism has significantly limited many frontline clinicians, often without considering the unintended consequences.

Some hospitals have resisted this erosion of autonomy from the bottom-up. However, there’s still a role for top-down authorities like the Joint Commission or CMS in endorsing autonomy. Practice guidelines from specialty societies could provide protection against medical malpractice, and some areas have successfully experimented with medicolegal “safe harbors” to reduce unnecessary consultations and resource utilization. In these cases, the safe harbors protect clinicians from liability if they adhere to established guidelines for common conditions such as low back pain and minor head trauma.

Granting autonomy to frontline clinicians means there will be misses. A nurse might misinterpret a verbal order. An ER doctor might miss a cauda equina syndrome. However, restricting autonomy doesn’t

necessarily prevent these misses. If every back pain patient receives a neurosurgery consultation, the consultant might still miss the true positive due to alarm fatigue. If every order must be manually entered by a physician into a cumbersome EHR, doctors will spend excessive time on computers, leaving less time for patient care. As Thomas Sowell says, “there are no solutions, only trade-offs.” Many institutions have traded away autonomy for a presumed sense of safety, only to end up with neither.

At one point, the pager was a low-friction means of communication; the doctor could be reached outside the hospital. Now, it acts as a natural barrier, protecting consultants from a barrage of micromanagement questions in environments lacking autonomy.

The pager isn’t the problem. The issue lies with the executive with the mindset that a neurosurgeon must be disturbed in the middle of the night for every colace order or to clear every cervical collar.

That’s the episode NPR should air.

Thank you Exhibitors!

CANS would like to extend our gratitude to our exhibitors! Without them, the annual meeting would not be the same.  Please make sure to stop and learn about products and services offered!

The following companies will be present and available in the Room of the Dons at the Intercontinental Mark Hopkins:

Astra Zeneca
BK Medical
Day Surgical
DePuy Synthes
Integra LifeSciences
Mitaka USA
Moeller Medical
Ruthless Spine
Surgeons Capital Management
Tobra Medical

Picture of Yagmur Muftuoglu, MD

Yagmur Muftuoglu, MD

CANS Resident Consultant PGY5

Residents Corner

– Riverside University Health System

“I don’t understand the need for these protocols; they seem more like inefficient roadblocks,” I sweetly yapped at the well-meaning lab managers, merely doing their best to keep me in line. As the words fell out of my mouth, I realized I had heard them many times before. These were sentiments uttered by wiser more senior residents, usually shared with other hospital staff, often of the nursing persuasion. 

Added to my urgency as a research-year resident is the importance I place on the scientific education and training of my young lab team, comprised mainly of two highly promising undergraduates. I cannot explain the wave of sadness that washed over me the day I needed to send one home to complete additional unforeseen paperwork. Or the day I realized they were struggling from lack of access to a few specific resources, something I immediately hustled to fix.

Neurosurgical residency offers unparalleled training in clinical and surgical skills, but also in negotiation and time management. Improvements I had thoughtfully made in these areas over the past few years, combined with a steady focus on pushing forward multiple projects, seem to have made me actually fit in less well in the lab, but this is a trade I will happily make. After all, swimming upstream and against the tide, or settling in where I do not naturally belong, have resulted in some of the best decisions I have made to date. 


CANS, Annual Meeting
Intercontinental Mark Hopkins, San Francisco, CA January 12-14, 2024

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. Joseph Chen in the preparation of this newsletter is acknowledged and appreciated.

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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