Newsletter

Volume 50, Number 12

Inside This Issue

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

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

CANS President

CANS’s 50th Anniversary Annual Meeting: Looking Back & Looking Ahead

President's Message

While we all believe that social upheavals in one part of the world can ultimately effect consequences far away (as, for example, in the expansion of a war beyond the initial two combatants to include other nations), classical physics assumes that physical phenomena are limited to where they take place, or that they cannot

instantly affect physical phenomena far away—this bedrock assumption about the laws of physics, referred to as ‘locality,’ was upended when the 2022 Nobel Prize in Physics was awarded to three researchers (Alain Aspect, John Clauser, and Anton Zeilinger) for providing experimental proof of the counter-intuitive phenomenon of QUANTUM ENTANGLEMENT, which permits subatomic particles that are inter-connected or ‘entangled,’ to continue to communicate and act in unison despite immense separation (without any physical connection or force between them). Physicist John Bell proposed the idea, Bell’s Theorem, in 1964, which states that entangled particles could be billions of light years apart and still remain entangled or reflect a sense of each other, SIMULTANEOUSLY!  This concept is a true mind-bender, as it implies communication between these subatomic particles at a pace faster than the speed of light, which classical Physics and Einstein told us was impossible without disrupting the spacetime continuum. Because of the mind-bending nature of the theory of quantum entanglement, Albert Einstein mocked the idea as “spooky action at a distance.”

The 2022 Nobel Prize in Physics was announced on Tuesday 4th, October of this year, and inspired me to read about Quantum Entanglement right away and to discuss it soon afterward in the OR with my residents and medical students as we admired an exposed brain. Interestingly, the last time I had this discussion on quantum entanglement was in 2017, when my then 11-year-old son Amman had created a website on the subject that he appeared to understand but the nuance of which I did not fully appreciate (till the Nobel Prize was given). The recent re-introduction of quantum entanglement to my consciousness made me ponder the impressive quality of the human brain in processing the same information differently when presented from a different source. Was this some complex brain bias, or was it just me not paying attention to a kid?

Astronomers look into space for evidence of life’s origins; theologians look into holy books for the same; philosophers look for wisdom in logic. As a neurosurgeon, I have always looked into the brain in search of the universal truths that others look for elsewhere. I never fail to be left in awe when I see the exposed brain; interestingly, not only has this fascination not waned over time for me, it has at times risen to a level one might describe as a spiritual experience.

I think that quantum entanglement offers my own cynical yet analytical brain an appetizer towards a reproducible, rational, and scientific worldview, which hunger other meta-physical explanations hitherto have failed to satisfy. Finally, I am being offered a way to bridge the distance between my consciousness and that of my patient/humanity in a way that was hitherto intuitively attractive to me but not based on overtly scientific principles. While we may be inches apart as surgeon and patient when we enter that magical organ in pursuit of a tumor or an aneurysm, the surgeon and patient are metaphorically and physically one, or in the rhetoric of physics, entangled. Another way of looking at it: taken together the patient’s 86 billion neurons and their approximately 920,000 km of axons and dendrites (reference: https://aiimpacts.org/transmitting- fibers-in-the-brain-total-length-and-distribution-of-lengths/)– and the same each for the neurosurgeon, residents, anesthesiologists, and nurses–could

cumulatively put us light years apart; yet, with what my 11-year-old son and the 2022 Nobel Prize committee have told me, it warms my heart to think that physical distance could be meaningless in some formulations of the laws of physics, defying locality as a prerequisite of interconnectedness, and in fact offering us a new twist on empathy, love, and affinity, whether separated by inches or light years. Is it far-fetched to posit that physically, the neurosurgeon and the patient whose brain she/he may be operating upon can be ‘entangled,’ working together to the same end?

I have always promised my patients the benefit of my education, experience, and, perhaps more importantly, the full scope of my humanity in support of the battle against their disease or predicament. Yes, the concept of quantum entanglement, as currently formulated, is about interdependent sub-atomic particles—an immediate connection, so to speak; however, such entanglement extrapolated into my microcosm of the universe, the operating room, does offer me a chance to connect with, and be connected to, the patient in front of me, and thus to all humanity in real- time, in a way that is unique and meaningful (without being fanciful).  It’s hard not to be excited about the immense possibilities for imagining humanity as a collection of sub-atomic particles that have the potential of entanglement/synergy/empathy/love/affinity, and not just as a clump of cells in a random broth, individuals disconnected from each other in both time and space.

See you at the Mission Inn & Spa, Riverside, CA For the CANS 50th Annual Meeting

January 13-15, 2023

For information about registration and room reservation Please see pages 25-27

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Report

This is the time of year when we look back and reflect on what we did and did not do. It is also the time when many of us make ambitious resolutions, many of which are destined to be ignored or forgotten.

This newsletter is a labor of love for this writer and your editorial committee. I hope we succeeded in providing you, our dear readers, with content that kept your interest. We know that not everyone agrees with every opinion expressed on these pages. But we are fortunate that the CANS Board has given us total editorial freedom. This reflects the maturity that CANS has accomplished over the years. It makes every CANS member and all neurosurgeons throughout the Country proud of our successes. CANS celebrates its 50th anniversary next month at the Annual Meeting that will be held at the Historic Mission and Spa in Riverside, California.

The Mission Inn was beautifully decorated for the Holidays!

One of our proud accomplishments is the monthly publication of “Women in Neurosurgery.” This reflects our commitment to addressing issues of gender equity from various female perspectives. In this issue, Rukayat Taiwo, MD, Neurosurgery Resident, PGY4, from Stanford University, advocates in her excellent essay “Embracing our Individuality.” She trains in an environment where women have been given equal opportunities over the last few years and where both male and female role models have paved the way; Gary Steinberg deserves special recognition. The fact that of the twelve “Women in Neurosurgery” essays we published this year, Stanford women neurosurgeons wrote five reflects Stanford’s admirable success. Clearly, not every institution has been able to accomplish the same degree of success, and much work remains to be done.

But clearly, things are changing. And change is affecting not only our profession but many others. The latest example is the orchestral world. The New York Philharmonic, an all-male bastion for most of its 180 years of existence, currently has 45 women and 44 men. And they dominate some sections of the orchestra more than others: 27 of the orchestra’s 30 violinists are women.

On September 30, California Gov. Gavin Newsom signed into law Assembly Bill 2098, which authorizes state regulators to discipline doctors who “disseminate misinformation or disinformation related to COVID-19.” The law, which is scheduled to take effect on January 1, defines “misinformation” as advice “contradicted by contemporary scientific consensus.” Newsom explicitly acknowledged the First Amendment issues raised by A.B. 2098 by writing, “it is narrowly tailored to apply only to those egregious instances in which a licensee is acting with malicious intent or clearly deviating from the required standard of care while interacting directly with a patient under their care.”

But as the New Civil Liberties Alliance (NCLA) points out in a federal lawsuit it filed yesterday, Newsom’s signing statement does not alter the broad language of A.B. 2098, which will be enforced as written. The NCLA, which represents five California physicians who object to the new law, argues that “it violates the First Amendment by punishing doctors based on the views they express and the 14th Amendment’s guarantee of due process by imposing an unconstitutionally vague standard of acceptable speech.”

This writer is so glad that we live in a country with the First and the Fourteenth amendments. And that we have a government with three independent branches, including the Judiciary, that acts as an arbiter in any dispute and as a balancing power for both the legislative and executive branches.

In this issue

  • This is a beautiful time of the Most everyone gets in the spirit of giving of themselves and of celebrating others. Brian Gantwerker illustrates the point beautifully: as a Jewish neurosurgeon, he always takes emergency calls on Christmas, allowing his gentile colleagues to be with their families without interruptions. This reminded me of when I came to Ventura in 1981. I joined the president of the only Jewish Temple in Ventura, Beth Torah, an Elder in the Presbyterian Church, and a dedicated Catholic. Raised Muslim and married to a Catholic, I replaced the founder of our group, who was also a dedicated Catholic. My wife Joanie and I, with three children under the age of five, celebrated Christmas and its magic and believed in Santa Claus. The late Paul Karlberg, my Jewish partner, signed up to be on call every Christmas. My magical time with my children was always protected. Thank you, Paul, and thank you, Brian!
  • Anthony DiGiorgio addresses a critical topic in his essay, Electronic Health Records & Resident Education, and how much time addressing it takes away from face-to-face patients care. I must confess that I, too, had to adapt to using EHR during the last few years of my practice. It was one of the primary reasons I decided to retire when I did; I enjoyed taking care of patients. The system that our hospital selected and my practice adopted was clumsy and “not ready for prime time.” It took away valuable face time with my patients or crucial time with my family, as I often had to
  • Finally, please read and reflect on President Javed Siddiqi’s final message. It offers a philosophical/scientific view of how we and our world are interconnected. It also offers us hope. Thank you, Javed, for this and for your

As we end this year, I take the editor’s prerogative to celebrate the career of America’s Doctor Anthony Fauci. I have previously expressed my admiration for Dr. Fauci. I think I am not alone in this sentiment; many of us admire him. I do believe that we all, physicians and Americans owe him a debt of gratitude. He wrote a guest essay in the New York Times in which he indicated that he learned to “expect the unexpected,” a lesson from which every neurosurgeon benefits. https://www.nytimes.com/2022/12/10/opinion/anthony-fauci- retirement.html?smid=url-share

May you enjoy your retirement, Dr. Fauci! HAPPY NEW YEAR!

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

Using the Retrospect-O-scope

My life is full of mistakes; they’re like pebbles that make a good road.
Beatrice Wood

Changing Times

In his famous song, “A Boy Named Sue,” written by the inimitable Shel Silverstein, Johnny Cash acknowledges that being named Sue may have prepared him for a tough life but that given a choice, he’d call his son anything but … Sue!

On December 5, 2017, seemingly in the blink of an eye, we lost our home to the vicious and very destructive Thomas Fire. It was, then, the largest wildfire in the history of the State of California. It burned 575 houses in our city of 100 000 people. Our home and all its contents burned to the ground; nothing was left. Even our three cars parked in the driveway burned and were almost unrecognizable. We were fortunate that we were not home, so we were safe. And miraculously, there were no fatalities in San Buenaventura; perhaps Ventura lived up to its lucky name.

557 on Fire: Morning of December 5, 2017. Photojournalist Rob Virela took this photo
Please note that the firefighters could not fight the fire; the fire hydrant in front of the house had no water.

I had just retired and was in Washington, DC, with my son Omar. We were both preparing to travel to Indonesia, the first of what I hoped to be many overseas trips. I had planned several with my wife Joanie and other family members and friends. Joanie was at our ranch in Texas and was not planning to go with me for this trip.

The trip was canceled, and we returned home to deal with the aftermath of this calamity. More than ever, our entire family needed to be together. But the home we lovingly referred to as 557 was no longer available, and we needed access to a place large enough to accommodate our family. Divine providence intervened, and friends of our family offered us the use of their ranch house in Hillsborough, CA; it was a magical haven where we sat together, hugged each other, and, yes, cried together and tried to start the healing process. It was great for a couple of newly minted nomads to spend our first Christmas with our entire family in this peaceful place.

The first item of business with which our family had to deal, in addition to the hundreds of more minor decisions, was whether or not to rebuild our house.

We loved 557 and everything about it. Our adult children loved it, too, and looked forward to spending their summers and holidays together there. We were blessed with six grandchildren then and dreamed of having them come often and achieve some of their milestones there. I remember vividly Zahra Joan taking her first steps there … Each of us had a strong emotional attachment to this beautiful refuge; it was our safe place; designing and building a home- something we had not previously done – can be a joyous experience.

So why not rebuild it? Why not, indeed? Added to the decision-making elements were the following facts: we had what was described to us as the best homeowner’s insurance coverage available; The city of Ventura promised to bend over backward to remove bureaucratic obstacles so rebuilding could proceed smoothly; I had the time to supervise such a project since I had just retired and was looking for things to keep me occupied.

The decision was made with a sunny optimism that made us giggle. We were at once excited and very apprehensive.

As the reality finally sunk in, we realized our mental health had suffered. We had to seek counseling and were told that we were experiencing PTSD. What? Is PTSD not something you developed after suffering/witnessing horrific experiences on the battlefield? We survived and dealt with this privately and with the help, support, and love of family members and friends.

Who would have predicted a worldwide Pandemic followed by significant supply chain problems, a significant increase in the price of building materials, and worldwide inflation? We didn’t.

What we should have predicted, however, was that bureaucracy is in any city’s DNA and every step of the permitting process took longer than expected – no, no one bent over backward; dealing with the insurance company was not as straightforward or seamless as promised, and it delayed our project significantly. And we also should have predicted that the State of California adds code upgrades to buildings almost daily, whether commercial buildings or private homes, these codes cost money.

An interesting, and I’d say sobering, piece of information I learned recently on the fifth anniversary of this awful fire is that more than half of the houses lost to the fire in our city have not been rebuilt. There are, of course, many reasons for this. But some say they gave up on this process since permitting took so long …

As COVID-19 hit, all our pleasant and exciting meetings with our architect and his team had to be done on zoom, and consequently, we missed a lot of the details; in fact, we overlooked some significant mistakes that came with a steep price we are paying now. Here went the joy and fun part.

Who imagined that the trend that started before the fire, of having to do everything online, would become the only option? Often, websites do not list a phone number one can call, adding to the everyday frustrations. And if you were lucky to find a number to call, the person on the other end of the line would be from a different time zone, continent, and world.

The silver lining? Well, Joanie and I learned a lot and “grew up.” If I had the time, I’d sit for a graduate degree in dealing with insurance companies. I’d pass it; I should write a book about this subject. One of the chapters would deal with the confusing language insurance companies use purposefully. Another, with the delay tactics they use that result in our reimbursement staying in their pockets for as long as possible, even after agreeing that it is ours.

It has been five years since the fire. We are in the “buttoning up” stages of building our house. But honestly, I didn’t know that so many unfinished items in this house fall under the “buttoning up” category. The good news is that we will soon have a beautiful place large enough for our entire family. The new 557 will hopefully soon be transformed into the home of our dreams by our grown children, our ten grandchildren, other members of our extended family, and friends.

We recently learned what it takes to pass the final inspection so that our city can grant us a certificate of occupancy. Very little. In addition to the safety features, including roof sprinklers and fire alarms installed earlier, one has to have one functioning bathroom, a range in the kitchen, not necessarily a refrigerator, and of course, water, electricity, and gas. And let’s not forget a mailbox at the curb with visible and reflective four inches-tall numbers. 557.

So, although the coveted certificate of occupancy was granted on December second, three days short of the fifth anniversary, our house is still being prepared to receive us. We had dreams of spending Thanksgiving and Christmas there. This did not happen. But our family was together for Christmas – Leyla and her family’s flight from Austin was canceled on Christmas. On December 26, we gathered at an empty and not entirely ready 557 – Leyla and her family were with us in spirit – and raised our glasses to celebrate a hopeful and happy future at this magical place!

View from Sunset Patio at 557 on December 26, 2022, at 4:35 PM

Now, using my infamous Retrospect-O-scope and asking myself: should we face a similar situation in the future, would we opt to rebuild? Probably not!

Quote for the Month​ of December

Quote of the Month

” The mind is like a car battery – it recharges by running.
Bill Watterson – Calvin and Hobbes


Donald Prolo, MD, FAANS, FACS

History of Neurosurgery in Santa Clara County 1957-2012 Personal Experiences

Historical Vignette

Stanford University School of Medicine

One of the major medical events in Santa Clara County was the transfer of Stanford University School of Medicine from San Francisco to the Stanford campus in 1959. Stanford Medical School celebrated its 100th year anniversary in 2008, having acquired Cooper Medical College of San Francisco in 1908. Cooper was the first medical school in California and previously had been associated with College of the Pacific, now University of the Pacific. From 1908 to 1959 Stanford medical students studied basic sciences (anatomy, microbiology, physiology, pharmacology, biochemistry, statistics, etc.) on the Stanford campus for four quarters then transferred to the Stanford Hospital on Clay and Webster Streets for clinical studies during the last two quarters of their second year and their third and fourth years.

Completion of the new medical school and hospital at Stanford in 1959 caused a major change to occur in the panoply of medicine in Santa Clara County. The Palo Alto Medical Clinic and local physicians became active participants in teaching programs at the newly constructed Palo Alto-Stanford Hospital. Stanford adopted the Valley Medical Center (VMC) as one of its teaching hospitals, having vacated its association with San Francisco General Hospital. Neurosurgeons at the new hospital in Palo Alto were Doctor John Hanbery and Doctor James Golden from the Palo Alto Medical Clinic, and community neurosurgeons Doctors Lawrence Arnstein and Dan Meub. Earliest neurosurgeon at El Camino Hospital was Doctor Robert Lichtenstein. From the 1950s onward neurosurgeons in San Jose included Doctors Pierce Barrett, Henry Harper, James Markham, Harold Lynge, Hector Mackinnon, Gray E. B. Stahlman (1922-1969), Leon Becker, A. Stephen Genest, Philipp Lippe and Kalman Cseuz. All of these neurosurgeons had completed their training outside of California at various medical centers throughout the United States.

Doctor John Hanbery graduated from Stanford University School of Medicine in 1945, completed a surgical residency at Stanford, a neurosurgical residency under Doctors Wilder Penfield and William Cone at the Montreal Neurological Institute in Canada, returned to Stanford as a professor, initiated the neurosurgery residency program and became the first Chairman of Neurosurgery at Stanford in 1961.

By September 1959 all new hospital and medical school buildings were ready for occupancy on campus. Early classes generally were deprived of an enriched clinical experience. There were few patients from whom to learn our profession, a source of resentment by most members of the class. The university was prescient in moving the school to campus in view of the subsequent growth in population and industry of Santa Clara County (Silicon Valley) in comparison with the land-locked San Francisco County, where the population mix was older and smaller in numbers. Further, interdisciplinary studies between medical school and university faculty were facilitated, leading to major collaborative medical breakthroughs in the years since the move to the campus.

Early Neurosurgeons in Santa Clara Valley Dr. Hector MacKinnon died in 1996. Dr. Harold Lynge, died in 2011, twenty years later. Both continued to provide neurosurgical expertise to the neurosurgical community for the rest of their years. Dr. Philipp Lippe was actively engaged with his multiple strong talents and energies directed toward the organizational and administrative medicine (AMA, CMA, California Association of Neurological Surgeons, American Academy of Pain Medicine, American Board of Pain Medicine and other national and regional neurosurgical, pain medicine organizations and hospital communities). His work was characterized by his brilliance, high ethical standards, and unique, tenacious advocacy for physicians in all areas of organizational medicine in Santa Clara County, California, and the United States. In 1991 he founded the American Board of Pain Medicine. In 1993 Doctor Lippe was honored for his many contributions to medicine, including the prestigious Benjamin Cory Award and the Robert Burnett Legacy Awards of the Santa Clara County Medical Association among many others

Personal History
I received full tuition scholarships to Yale and Stanford Universities but chose to remain in California. Following college, I attended Stanford University School of Medicine and then did an internship at Johns Hopkins Hospital in Baltimore, Maryland. I returned to Stanford for neurosurgery residency.

The neurosurgery training at Stanford in those years included a year at Valley Medical Center before chief residency year at Stanford. After I finished my residency, I returned to Valley Medical Center as Chief of Neurosurgery there for one year. I decided it would be better to enter private practice, became a partner with Harold Lynge and worked with him in his office from 1971 to 1974. I thereafter had my own solo practice from 1974 until 2005, after which I stopped primary operative neurosurgery, but continued as Stanford Clinical Professor of Neurosurgery, a neurosurgical consultant and operative assistant.

My daughter Laura graduated from Stanford University School of Medicine in 2012 with her MD/PhD and began her residency in neurosurgery at Stanford to continue this tradition.

 

Personal interests

  • Tissue Transplantation

I became interested in tissue transplantation after caring for a pediatric patient as Chief Resident at Stanford. She suffered Reye’s Syndrome with massive cerebral swelling at age 2, following the use of aspirin. To decompress her brain, our surgical team exteriorized half of her cranium, preserved the skull frozen until the swelling subsided in a couple of weeks, and then replaced this large hemi cranial skull plate. She recovered fully and was a captivating, very active little girl. This experience stimulated my scientific interest in the healing of bone, especially skull, and the field of tissue transplantation. Our laboratory developed the ethylene oxide sterilization technique, which allowed bone to be removed from decedents in a nonsterile environment, and secondarily safely and effectively be sterilized. Our laboratory procured, processed, and distributed over 50,000 bone, fascia, dura mater, tendon implants to surgeons in the United States and internationally between 1975-1995 .

  • Endovascular Neurosurgery

Another interest of mine resulted in the first treatment delivered by what is now called Endovascular Neurosurgery. When I was a resident at Stanford, a patient presented at the Palo Alto Veterans Administration Hospital in 1969 with a carotid-cavernous sinus fistula (CCF), causing a blind, paralyzed right eye. It seemed to me that it would be a less formidable operation if one could achieve the same result with avoiding the craniotomy altogether. Dr. Tom Fogarty in cardiovascular surgery and I finished residency at the same time in 1970 at Stanford. I saw some Fogarty catheters in his office and asked him for one. I then visited the Stanford morgue at 20 autopsies, and visualized after the brain was removed, I could advance the balloon catheter into the cranial space easily in all decedents. During the operation at the VA, I dissected and opened the internal carotid artery, introduced the Fogarty catheter into the carotid siphon at the site of the fistula, inflated the balloon with radiocontrast material, occluded the catheter tubing in the neck, ligated the internal carotid artery and the fistula disappeared; the procedure was a wonderful success The patient regained full eye function and normal cosmetic appearance. I subsequently developed another catheter (Prolo catheter) that self-sealed and the procedure could be performed entirely from the neck.

  • Halo Immobilization and Rescue Board for Injured Cervical Spines

When I was a resident, Dr. Hanbery allowed me to attend a meeting at Rancho Los Amigos in Los Angeles, a rehabilitation center associated with USC. Many patients there had contracted polio with paralysis of extensor muscles of the neck, which resulted in their head and neck being positioned in extreme flexion. With this paralysis the patients had difficulty breathing and looked at the ground. To allow patients to maintain an erect position of the head and neck, their cervical spines were fused in extension. Postoperatively patients were placed in a halo-vest for several months.

At Valley Medical Center in 1970, I cared for many patients with spinal cord injuries. I began utilizing the halo attached to a plaster body jacket or at times to pelvic iliac fixation (among paraplegic patients) with long metallic posts connecting the halo with the pelvic iliac rods for long cervical spine fusions. In addition, I invented a Cervical Stabilization-Traction Board (Prolo Board) used at accident scenes for injured patients suspected or confirmed to have suffered a spinal injury with an unstable cervical spine.

  • Organizational Affairs

Under the tutelage of Doctor Phil Lippe I was able to be very active in medical organizational affairs, more toward the end of my career, and in a proactive way work to attempt to advance the cause of the sacrosanct patient/physician bond, a bond that was established by the Hippocratic Oath over 2400 years ago.

Senior Vice President

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

A Note from Kate Orrico

You may have seen news accounts that Congressional leaders reached a deal on a $1.7 trillion omnibus spending bill. Unfortunately, the legislation falls short in several important areas, but our advocacy efforts resulted in some positive outcomes. Some highlights:

  • Medicare Payment Physicians face an 8.5% Medicare payment cut (4% for Pay-As-You-Go Act or PAYGO and a 4.5% Medicare Physician Fee Schedule) on Jan. 1, 2023. Despite all our advocacy efforts, the bill does not prevent the entire cut. The budget deal includes a two-year postponement of the 4% PAYGO cut (triggered by the passage of the American Rescue Plan Act last year) for two years. It allocates a 2.5% positive adjustment to physician fee schedule payments in 2023 and 1.25% in 2024.

This outcome is disappointing and falls short of the 4.5% relief we asked for, resulting in a 2% reduction to the Medicare conversion factor (CF) for 2023 and, at minimum, a 1.25% CF reduction in 2024 (other policies scheduled to be implemented in 2024, including the new G2211 add on code for inherently complex evaluation and management services — which neurosurgeons cannot likely use — will result in even higher cuts).

  • Alternative Payment Models. Bonus payments for physicians participating in Medicare advanced alternative payment models are extended for one year through 2025, although the bonus payment for 2025 will be 5% rather than 5%.
  • Prior Prior authorization reform legislation did not make it into the bill due to the steep

$16 billion Congressional Budget Office cost estimate — though the Centers for Medicare & Medicaid Services issued three proposed rules in December that incorporate most of the provisions of the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018), so we are making good progress on this front. Congressional leaders have assured us that it will pass legislation to codify these regulatory changes in the 118th Congress.

  • Telehealth. The legislation extends current COVID-19 public health emergency telehealth flexibilities for two years through 31, 2024.
  • Graduate Medical Education (GME). The bill provides funding for an additional 200 Medicare- supported GME residency positions — with one-half dedicated to psychiatry or psychiatric subspecialty residencies as part of the mental health improvements included in the legislation. The budget deal also includes $385 million, an increase of $10 million, for Children’s Hospitals
  • Children’s Health Insurance Coverage. Funding for the Children’s Health Insurance Program (CHIP) is extended for two years through fiscal year In addition, Medicaid and CHIP will now offer 12 months of continuous coverage for children to ensure that the 40 million children on Medicaid and CHIP have uninterrupted access to health care throughout the year.
  • Advanced Research Projects Agency for Health (ARPA-H). The bill includes $1.5 billion, an increase of $500 million above the fiscal year 2022, for ARPA-H to accelerate the pace of scientific breakthroughs for diseases such as Alzheimer’s disease and cancer.

National Institutes of Health (NIH). The legislation provides $47.5 billion for NIH, an increase of $2.5 billion above the fiscal year 2022. The bill includes an increase of no less than 3.8% for each institute and center to support a wide range of biomedical and behavioral research, as well as targeted

investments in several high-priority areas, including $216 million for the NCI component of the Cancer Moonshot; an increase $45 million for research related to opioids, stimulants

and pain/pain management; and $12.5 million for firearm injury and mortality prevention research (an additional $12.5 million has also been allocated to the Centers for Disease Control and Prevention).

  • Medical Device Coverage. The legislation extends pass-through status under the Medicare program for certain devices for which pass-through status would have otherwise expired on Jan.1, 2022, for one additional year through 31, 2023.
  • Medicare Payment Sequester. As with past omnibus spending bills, Congress paid for the Medicare provisions by borrowing against the future and offset part of the bill by extending the Medicare sequester payment cuts through the first six months of fiscal year

More details will be forthcoming after I have had a chance to review the 4,000+ page bill and the various prior authorization proposed rules!

In the meantime, the surgery community will continue our efforts this week to encourage Congress to stave off the entire payment cut — though this is likely a futile effort at this point — and turn to permanent reform in the 118th Congress.

Let me know if you have any questions, comments, or complaints. Katie

P.S. Happy Holidays to you all. We are beyond blessed to work with you all and for a medical specialty that is second to none!

Picture of Brian R. Gantwerker, MD, FAANS, FACS

Brian R. Gantwerker, MD, FAANS, FACS

I Believe in Miracles

“There is nothing more awe-inspiring than a miracle except the credulity that can take it at par.”
~ Mark Twain

Private Practice Corner

At the outset of this season, I already know I will be on call on Christmas. Over the years, I have ensured I was on call for the holidays. Dubbing myself “The Christmas Jew,” I wanted to make sure no one had to miss time with their

families. It was an important time for many of my colleagues who celebrate this time with their loved ones. For my family and me, it was a time to catch a movie and eat a lot of Chinese food. My favorite holiday Hanukkah was eight nights wide, so I had plenty of time to catch lighting a candle or two and consume inappropriate amounts of my Persian wife’s take on my grandpa’s latkes (no comment if they are better or not).

This is the time of awkward hospital holiday parties and actively avoiding the ICU potlucks for fear of putting on fifteen pounds, beyond the standard winter five to ten. It also reminds me of the reason for the season – of things that happen, seemingly out of divine intervention or, at least, incredible serendipity. I am inspired to reflect on unlikely circumstances that somehow figured into a happy conclusion to a dire situation.

Growing up, lighting candles was serious business. My father would break out the same tattered blue prayer book that he likely had since he was in his early double digits, stained with various colors of candle wax, like technicolor tree wings, accumulating over the decades. He would pray the standard two prayers and then the third prayer, the standard one all Jews know – the prayer for thanking G-d for bringing us to the holiday, safe and sound. It is said at every major holiday, but when we did it for Hanukkah, my father would place special emphasis on it, like an exclamation point on the year. We relished it because we were all alive, all our loved ones were around us, and, for this short little time, at least, all was well. We often had both Jews and Non-Jews at our table, as it is customary to invite everyone to celebrate the miracle of the oil after the Seleucids ransacked the Temple.

My gentile friends are also similarly ensconced in the miracle of Joshua Ben Joseph’s birth, the journey of his parents and finding shelter in a simple manger, and the arrival of strangers who somehow knew where to find them and brought gifts to honor his birth. His parents realized quickly that he was extraordinary and would be enormously influential in the time to come. Large family gatherings, traditional meals, and an entire season that began the day after Thanksgiving brought the generations together.

In many other faiths and cultures, the miraculous is also celebrated. It is a time of wonderment and a return to innocence. In Ramadan, the miracle of the first revelation of the prophet is celebrated with prayer, fasting, and community. With Diwali, the miracle of Rama’s victory over the forces of evil of Ravana and his return to Ayodhya victorious is celebrated with decorations, cleaning of the home, and wearing of beautiful and colorful finery.

This particular season is a time to gather, laugh, eat, exchange greetings and gifts, and fill houses with cheer. But the celebration is sometimes delayed and even altogether missed for sick patients and their families. And, for some of us, to ignore the season, get to work, and tend to somehow much sicker patients.  Invariably, something awful (usually a tumor or fulminant infection) would come in. My pediatric mentor would always present another case of Pott’s Puffy Tumor titled “Blue Christmas,” after the Elvis classic with the haunting refrain behind his plaintive crooning.

In neurosurgery, as we trained during residency and in our independent formative years, we have moments when we need just a little something extra. During residency, we were resigned to missing things. Post-residency, the work goes on – an especially bad patient case, a harrowing moment of lost potential after an otherwise complex but successful case, or an incident in life when it was simply too close for comfort. We have all had that moment when you are in practice, especially outside the academic sphere, and you are new to the world where nothing that you learned in residency seems to be able to slow the freight train thundering coming at you down the tracks.

Early in my career, I had a small handful of cases where nothing was going right during or afterward. Every management decision I made that I thought prudent seemed to reel back and bite me on the hand. I had hoped to ping a colleague or make a phone call to a former mentor. Unfortunately, I was self-conscious, nervous, and perhaps full of a bit of hubris. I look back and am grateful for whatever luck or grace happened to me to resolve the situation.

Now older, a bit wiser, and open to discussing challenging cases, I am grateful for the lessons learned. When faced with challenges, I read papers, phone a friend, and troll the literature. Between past difficulties and current intelligent colleagues, a solution presents itself. Thankfully, these situations remain infrequent. With my experience, I have become less likely to believe in the miraculous. Choosing to opt for evidence and facts, life has become a bit less wondrous and, in some ways, gratefully mundane.

The way I practice and how we all practice has evolved. Specific patterns of doing surgery even have become more mainstream. We have all gotten better at what we do. Now there is data to support and undercut certain decisions we have made in the past. The wonderful thing about practicing medicine is that there is always something to be learned. It might be technical, didactic, or cognitive things that we must continue to accommodate in our daily lives.

Much of medical practice is being overrun with guidelines, and those in medicine are shaking their fists full of papers rife with data. Should we eschew the wonderment of discovery, the miracle of our imagination in solving problems, in favor of study after study of good data? It feels as though as we have gone further in the lifeline of practice, we have lost our innocent wonderment. I recently participated in an informal poll on a social media site for professionals, and one of my colleagues spoke of “but the guidelines say…” to preface his answer.

I fear that in this age of big data, we have lost our ability to think outside the convention, to come up with novel ideals in favor of the safety blanket of cookbook answers and standards for every aspect of every facet of our professional lives. My concern grows as more physicians, especially surgeons, point to these guidelines to justify increasingly aggressive surgeries. As I see more patients coming to my clinic status post T10-Pelvis fusions with persistent gait difficulties and who happen to have massive cerebral ventricles, I grow wary of the loss of our collective innocence. We should be aware of the better ways to treat patients as we get better at decoding these problematic questions. We must ask ourselves how far we will let data push us down the diagnostic and treatment chain and at what point we will have stopped lifting our heads to realize we got lost.

As we enter this season of togetherness, fellowship, and high glycemic indices, I hope we can remember the wonderment and the miraculous, think of how to solve problems in reasonable and creative ways, and honor our professional youth, experience, and also our common sense.

From CMA

The Medical Board of California is warning physicians that scam artists have begun posing as law enforcement officers, as well as U.S. Drug Enforcement Administration (DEA) agents and medical board staff calling California physicians as part of an extortion scheme.

Scammers posing as law enforcement may tell victims they have missed a court date as an expert witness and have a warrant for their arrest. Scammers posing as DEA agents may tell victims their license is suspended for illegal drug trafficking and the suspension means they will not be able to practice. The scammers may provide an “Agreement for the Bond and Protocols” that includes statements that licensees are not to share or disclose the investigation to any third party and agree to a bond fee payment of $25,000.

The scammers’ phone number may show up as the medical board’s toll-free number (800) 633-2322, or, if posing as law enforcement, they may impersonate actual law enforcement officers using their real names.

Please note, law enforcement officers, DEA agents and medical board staff will never contact physicians by telephone to demand money or any other form of payment. If you receive one of these calls, refuse the demand for payment. Please also consider the following:

If the caller is stating they are from the DEA, immediately report the threat using the DEA’s Extortion Scam Online Reporting form. If the caller insists that they speak with you right away, tell them that you’ll call them back directly. At this point, some scammers will offer you a phone number as a way to verify they are who they say they are. Don’t call the number the scammers provided; instead call the medical board’s toll-free number at (800) 633-2322.

If the phone number of the caller appears to be the medical board’s toll-free number, it is recommended that you submit an online complaint with the Federal Communications Commission (FCC) using the FCC’s Consumer Complaint form.

 

January deadline approaches for signing the state’s first-ever data sharing agreement

The California Health and Human Services Agency (CalHHS) has opened its new online portal to allow practices to sign California’s Data Sharing Agreement. The agreement is part of the state’s new Data Exchange Framework meant to improve health information exchange. Under state law, physician practices and medical groups are required to sign a template Data Sharing Agreement by January 31, 2023.

New state law requires physicians to notify patients about Open Payments database

A new California law that takes effect January 1, 2023, requires California physicians to provide patients with a written or electronic notice about the availability of the federal Open Payments database. It also requires physicians to post in their offices and on their websites a notice informing visitors about the Open Payments database.

New law requires providers to submit immunization data to a California registry

Effective January 1, 2023, a new state law requires California health care providers who administer vaccines to enter the immunizations they administer into a California immunization registry (CAIR OR RIDE/Healthy Futures). They will also be required to include race and ethnicity information for each patient in the immunization registry to support assessment of health disparities in immunization coverage.

CDPH urges physicians to prescribe COVID19 therapeutics to mitigate impact of winter respiratory surge

With the health care system under great strain due to the convergence of rising rates of COVID-19 and record- breaking rates of influenza and RSV, the California Department of Public Health (CDPH) is urging providers to test any patient with suspected COVID-19 and influenza, as appropriate, and evaluate all symptomatic patients with a positive COVID-19 test (of any type) for treatment with one of the recommended therapeutic treatment options.

Picture of Anthony M DiGiorgio, DO, MHA, FAANS

Anthony M DiGiorgio, DO, MHA, FAANS

Electronic Health Records & Resident Education

Academic Corner

Residency was difficult. Having finished it a mere three-plus years ago, the anguish is still fresh for me.

One of the worst parts was feeling like I was tethered to a computer. Our hospital switched from paper charts to electronic health records (EHR) in the second month of my intern year, so nearly my entire training was done with computer charts.

 

There are advantages, to be sure. Quickly being able to pull up imaging and labs is way better than hunting for hard copies. Vital signs can be visualized from anywhere. Chart checking can be done at home in one’s pajamas.

Yet, it was that ease of access, that ability to be in the electronic chart, became an

EXPECTATION to be in the electronic chart.  “We took calls from home, covering two hospitals.  But calls weren’t spent purely at home, next to a computer. Much of it was spent driving between hospitals. Additionally, since the frequency of calls was so high, we went out of the house, running errands or even trying to enjoy a little bit of life outside the hospital. Yet, I recall leaving all my groceries in the checkout line because a nurse refused to take a verbal order, insisting I place it immediately …

As faculty, I noticed the residents had the same sentiment. Their call was dominated by computer work. They similarly felt tethered to their computers. So, when I saw that we had the ability to audit the electronic medical records and find out exactly how much time residents spend on the EHR, I jumped at the chance.

The results were remarkable: the on-call residents spent 20 hours logged into the EHR over a single shift.

Even more notable is that this number didn’t surprise our residents. This number wouldn’t surprise any residents, nurse practitioners, or physician assistants. The practice of medicine is the practice of navigating an EHR.

Our paper was published in the Red Journal last month and already has over 1,000 views.  It’s novel in neurosurgery but aligns with work in other specialties. Cumulatively, surgery residents spend about eight logged into a computer. Non- surgical residents have it even worse, spending around 40% of their time on the EHR while only 12% of their time on direct patient care. Residents routinely take EHR obligations home, completing nearly a third of them outside of regular working hours.

Identifying this burden is just the first step. Now we must uncover HOW this happened in order to fix it.

Because we could see exactly what part of the EHR the resident was in, our data identified many areas where well- meaning regulations have added to the administrative burden. Things like the appropriate use criteria, patient privacy “break the glass” navigators, and clinical decision support tools add up to a significant portion of our residents’ EHR time. They spent a substantial amount of time simply searching for orders.

Many of these regulations come from the federal government through the Centers for Medicare and Medicaid (CMS). That is where CANS can help. The Washington Committee has already taken a position advocating eliminating Appropriate Use Criteria. We need to encourage targeting other regulations. Additionally, reversing the ban on physician-owned hospitals would help, as the EHR burden in hospitals owned (and run) by physicians is significantly reduced.

In the long run, I hope our research can help reduce the EHR burden that all physicians face, not just residents. This EHR burden is inefficient and expensive. This makes it an issue affecting access to care and something we should all be concerned with.

From CMS

Review and Dispute Reminder: Last Chance to Review Open Payments Data in the System!

Program Year 2021 Open Payments data is available for review and dispute through December 31, 2022.

On June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) published Program Year 2021 Open Payments data along with updated and newly submitted data from previous program years. The Program Year 2021 records are available for review and dispute in the Open Payments system through December 31, 2022, so be sure to review data attributed to you as soon as possible! Learn more about reviewing and disputing Open Payments data.

Review Now

Covered recipient review of the data is voluntary, but strongly encouraged. If you believe any records attributed to you are inaccurate or incomplete in any way, you may initiate a dispute and work with the reporting entity to reach a resolution. To review and dispute records from earlier years that are no longer available within the Open Payments system, you must contact the reporting entity directly.

Records are only available for review in the Open Payments system until the end of the calendar year in which they are first published; you can see previous years’ data by searching the data

at https://openpaymentsdata.cms.gov/.

For more information on the review, dispute and correction process visit the Covered Recipient Review and Dispute Page

CMS proposes rule to improve prior authorization processes

The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule that would streamline prior authorization processes for certain payors. The proposed rule would require electronic prior authorization processes, shorten the time frames respond to prior authorization requests, publicly report certain prior authorization metrics and establish policies to make the prior authorization process more efficient and transparent.

Picture of Rukayat Taiwo, MD

Rukayat Taiwo, MD

Neurosurgery Resident, PGY4 Stanford Health Care
Embracing our Individuality

Women in Neurosurgery

At the most recent Congress for Neurological Surgeons (CNS) conference held in October 2022, I joined a table with emeritus Stanford faculty, Dr. Frances Conley. I wish I could claim that in the moment I appreciated the experience for what it

was – a beautiful juxtaposition of old versus new, my presence at the table paying homage to the sacrifices made, challenges faced by the women in neurosurgery that came before. However, reality was far less poetic. It was not until after the event that I learned I had been conversing with not just any “prior Stanford faculty” but the first female neurosurgery faculty member in the country. Her explosive memoir “Walking Out on the Boys”, detailed the challenges of being a female neurosurgeon in the 1960-90s.

As I reflect on the legacy of Dr. Frances Conley and other women in our field, it brings to mind a popular riddle: “A father and a son are in a horrible car crash that kills the dad. The son is rushed to the hospital; just as he’s about to go under the knife, the surgeon says, I cant operate that boy is my son. Explain how this could be. When I first started telling this riddle, the hilariously outlandish responses I got spurred me to keep telling it. In recent years, the responses have become less amusing and more comforting as the answer, that the surgeon was the son’s mother, has become less elusive. I like to think of this as a reflection of the legacy of women who came before me – slowly chipping away at the presumption that women do not belong in surgery. I am grateful I get to walk down a path that has been paved. Women now have a place at the table. But can we show up wholly as ourselves?

In our quest to demonstrate that we are as adept as our male colleagues, we alter our personalities to claim our place. At various points in my training, I have been advised to adopt artificial mechanisms– all with the theme of scrubbing myself of “feminine” traits. Speak with a louder, deeper tone to garner respect; keep laughter to a minimum; insist on using titles; forgo outward expressions of individuality through makeup or fashion. And despite this, I am mistaken by patients for other members of the care team rather than their physician, an experience recalled by countless women in medicine.

However, these attributes I have tried to emulate are not traits I would particularly admire in a male counterpart, or see as a credit to their competency. In fact, many male mentors I admire in our field have broken this prototype and are still celebrated as proficient and reliable. Women should not have to denounce their individuality or biology to be respected as equals. Pregnant neurosurgeons should not feel compelled to demonstrate their commitment to the profession by operating even while in labor. Women should be able to talk about their children and families without fear of being perceived as sentimental or lacking the appropriate priorities.

Thankfully, I have eight fearless female clinical faculty at Stanford who have shown me that women who are unapologetically themselves can succeed in Neurosurgery. I have learned that you don’t have to raise your voice to garner respect, that you can partake in seemingly menial aspects of patient care and still be held in high esteem, and that quietness and confidence can co-exist in harmony. I am also grateful to be in a community that takes tangible steps towards improving diversity and inclusion, as evidenced by Stanford being the first institution to award tenure to a black female faculty member.

Although there is an increasing number of women in neurosurgery, perceptions of how a neurosurgeon should look or behave are not much different from when Dr. Conley first picked up her medical textbooks. I wish it were as simple as challenging attendings to check their bias before assuming the female trainee that walks into their operating room with eyeliner has less surgical prowess than their male counterpart. However, history demonstrates that stereotypes change through repeated experiences that counter preconceived notions. So, I have a message for my fellow female trainees: as we progress in our careers and accrue accolades, let us embrace our individuality, wherever they may lie on the masculine-feminine spectrum. Hopefully, someday we will sit at a table with our younger counterparts who are unabashedly themselves and appreciate the role we have played in paving a smoother path than the one we trod.

Photo of the Month

Night Blooming Cactus, also known as Sweet Potato Cactus – Cereus Cactaceae This photo was taken on July 6, 2022, at 10: 31 AM in Ventura, CA By Moustapha AbouSamra, MD - i-Phone X

Adela Wu, MD

Looking Back and Planning the Future.

Resident's Corner

As 2022 winds down, I reflect on the past year and what to look forward to next. Currently a fifth-year resident, I am on the tail end of my program’s dedicated period for professional development. I’ve had the unique opportunity to learn new research methods and philosophies for providing high-

quality care for my future patients. For part of the time, I delved into medical humanities and science journalism as well, going back to my roots as a literature major. I’ve also had the singular joy of welcoming my baby daughter this past spring and watching her grow and explore her world. People have often told me that the experience as a new parent would be a big but good change. And it has been – bigger and better than I could have ever anticipated. Assuming this new role as a mom also meant that I had to be a leader in a different sense than I had ever taken on before. There is no manual to parenting, no matter what numerous online blogs or well-meaning relatives may say. Similarly, there is no handbook to gaining confidence and being a leader in a job like neurosurgery either.

 

In late June next year, I will officially be considered a senior resident, one step closer to becoming a chief resident leading a service at our primary hospital. One step closer to graduation. I’ve started thinking about how I would like to approach the final years of neurosurgery residency. I’m excited to return to the operating room on a regular basis and take on new responsibilities. At the same time, I admit that I am nervous about the next two years as well. It reminds me of how I felt before my daughter was born: anticipation and excitement tinged with some apprehension. As I’ve also often heard, lifelong learning is a pervasive part of working in medicine. And, from residency so far, I’ve already found that no amount of prior experience or textbook knowledge could ever completely prepare for what might happen in the next surgery or with the next patient. At the same time, when I become a senior, a new challenge I’ll tackle is how to teach and mentor incoming interns and junior residents and how to provide a safe environment for everyone to learn.

 

My class of PGY5 residents is involved in interviewing residency applicants this year. In preparing for these interviews, I think about how I felt back in 2017 when I was preparing for the match myself. Now, while most programs are still hosting interviews virtually, ours invited the medical students in person. I hope that they see some of the same things I saw when I was on the interview trail – putting faces to names of potential future colleagues, a sense of how residency programs function, and the thrill of being on the threshold of the next big step in their education and careers.

 

In our program, the relationship between the chief resident and the on-call junior resident is especially important, and these amazing medical students I’ll be meeting would be my future colleagues. I want to provide a good balance of guidance and support and enough space for them to learn independently and safely for the sake of their patients. When I was the on-call consult resident, I remember learning how to construct management plans for patients presenting with spinal trauma, for example, and my chief patiently scrolling through the CT, and MRI scans with me and teaching additional salient points about treatments for fractures after I proposed my own preliminary plan. Another moment I distinctly remember was my chiefs checking in on how I was feeling after a particularly busy night where I performed three emergent DVDs. I want to emulate the same combination of empathy and leadership as well as I embark on the last years of residency.

From the DEA

Suspicious Orders Report System (SORS)

Centralized database required by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act

On October 23, 2019, DEA launched the Suspicious Orders Report System (SORS) Online, a new centralized database required by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act, Pub. L. 115-271). Reporting a suspicious order to the centralized database established by DEA (SORS Online) constitutes compliance with the reporting requirement under 21 U.S.C. 832(a)(3). All registrants who distribute controlled substances (within the meaning of 21 U.S.C. 802(11)) are required to design and operate a system to identify suspicious orders and notify DEA of suspicious orders. 21 U.S.C. 832(a). This obligation applies to all registrants if they distribute controlled substances, including the following:

  • Distributor
  • Manufacturer
  • Importer
  • Pharmacy
  • Hospital/Clinic
  • Teaching Institution
  • Practitioner
  • Mid-Level Practitioner
  • Mid-Level Practitioner-Ambulance Service
  • Researcher
  • Analytical Lab
  • Narcotic Treatment Program (NTP)

The SUPPORT Act states the term “suspicious order” may include, but is not limited to: an order of a controlled substance of unusual size; an order of a controlled substance deviating substantially from a normal pattern, and; orders of controlled substances of unusual frequency. Reporting SORS to the Administrator of the DEA and the Special Agent in Charge of the Division Office of the DEA for the area in which the registrant is located or conducts business local DEA Field Office and DEA Headquarters, or to DEA’s centralized database, satisfies the requirement to report such orders to the Administrator of the DEA and the Special Agent in Charge of the Division Office of the DEA for the area in which the registrant is located or conducts business. 21 U.S.C. 832.

 

DEA registrants that are ARCOS Online and ARCOS EDI reporters should utilize their current ARCOS log on information to access the system. DEA registrants that are not currently ARCOS reporters may register on the website in order to report SORS to DEA’s centralized database. The registration process is as follows:

  1. Go to https://apps2.deadiversion.usdoj.gov/arcos-online and click on “SORS Registration (for Non- ARCOS Reporters)”
  2. After completing the initial registration, a confirmation e-mail will be sent to the e-mail address
  3. Once DEA approves the registration, another e-mail will be sent with a temporary
  4. Go to https://apps2.deadiversion.usdoj.gov/arcos-online and type in your username and the temporary The system will require you to change the temporary password.
  5. Upon successfully changing the password, the account will be fully registered to report to the SORS Online

For more information, contact SORS@dea.gov

Tidbits November

Tidbits December

December 1 – The iconic French baguette was added to UNESCO’s famed cultural heritage list. French President Emmanuel Macron called it “250 grams of magic and perfection in our daily lives.” One of my favorite foods. Period.

December 2 – Isaac Asimov’s “I, Robot” was published in 1950. The book imagines the rise of intelligent machines until they ultimately threaten humanity, a fear humans haven’t overcome. A work of fiction, Asimov’s vision of a robotic future is more prescient than ever.

 

December – 3 Around 2,500 people stripped off for a naked photoshoot on Australia’s Bondi Beach to raise awareness for skin cancer. The shoot was organized by photographer Spencer Tunick and Skin Check Champions, a charity that runs free, educational skin check clinics.

December 5 – 11 National Influenza Vaccination Week. The National Foundation for Infectious Diseases (NFID) urges everyone age six months and older to get annual influenza (flu) vaccine, especially adults whose chronic health conditions put them at higher risk. The Flu season is upon us, and it is not too late to get the vaccine!

December 7 – Japan attacked Pearl Harbor on this day in 1941. Ralph B. Cloward, a young, innovative, and charismatic neurosurgeon, reported to Tripler Hospital, a 250-bed Army hospital with 3 ORs, on December 7, 1941. Within two hours, they had 1500 patients. Cloward was assigned the OB room with a small portable suction machine for newborn tracheas. He operated from December 7 to late at night on December 10. He called it a “3 days round-the-clock surgical marathon.” He operated on 42 patients, mostly with shrapnel injuries. He crashed his vehicle during his late-night drive home. He was unharmed. An important history of one of my personal heroes.

December 7 – Fifty years ago today, this iconic photo, known as “Blue Marble,” was taken by NASA astronauts Eugene “Gene” Cernan, Ronald Evans, and Harrison Schmitt on December 7 using a Hasselblad camera and a Zeiss lens, about 45,000 kilometers (28,000 miles) away from home, as the Apollo 17 crew made its way to the moon. Let’s protect this precious marble.

December 8 – The start of the commercial Dungeness crab season in California has been delayed for the third time to protect humpback whales from becoming entangled in trap and buoy lines. It was supposed to start on November 15. The state Department of Fish and Wildlife said that commercial crabbing will be delayed until at least Dec. 30. The crab industry is one of California’s major fisheries, and the Dungeness crab is especially popular around the holidays.

The fish and game department said last month that at least 15 confirmed entanglements of humpback whales by fishing gear off California this year, including three involving Dungeness crab gear.

 

December 9 – U.S. District Judge Donald Molloy permanently blocked a section of the law that the state of Montana said was meant to prevent employers — including many healthcare facilities — from discriminating against workers by requiring them to be vaccinated against communicable diseases, including COVID-19. In his ruling, he wrote: “The public interest in protecting the general populace against vaccine-preventable diseases in health care settings using safe, effective vaccines is not outweighed by the hardships experienced to accomplish that interest.” A person’s choice to decline vaccinations does not outweigh public health and safety requirements in medical settings.

December 11 – The Artemis 1 Orion uncrewed spacecraft splashed down in the Pacific Ocean, off the coast of Mexico, after its historic and successful trip to the moon. The flight coincided with the 50th anniversary of the landing of Apollo 17 on the moon. The Orion spacecraft will carry astronauts to and from the moon in the coming years. Welcome home.

December 12 – The US Supreme Court refused to block a California law banning flavored tobacco, clearing the way for the ban to take effect next week. This law was set to go into effect early last year, but it was suspended while voters considered a proposition challenging it. The tobacco industry spent millions of dollars supporting the proposition, but 63 percent of the state’s voters approved the law last November. I believe the voters are correct.

December 12 – The world-famous mountain lion, a cougar known as P-22, was captured by the California Department of Fish and Wildlife and the National Park Service. The cougar was reportedly in stable condition after being tranquilized in the Los Feliz neighborhood near Griffith Park. P-22 wears a GPS tracking collar as part of a Park Service study and has been recorded roaming residential areas. Los Feliz resident Sarah Picchi told the Los Angeles Times that the big cat was tranquilized in her backyard shortly before 11 a.m.

Photo was taken by remote camera

December 13 – Scientists at Lawrence Livermore National Laboratory in California announced they had crossed a major milestone in reproducing the sun’s power in a laboratory; they achieved nuclear fusion using 192 lasers. For decades Scientists said that fusion could provide a future source of bountiful energy. This is such an important discovery. I am elated.

December 13 – Outgoing Oregon Governor Kate Brown commuted the sentences of all 17 people on death row; they will serve life imprisonment without the possibility of parole. She indicated: “Since taking office in 2015, I have continued Oregon’s moratorium on executions because the death penalty is both dysfunctional and immoral. Today I am commuting Oregon’s death row so that we will no longer have anyone serving a sentence of death and facing execution in this state.”

 

December 14 – Amgen, a biotechnology company based in Thousand Oaks, CA, and one of Ventura County’s biggest private employers, as well as one of the world’s largest biotech companies, acquired Horizon Therapeutics, a biotechnology company based in Dublin, Ireland, that has developed several treatments for rare diseases. Amgen paid $28B in the biggest healthcare industry deal in 2022. Amgen has been on a buying spree recently, with four other acquisitions in 2021 and 2022, but the Horizon deal is by far the largest. Ventura County!

December 15 – 100,000 nurses will walk out in a one-day work stoppage that could slow treatment in hospitals and clinics across England. They join postal workers and railway employees who already walked out holding up Christmas packages and disrupting the travel plans of millions two weeks before the holiday. Many are calling this a winter of discontent. The grass is not greener on the other side.

December 15 – California Air Resources Board approved an aggressive plan to achieve carbon neutrality in the state by 2045. The plan will move one of the world’s largest economies to renewable energy and away from fossil fuels. The board said the plan would cut air pollution by 71% and gas emissions by 85%. Beginning in 2026, all new residential buildings will be required to install electric appliances. The requirements will extend to commercial buildings in 2029.

The board previously approved a rule requiring all passenger vehicles sold in the state to be zero-emission by 2035. Better get used to electric stoves!

December 15 – California regulators voted unanimously to significantly reduce how much utilities must pay homeowners with rooftop solar panels for the power they send to the electric grid. Now that every newly built home is required to have solar panels!

December 16 – The Senate gave final approval to, among other things, rescind the Pentagon’s mandate that troops receive the coronavirus vaccine, defying President Biden’s objections. Really?

December 16 – The University of California and its academic workers announced a tentative labor agreement, signaling a potential end to a high-profile strike that has disrupted the 10-campus public university system for more than a month. Just in time for finals.

December 17 – P-22, the celebrated mountain lion that took up residence in the middle of Los Angeles and became a symbol of urban pressures on wildlife was euthanized after dangerous changes in his behavior. An examination revealed serious health issues, including kidney failure and heart disease. Rest in Peace, P-22.

December 20 – NASA announced that  Mars InSight Spacecraft, which arrived on the surface of Mars more than four years ago to measure the red planet’s seismic activity, lost power because of Martian dust covering its solar panels; it was unlikely for it ever to hear from it again.

December 31 – Dr. Anthony Fauci, America’s Doctor, retired from the NIH after a 55-year illustrious career. Thank you, Dr. Fauci!

Anthony Fauci as a first-year Anthony Fauci ready to retire
medical student in 1962
Anthony Fauci ready to retire

CANS MISSION STATEMENT

To Advocate for the Practice of California Neurosurgery Benefitting our Patients and Profession

CANS 50th ANNUAL MEETING! REGISTER TODAY!

Annual Meeting Agenda/Links

50th Anniversary of CANS: Looking Back & Looking Ahead
SCHEDULE of EVENTS January 13-15, 2023

FRIDAY

2-4pm CANS Board Meeting (open to all members-light bites before/during) Santa Barbara

6:30 – 8:30          Opening Night Reception (Attendees, Guests & Exhibitors) | Grand Parisian/Glenwood Tavern

SATURDAY | Meeting in Galleria | Exhibits in Grand Parisian

6:30–7:40      Continental Breakfast | Please visit EXHIBITS | Grand Parisian

7:45-7:50              Javed Siddiqi, M.D.                        President’s Report

7:50-7:55              Brian Gantwerker, M.D.Secretary’s Report Voting: BOD/Nominating Committee

7:55-8:00              Ciara Harraher, M.D.                      Treasurer’s Report

Session 1:            Plenary Session #1–50th Anniversary Panel: CANS LOOKBACK Session Champions: Abou-Samra/Deb Henry/Odette Harris

Moderators: Lauren Stone, Saman Farr Panelists: Stone, Farr, & Speakers

8:00-8:20              50 Years of CANS: Austin Colohan, MD 8:20-8:40      DEI in CANS: Odette Harris, MD

8:40-9:00              Evolving perspectives on family priorities in CANS: Langston Holly, MD 9:00-9:20      Inclusion of Osteopathic Neurosurgeons in CANS: Dan Miulli, DO

9:20-9:45              Panel discussion/Q&A

9:45-10:15           Special Topic: Consequences of AB35 for Neurosurgeons: Robert Fessinger (Defense Attorney, CAP- MPT)

10:15-10:25         Q&A

10:25-10:30         50th Anniversary Acknowledgement Video: Congressman Ted Lieu 10:30-11:00        Break: Please visit exhibits in Grand Parisian

Session 2:            Plenary Session #2–Panel: Funding Innovation in Neurosurgery Session Champion: Javed Siddiqi

Moderators: Adela Wu, Javed Siddiqi Panelists: Wu, Siddiqi, Adler, Ethell, Khalessi

11:00-11:10         Neurosurgeons as Innovators: Historical Perspective: Adela Wu, MD & Javed Siddiqi, MD 11:10-11:30  How Can I fund that idea #1: John Adler, MD

11:30-11:50         How Can I Fund that idea #2: Doug Ethell, PhD

11:50 – 12:10     Incorporating Innovation into NSx Residency Training: Alex Khalessi, MD 12:10– 12:30       Q & A

12:30 – 1:30 Lunch with Exhibitors | Grand Parisian Session 3: CONCURRENT BREAKOUT SESSIONS

BreakOut Session #1: EARLY CAREER FINANCIAL PLANNING |Galleria

Session Champion: Steve Graeber Moderator: Saman Sizdahkhani, Jason Duong Panelists: Sizdahkhani, Duong, speakers

1:30 – 1:50          Locum Tenens as bridge to regular job: JERRY NOEL, DO

1:50 – 2:10          Insights into my own early career financial planning: BRIAN GANTWERKER, MD

2:10- 2:40           Planning for Early Career Neurosurgeons: estate planning, disability insurance, life insurance, etc STEVE GRAEBER

2:40 – 3:00          Q & A

BreakOut Session #2: LATER CAREER RETIREMENT PLANNING | Santa Barbara

Session Champion: David Maupin, CFP Moderator: Javed Siddiqi, Mark Linskey Panelists: Siddiqi, Linskey, and Speakers

1:30-1:50              Retirement: gradual vs. cold turkey: Gary Goplen, MD

1:50-2:10              Retirement Transition paradigms: locum tenens: Deb Henry, MD 2:10-2:30      Financial Strategies for Retiring Neurosurgeons: David Maupin 2:30-3:00     Q & A

Session 4:            | Galleria

PLENARY SESSION #3–PRESIDENTS’ PANEL: Next Half-Century of CANS

Session Champion: Ciara Harraher Moderator: Harraher, Javed Siddiqi Panelists: Siddiqi, Harraher, speakers

3:00 – 3:20          Value of Mentorship: Mark Linskey, MD (Mentor Perspective) 3:20 – 3:40         Value of Mentorship: Saman Farr (Mentee Perspective)

3:40 – 4:00          Generational Planning for CANS Leadership: Joe Chen 4:00 – 4:20       Value of CANS to its Membership: Praveen Mummaneni 4:20 –4:45         Q & A

4:45-5:00              George Ablin Distinguished Public Service Award: Father Boyle (Introduced by Dr. Linskey, and award presented by Drs. Linskey & Siddiqi)

SATURDAY BANQUET –MUST HAVE TICKET

6:30 PM               Cocktails

7:00 PM               Formal Dinner

Mission Inn Historian15 minutes

Byron Cone Pevehouse Distinguished Service Award Presentation:

Dr. Lawrence Marshall (Introduced by Dr. Linskey; award presentation by Drs. Siddiqi & Linskey) Presidential Address: SIDDIQI 15 mins (with Marco Lee introduction)

Intro of Dr. Joe Chen, Incoming President, by Dr. Siddiqi ( 5 mins)

SUNDAY| Meeting

7:00-7:30              Breakfast | Please visit Exhibits | Grand Parisian/Glenwood Session 1:            Updates & State-of-the-Art Neurosurgery

7:30 – 7:40          CMA update: Brian Gantwerker, MD

7:40 – 7:50          CSNS Update: Patrick Wade, MD/Mark Linskey, MD 7:50 – 8:00   Washigton Committee Update: Alex Khalessi, MD

8:00 – 8:20          Revolutionary Ideas: SURGICAL CURE FOR ALZHEIMERS Doug Ethell, PhD 8:20 – 8:30  Q&A

8:30 – 8:50          On the Horizon: EMERGING DEVELOPMENTS IN SPINAL CORD INJURY THERAPIES

Omid Hariri, DO

8:50 – 9:00          Q&A

9:00-9:30              BREAK-PLEASE VISIT EXHIBITS| Grand Parisian

9:30-11:30           RESIDENT PRESENTATIONS | Galleria

9:30-9:40              John Yue, MD; University of California San Francisco

“Risk Factors for Prolonged Hospital Length of Stay after Traumatic Brain Injury”

9:40-9:50              Peyton Nissan, MD;Cedars-Sinai

“Arachnoid Cyst of the Cerebellopontine Angle: A Systemic Literature Review”

 

9:50-10:00           Melissa Janssen, DO; Loma Linda University Medical Center

10:00-10:10         Tejas Karnati, MD;University of California Davis 10:10-10:20         Kunal Patel, MD;University of California Los Angeles

“Amine Chemical Exchange Saturation Transfer Echo Planar Imaging (CEST-EPI) Visualizes Infiltrating Glioblastoma Cells and Prognosticates Progression Free Survival in New and Recurrent Glioblastoma”

10:20-10:30         Ajay Ramnot, DO; Desert Regional Medical Center

“Thoracic Pedicle Screw Placement Utilizing Hands-On Training Session on Three-Dimensional Models”

10:30-10:40         Adela Wu, MD; Stanford University

“Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors”

10:40-10:50         Angie Zhang, MD; University of California Irvine

“The Market Landscape of Online Second Opinion Services for Spine Surgery”

10:50-11:00         Maxwell Marino, DO; Riverside University Health System

Neurosurgical Outcomes in Severe Traumatic Brain Injury Between Service Lines – Review of a Single Institution Database

 

11:00- 11:10        Alexander Tenorio, MD; University of California San Diego

“The impact of the Mexico-San Diego Border Wall Extension on Spinal Injuries.”

11:10-11:20         Saman Sizdahkhani, MD; University of Southern California

“Discrepancy in Neurologic Outcomes Following Aneurysmal Subarachnoid Hemorrhage as a Function of Socioeconomic Class”

11:20-11:30         Q & A | Resident Awards RAPID FIRE SESSION

11:30-11:32         John Yue, MD University of California, San Francisco

“Clinical Profile of Traumatic Brain Injury Patients Undergoing Acute Cranial Surgery: Report from the 18-Center TRACK-TBI Study”

 

11:32-11:34

11:34-11:36

11:46-Noon        Q & A

 

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Exhibitors

Thank you to our Exhibitors!

Visit them all at the upcoming meeting!

 

Aesculap 

Astra Zeneca 

BK Medical 

Brainlab 

CAPP

DePuy Synthes 

Fujifilm

Integra LifeSciences 

META Dynamic 

Medtronic

Mitaka USA 

Moeller-Medical 

Natus

Sophysa 

Stryker Spine

Surgeons Capitol Management 

Surgical Neurophysiology 

Surgical West

Zap Surgical 

Zimmer Biomet

Calendar

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 (emily@cans1.org) or fax (916-457-8202). 

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

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  • Past newsletter issues are available on the CANS website at cans1.org.

If you do not wish to receive this newsletter in the future, please E-mail, phone or fax Emily Schile (emily@cans1.org, 916-457-2267 t, 916-457-8202 f) with the word “unsubscribe” in the subject line

CANS Board of Directors

CANS Board of Directors