Newsletter

Volume 50, Number 12

Inside This Issue

Joseph Chen, MD

Pandemics and our diminishing control over the delivery of healthcare.

President's Message

That COVID has been front and center of our collective consciousness for roughly three years has resulted in a tremendous amount of news fatigue.  Just as the pandemic has been abating from the front pages (thankfully), I contracted COVID for the first time.  My wishful thinking that it was a cold or bronchitis was ruined when my wife tested me, and lo and behold, I got a positive result.  

A bit demoralizing, as I had successfully dodged the virus over three years, ducking in and out of the ER and ICU countless times and having had encounters with and operated on many patients who subsequently were shown to be COVID-positive. Prior immunizations and a course of Paxlovid did spare me from the worst. I definitely felt lingering effects from the virus which were certainly different from any cold or flu that I have had in the past.

I can’t help but amuse myself with the odd phenomenon that early in the pandemic, contracting COVID seemed to be a sign of being “unclean”, but now it seems to be just being part of the crowd.  By the beginning of 2023, most people didn’t seem to be very impressed by my illness, and rightly so.  Life has moved on.

The biology, prevention, and treatment of the virus have always been a straightforward matter of public health investigation, hygiene, and medical science.  What has not been straightforward, however, was the social and political response. 

While the flu pandemic of 1918 resulted in substantial loss of life and severe disruption of the global economy, its effect on global power structures and thinking was muted.  Coming on the heels of World War I and followed by the astounding economic and technological expansion of the 1920s ensured that it would be a mostly forgotten historical footnote.

The present geopolitical situation does not appear to be as sanguine, however. There has been substantial domestic and international political conflict and sensationalism that was supercharged by the further instability precipitated by the pandemic and the response to it.  COVID has profoundly affected societal equilibrium in many ways, which will be studied for years to come.

Within our field of healthcare, it is interesting to see the recent diverging fortunes of physicians and nurses.  While both have borne the huge burden of caring for the most afflicted, physicians have not seen an increase in demand that would result in the increased salary that nurses have deservingly seen in recent years.  That, even though physicians are the linchpin of any medical care delivery system. 

There are many reasons for this divergence, which will take many pages of analysis to unpack.  From a power dynamic, while physicians continue to have a high degree of discretionary control over individual clinical encounters, control over the broad industrial delivery of healthcare continues to diminish at an accelerating rate.

While small, our specialty, by the circumstance of taking care of many of the most critically ill and vulnerable, has an outsize role in American medicine.  Organizing together on behalf of our community of neurosurgeons is the first foundational step in making sure that we have a voice and influence to guide the discussion of policy issues that will result in changes to our ability to provide the right and best care to our patients.

This is not something that can be done as a collection of individuals.  It is not something that can be delegated to corporations, hospitals, and payers who are fundamentally at odds with the concept of the physician-patient relationship and individualized care.  It is something that we must do as an organized group.

I appreciate your CANS membership, our country’s largest such association, and ask you to reach out to your colleagues to join and support this organization.  I also ask that you take the time to reach out to us and voice your opinions and concerns regarding the present and future of American neurosurgery so that we may represent your interests more effectively.

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

The Ups and the Downs

Editor's Report

February was a month of many happy/celebratory occasions but also a month of devastating tragedy.

On February 6 at 4:17 AM, local time, Southern Turkey – Now formally Türkiye – and Northwest Syria were struck by a 7.8 magnitude earthquake followed by hundreds of aftershocks as well as a second 7.5 earthquake leading to massive damage and many, many fatalities – at least 48,000 – and injuries. It was and is a veritable humanitarian disaster and is still unfolding. The strongest earthquake in more than 80 years struck an area still reeling from the aftermath of the civil war in Syria. The Northwestern Syrian’s infrastructure is already badly damaged, with millions of IDR – Internally displaced Refugees/Syrians, and about a million Syrian refugees in the Gaziantep Turkish Provence, the quake’s epicenter. And to make matters worse, the quake struck during a winter storm with freezing weather. I still have family members who live in Tartous, Northwest Syria. Thankfully they were not harmed. Please see a short account of the causes of this earthquake in ”Tidbits.”

As to causes for celebration:

  • February is Black History Month
  • On February 6, a Texas Court agreed with AANS/CNS and TMA – Texas Medical Association, and other organizations that the final Administration’s interpretation/ruling of the No Surprise Act was in error and that the final rules “improperly restrict arbitrators’ discretion and unlawfully tilt the arbitration process in favor of the QPA.”  Accordingly, the court found that “the Department impermissibly altered the Act’s requirements” and directed the Administration to issue final rules consistent with the court’s decision.Of course, the Administration may appeal this decision.
  • Valentine’s Day is now celebrated everywhere on February 14, even in Saudi Arabia – please see the tidbits section. And please see the photo below from Pakistan.

But it was not always this way. When I left Syria in 1972, there was no such celebration. And being the hopelessly romantic type, I was overjoyed to learn about this lovely holiday in 1973 since I was already seriously dating Joanie, the love of my life.  I have since celebrated it “religiously.” My life is now blessed with many Valentines, as I hope yours is also.

  • Langston Holly and Dr. John Ratliff will join Dr. Javed Siddiqi on the Awards Committee.
  • We are proud to debut a new column about Neurosurgeons as Innovators. This month’s column was written by John Adler, who dedicated his life and career to perfecting radiosurgery, and in the process, became a successful entrepreneur. I know you’d enjoy reading his essay. By the way, John is not finished innovating.

As always, please e-mail me at mabousamra@aol.com or call me at 805-701-7007 if you have any suggestions or criticism.

I hope you enjoy this issue.

John R. Adler, Jr. MD

Dorothy & TK Chan Professor, Emeritus
Stanford University
Editor-in-Chief Cureus.com

Neurosurgical Entrepreneurship

Innovators in Neurosurgery

Throughout the history of modern medicine, neurosurgeons have been arguably one of the more innovative specialties. The exceptionally poor outcomes with nearly all brain procedures prior to Cushing’s arrival must have been hard to stomach for any surgeon and pushed the specialty to open its collective mind to new approaches and technologies. Meanwhile, the unique challenges of dealing with the most delicate anatomy in the human body have also compelled neurosurgeons, more than other physicians, to imagine less invasive approaches. Regardless, a restless innovative spirit lives on in our specialty today.

Although the refinement of surgical approaches by innumerable neurosurgeons has transformed clinical outcomes over the generations, much the same can be said for all specialties. What makes neurosurgery unique is its proclivity for groundbreaking technological innovation. In my own professional career, I have witnessed the arrival of the operating microscope, modern computerized imaging and stereotaxy, image-guided surgical navigation, radiosurgery, deep brain stimulation, surgical robots, and more, technologies that were largely pioneered by neurosurgeons. Nevertheless, it is also worth pointing out that many neurosurgical technologies we take for granted today were pioneered by non-neurosurgeons, such as most endovascular techniques, endoscopy, bone drills, and modern spinal instrumentation.

What is clear is that important technical innovation in surgery has become increasingly complex. Generations ago, Harvey Cushing and an eccentric inventor (William Bovie) could “cook up” electrocautery all by themselves and bring it into the operating room with little oversight. Moreover, angiography emerged largely via self-experimentation. Rongeurs, scissors, scalpels, sutures, bone wax, and scalp hooks were developed ad hoc using local machines, hardware, and fishing tackle shops as resources with essentially no regulatory oversight. Innovation was pure and simple. Looking back on those times, it is hard not to be jealous. Today, most technological innovation in our specialty and medicine is generally very complex, expensive, and time-consuming process. This is a “painful” lesson I have come to learn first-hand over the course of my own 35-year career.

I just stumbled into surgical innovation like so much of my life course. In particular, I had no personal concept of technological innovation until I landed at the Karolinska Institute late in my residency (1985-6) where I met the charismatic and rather eccentric Lars Leksell. Most neurosurgeons pride themselves in their craftsmanship and technical skills, but not necessarily Leksell. Although his operating days were behind him, and I had no way to judge his skill in the operating room, it was clear that for Leksell, imagination, and creativity were what he prized most. He just thought differently than almost another neurosurgeon I have ever met, with the possible exception of MGH’s Bill Sweet and then, later in life, notable CANS member Robert Rand. Leksell was the type of quintessential restless force of nature who somehow figures out how to move mountains, and in doing so, the specialty to which he devoted his life. Upon meeting him, and understanding his life’s greatest accomplishment, radiosurgery, I knew what I wanted to do with the rest of my life. It was literally love at first sight! What I didn’t appreciate was that behind-the-scenes others were doing some of the heavy lifting for Lars Leksell, which had been critical to making his dreams a reality. Physicist Borje Larsson, Leksell’s lifelong technology partner, was brilliant in his domain, while Leksell’s two sons also played significant roles in commercializing his inventions via Elekta. However, the idea that an individual neurosurgeon could have an enduring impact on our specialty was too alluring for me to ignore, and I have never looked back from that perspective.

My own journey within innovation (much like Leksell’s) was centered on the once and still fast-emerging field of radiosurgery, yet very different than Leksell. My personal path also involved a deep dive into entrepreneurship. Without a true mentor in my career, I had to figure things out for myself if the ideas that burned deep within me could become a reality. Living in Silicon Valley did give me a unique lens through which to examine medical innovation relative to the broad field of invention. Yet, in the end, I learned some hard lessons.

I have come to believe that life science innovation, especially in the therapeutic domain, is probably the most difficult type of invention in the modern world. The barriers to innovation are enormous. Firstly, the complex technical mastery required to make something important and relevant to healing human beings, especially in their brains, is not trivial. Secondly, the timeline for such innovation is often much longer than almost any other technology, short of pharma

and the biggest moonshots of all, such as fusion reactors and self-driving cars. However, these later technologies have the advantage of better capturing the public imagination and the massive funding needed for commercialization. While government regulation is a barrier to making innovation real, a much bigger challenge is reimbursement, which as a practical matter, is all driven by the government in almost every country in the world. It is a sad reality that without reimbursement, there is NO innovation, while every power in the healthcare universe resists such payments. In effect, all stand in opposition to innovation.

Meanwhile, surgeons, and very often their medical societies (but not CANS!!), bankrolled by wealthy incumbent medical devices and pharma, and contrary to their reputations, resist innovation. Since successful innovation is invariably accompanied by winners and losers, those in the healthcare universe that have been previously financially successful (the winners) have little stomach for risky innovation. So they go out of their way through politics and legal maneuvers to sabotage disruptive inventions. Finally, all surgeons are quickly aware that many/most “novel” procedures fail to “pass the test of time and ultimately disappear; There is little appetite for a “learning curve“ that is likely to be littered with failure.

Despite the above challenges to getting a new technology accepted by the healthcare system, the occasional intrepid surgical spirits agree to buck the odds and become early adopters. In my present missive, I’d like to give a huge shout-out to all these individual surgeons and their patients, who are the unsung heroes in the medical innovation story and truly deserve our collective praise. In my own career, I am unsure what I am prouder of, having “invented” the CyberKnife (with help!) or being the physician who first showed the capabilities of this new technology in treating patients. Technical innovation is nothing without accompanying breakthrough clinical innovation, which frankly scares many otherwise incredibly talented neurosurgeons. Smartly or not, these surgeons who claim to embrace innovation want someone else to test the limits and work out the kinks of a new (“RISKY”) technology. Yet still, a small handful of neurosurgeons have, through the years, stood up to become the tip of the innovation spear. I cannot say enough how much these neurosurgeons are my own heroes!!

Entrepreneurs are born, not made, which is true for neurosurgery. While the psychological rewards for being involved in medical device entrepreneurship are substantial, life is every bit as grueling, and maybe more so, than being a busy clinical neurosurgeon. The workdays are long, while night call is replaced with frequent international travel making jet lag just part of life. Ultimately, I see many similarities between neurosurgery and innovation and believe them to be deeply intertwined, even if only a handful of us pursue the combination as a career. The gratification of knowing that somewhere in the world, patients are being treated and lives are being saved, by my inventions, as I sit and write this little story is beyond gratifying.

Quote for the Month​ of February

Quote of the Month

” As we grow older, we become both more foolish and more wise.
La Rochefoucauld

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

End of Life Care
Loss of Decisional Capacity
Dying with Dignity

Age comes only to the truly blessed.
Sister Joan Chittister – “The Gift of Years – Growing Older Gracefully”

Changing Times

When we face ethical questions in a patient’s care, we always think that a patient’s autonomy should be respected and protected. Additionally, in End of Lile care EOL, autonomy is often associated with dignity . Jukka Varelius, a medical ethicist, defines autonomy as “self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice.” Please read Elizabeth Bruce, MD’s article in Op-Med, January 3, 2023. Dr. Elizabeth Bruce is a former public school teacher and current PGY-1 psychiatry resident physician at the University of Michigan. https://www.doximity.com/newsfeed/5e8d8142-5f3a-46c1-8cd5-ea887e8e352c/public

***

Recently, I visited my friend Rob, who is in a memory care facility in Denver, Colorado. He used to be a strapping, healthy 6’4’’ tall individual. I used to train for my marathons with him; he was instrumental in helping me complete two of my marathons: LA and the Avenue of the Giants. He now has Lewy Body Dementia. He cannot care for himself; he cannot walk alone or even stand unsupported; he cannot feed himself. His recent memory is gone. His long-term memory is almost totally gone … In short, I witnessed a Rob, who was a skeleton of his old self. He drools, is incontinent, and depends on others; this is not the Rob I knew. His care, at best, is suboptimal, but this is the best available. I will say that the “home,” his memory care facility, is very depressing. I would not want to be there. And I do not wish to be in Rob’s situation.

In California, like in several other states, we have the legal option to choose “death with dignity,” that is, to decide when to end our life of suffering. It is also called Medical Aid in Dying MAID. There are justifiably strict conditions in order to qualify:

  • Must be a resident of California.
  • Must be diagnosed with a terminal illness or be on Hospice.
  • Must be of sound mind and able to decide.
  • Must be able to confirm the decision at an interval.
  • Must be able to drink the lethal cocktail without help.

Early in his course, and as he was declining physically, but not yet mentally, Rob told his daughter, an RN, that if he had a gun, he would have ended his own life. She explored his death with dignity options with his treating team at the University of Colorado. The answer was: that he did not qualify and will never qualify. He does not have a terminal illness, and as he gets closer to the end, he would be demented and incapable of making a rational decision, a Catch-22 situation.

Unfortunately, they were correct. “Death with Dignity” does not apply to Rob.

***

Canada recently adopted a policy that allows death with dignity to be applied to people who are not terminal but are suffering with no hope of curing the cause of their suffering. https://www.nytimes.com/2022/09/18/world/canada/medically-assisted-death.html?smid=url-share

This is not available to us in the US, specifically in California.

Back to the loss of decisional capacity.

***

We are advised to have an advanced health care directive. My wife and I have one. And I still have total decisional capacity.

It is easy for me to decide now to exercise my right to Medical Aid in Dying should I find myself suffering from a terminal illness. In fact, it is logical.

What is more difficult is what I should do if I suffered from a devastating but non-terminal illness, both before and after losing my decisional capacity. In the former scenario, the Canadian option is reasonable; I hope a similar alternative will become available in California. But I am afraid there is no help available once I lose my decisional capacity.

I bet that I am not the only one afraid to end up like Rob.

***

This is a topic worth thinking about, studying, debating, and even bringing to the national consciousness.

Is it not reasonable to articulate my wishes now while possessing my decisional capacity? To express my desire to take advantage of Medical Aid in Dying, even in non-terminal but devastating illnesses?

And if my wishes were expressed correctly while I can decide, is it not ethically appropriate to expect them to be honored, even when I reach that dreaded stage when I no longer have my decisional capacity?

My wishes are simple: keep my autonomy and die with dignity!

Photo of the Month

The photo taken by Moustapha AbouSamra, MD, on January 5th, 2023 in Duarte, CA. iPhone XIII Pro

From Katie O. Orrico

Senior Vice President Health Policy and Advocacy
American Association of Neurological Surgeons/Congress of Neurological Surgeons

No Surprises Act/TMA Lawsuit - Ruling February 6, 2023

From Katie O. Orrico

The No Surprises Act, which went into effect on Jan. 1, 2022, bans surprise medical bills for out-of-network care and establishes a process for resolving payment disputes between health plans and providers. Unfortunately, the final rule implementing the law continued to give preference to the qualifying payment amount — or median in-network rate — which unfairly favors insurers when settling out-of-network payment disputes. When resolving payment disputes, the law requires arbiters to consider several factors equally — not just median in-network rates — including the physician’s training and experience, the severity of the patient’s medical condition, prior contracting history, health plan market share and other relevant information.

On Oct. 19, the AANS and the CNS spearheaded a physician-led amicus brief, along with the Physician Advocacy Institute, supporting the Texas Medical Association’s (TMA) new lawsuit challenging these rules. Other medical groups, including the American Medical Association, also filed amicus briefs supporting the TMA lawsuit. (Click here to read neurosurgery’s amicus brief and here for the accompanying press release.)

On February 6, 2023, the Texas court issued its ruling backing the TMA finding that the final rules “improperly restrict arbitrators’ discretion and unlawfully tilt the arbitration process in favor of the QPA.”  Accordingly, the court found that “the Department impermissibly altered the Act’s requirements” and directed the Biden Administration to issue final rules consistent with the court’s decision. We now wait to see of the administration will appeal the ruling.

This is a significant victory in our advocacy efforts to ensure that commercial health plans fairly pay physicians for out-of-network services (which, in turn, should improve physician/health plan contracts for in-network care).

Picture of Karin Muraszko, M.D.

Karin Muraszko, M.D.

Former Chair of the Department of Neurosurgery

The University of Michigan Medical School Celebrates Muraszko’s
‘Near-Mythical Status’
Reprinted From “Michigan Medicine”

Women in Neurosurgery

February 8, 2023  FOUND IN: Our EmployeesTop StoryU-M Medical School

On Feb. 3, colleagues, former students and trainees, and friends gathered to honor Karin Muraszko, M.D., for her groundbreaking achievements as a woman leader in medicine. Many did so in the D. Dan and Betty Kahn Auditorium, site of the inaugural Women in Academic Medicine event, hosted by the U-M Medical School. Others chimed in from far away. 

In pre-recorded remarks, CNN chief medical correspondent and neurosurgeon Sanjay Gupta, M.D., said: “[Muraszko] has impacted so many of our lives in countless ways; someone who has deservedly taken on near-mythical status at Michigan, in the United States, and all over the world, and someone who has saved and improved countless lives.” Gupta is a U-M alumnus for undergraduate, medical school and neurosurgery residency who trained under Muraszko. He continued: “She is someone I take immense pride in calling a mentor, a champion for change and, most importantly, a friend.”

Gupta’s message kicked off a well-deserved tribute to Muraszko, who enjoyed a distinguished 13-year tenure as the first woman to lead a neurosurgery department in the U.S. Gupta was the first of many well-wishers to salute Muraszko’s 40-plus year career as a leader in the field of neurosurgery, and to celebrate her as the inaugural recipient of the Women in Academic Medicine Impact Award.

The award presentation capped a two-hour event that also included a keynote address by U-M adjunct faculty member and Emory University Chair of Radiation Oncology Reshma Jagsi, M.D., D.Phil., and a panel of faculty members and a medical student discussing their often-turbulent journey as women in academic medicine. 

The archived livestream can be accessed at: https://www.youtube.com/watch?v=hF_oqmug0HE.

Celebrating National Women Physicians Day
U-M Executive Vice Dean for Academic Affairs and Chief Academic Officer Debra F. Weinstein, M.D., noted that the U-M event coincided with National Women Physicians Day and provided the perfect springboard to “invigorate ongoing work to accelerate the success and advancement of women in medicine.”

As part of the festivities, Weinstein surprised the day’s honoree by announcing that the annual award would be renamed the Karin Muraszko Women in Academic Medicine Impact Award.

”When I became chair of neurosurgery here, (former UMMS deans) Allen Lichter and Jim Woolliscroft did more than just take a chance on me; they also gave me the tools to succeed. It is a hallmark of Michigan that they try to create a path for you to be able to succeed,” Muraszko said. “As we celebrate women, we should celebrate each of us as individuals and human beings who sometimes are capable of so much more than we thought possible.”

A video of colleagues talking about Muraszko and the impact she has had on them and Michigan Medicine, can be found here: https://www.youtube.com/watch?v=TqQn-EhAR3o.

Change is ‘the right thing to do’
In her remarks, Muraszko said that, as an institution, Michigan is always trying to find its way. Four panelists echoed the sentiment that the U-M is in a unique position to help advance women in academic medicine, and to help them overcome challenges and excel.

“Bias used to be very explicit,” said Huda Akil, Ph.D., the Gardner C. Quarton Distinguished University Professor of Neurosciences in the Department of Psychiatry. “What needs to change needs to change rapidly and systemically; not because women are having a hard time, but because it is the right thing to do.”

Michelle S. Caird, M.D., the Helen L. Gehring Professor and chair of the Department of Orthopaedic Surgery, noted that only 6 percent of orthopedic surgeons are women, and 15-16 percent of residents are female. She said her department is making strides in recruitment and hiring, but perception remains an obstacle.

“There is a change, and I celebrate that, but we are still near the bottom,” Caird said. “We have so many opportunities. Women feel, even with a woman as a chair, much more cautious and afraid of what the institution might do to them, or how it might affect them and their families.”

Susan J. Woolford, M.D., M.P.H., an associate professor of pediatrics in the medical school and associate professor of health behavior and health education in the U-M School of Public Health, said that one of the problems is representation.

“I have seen signs of improvement over the past few years, but if we want to change representation, we have to change what we reward,” she said. “It is like swimming against the tide. We are at a moment when we have an opportunity to make a huge difference.”

Courtney Burns, a third-year medical student at Michigan, recalled a story from the operating room in which the attending surgeon made a disparaging sexual remark about her appearance. She said a colleague comforted her and stated that was not appropriate.

“I talked to my mentors and found it wasn’t just me, or a me problem,” Burns said. “Don’t be afraid to find your safe people that you can discuss things with. There is so much power in speaking your experiences, and I encourage you do that.”

In her talk, Jagsi highlighted several studies that have shined a light on bias toward women in academic medicine. This includes the “Karin Muraszko Study,” which looked at sex, role models and specialty choices among graduates of U.S. medical schools in 2006-08.

“The idea was looking at the powerful influence of role models like [Muraszko],” Jagsi said. “One of the most important findings of the study is when we looked at what students were looking for in programs, in residencies and departments, it was actually the overall inclusion of women. You want to go to a place where you look like you actually belong.”

A video of senior leadership, faculty, and students sharing their thoughts about why Michigan Medicine is committed to advancing opportunities for women in all areas of health care can be viewed here: https://www.youtube.com/watch?v=aFQpVuBYAOA.

From AANS

Help Shape Neurosurgery’s 2023 Advocacy Agenda

Each year the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) establish neurosurgery’s legislative and regulatory advocacy priorities for the coming year. The committee is seeking neurosurgeon input to assist the AANS/CNS Washington Committee with this process.
Please click here to complete a brief survey, so your feedback is incorporated into the committee’s deliberations.

  • Biden Administration Renews COVID-19 Public Health Emergency Declaration

On Jan. 11, U.S. Department of Health and Human Services Secretary Xavier Becerra renewed the COVID-19 public health emergency (PHE) declaration. The PHE was extended for an additional 90 days. This means that all telehealth and other waivers and flexibilities implemented during the PHE will remain in effect. The department has also stated that it will provide 60 days’ notice when a decision is made to terminate the declaration or let it expire.

  • Congress Passes Legislation to Mitigate Steep Medicare Payment Cuts

Before adjourning in 2022, Congress passed legislation to mitigate a combined 8.5% Medicare physician payment cut (a 4.5% Medicare Physician Fee Schedule (MPFS) and a 4% Statutory Pay-As-You-Go Act (PAY GO) of 2010 cut). The Consolidated Appropriations Act, 2023 (P.L. 117–328) provided partial relief from the cuts as follows:

  • 2.5% positive adjustment to the MPFS conversion factor (CF);

  • 1.25% positive adjustment to the CF in 2024; and

  • Postponement of the 4% PAYGO cut for two years.

Despite this action, neurosurgeons face a 3% pay cut in 2023 (a 2% reduction in the MPFS CF and 1% due to changes in work values) and a minimum 1.25% cut in 2024.

In the immediate run-up to passage of the omnibus spending bill, the AANS and the CNS engaged in a variety of advocacy activities urging Congress to stop the full cut, including:

  • A Surgical Care Coalition letter urging Congressional leaders to prevent the entire Medicare physician payment cut. Subsequently, John K. Ratliff, MD, FAANS, former chair of the AANS/CNS Washington Committee, was quoted in a press release about the letter, stating, “During a time when neurosurgical practices are facing steep inflation coupled with a system that fails to keep pace with the costs of delivering care, it would be Congressional malpractice if lawmakers fail to prevent the entire 4.5% Medicare physician payment cut.”

  • Collaborating with bipartisan members of Congress on several letters to congressional leadership urging action to prevent the Medicare payment cuts, including a letter led by Reps. Susan Wild (D-Pa.) and Mariannette Miller-Meeks, MD, (R-Iowa) and a letter from the Doctors Caucus.

  • letter from the Alliance of Specialty Medicine to Sen. John Kennedy (R-La.) expressing support for the Protecting Medicare Patients and Physicians Act (S. 5194), which would have prevented the 4.5% MPFS cut. Similar legislation, the Supporting Medicare Providers Act (H.R. 8800), was introduced by Reps. Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.) in September 2022.

  • A Surgical Care Coalition letter to congressional leaders expressing disappointment that the omnibus bill failed to prevent the entire cut.

  • An Alliance of Specialty Medicine letter to congressional leadership expressing disappointment with Congress’ failure to stop the full Medicare cuts.

  • Former Washington Committee Chair Featured In Article about Medicare Cuts

On Jan. 6, Becker’s ACS published an article titled “CMS in the last year: 5 leaders weigh in.” The article featured John K. Ratliff, MD, FAANS, past chair of the AANS/CNS Washington Committee, who stated, “Once again, we are facing another year of devastating cuts to a Medicare system that is already ill-equipped to meet the needs of millions of Americans.” Dr. Ratliff went on to “urge Congress to not only stabilize payment levels in the short term but also transform the system into one that is stable and reliable in the long term.”

  • Neurosurgery Priorities Addressed in Omnibus Spending Bill

The Consolidated Appropriations Act, 2023 (P.L. 117–328) — a $1.7 trillion omnibus spending bill to fund the federal government — addressed several of organized neurosurgery’s advocacy priorities. The legislation:

  • Provides bonus payments for physicians participating in Medicare advanced alternative payment models, extending them for one year through 2025 — although the bonus payment for 2025 will be 3.5% rather than 5%;

  • Extends the current COVID-19 public health emergency telehealth flexibilities for two years through December 2024;

  • Provides funding for 200 Medicare-supported graduate medical education (GME) residency positions and increases funding for the Children’s Hospitals GME program;

  • Includes funding for the Children’s Health Insurance Program for an additional two years through FY 2029;

  • Increases funding for the National Institutes of Health; and 

  • Allocates $25 million for firearm injury and mortality prevention research.

Unfortunately, despite neurosurgery’s advocacy efforts and encouragement, and strong bipartisan support in both the U.S. House of Representatives and Senate, the spending bill did not incorporate the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018), which would streamline prior authorization in the Medicare Advantage Program. A $16 billion cost estimate from the Congressional Budget Office stalled progress.

Click here for a summary of AANS/CNS 2022 legislative accomplishments.

  • Medical Liability Reform Legislation Introduced

On Dec. 15, 2022, Reps. Lou Correa (D-Calif.) and Richard Hudson (R-N.C.) introduced medical liability reform legislation — the Accessible Care by Curbing Excessive LawSuitS (ACCESS) Act (H.R. 9584). Among other things, the bill would:

  • Cap non-economic damages at $250,000;

  • Limit attorney fees so that damage awards go to the patients in need;

  • Provide for the full and unlimited recovery of economic damages; and

  • Allow for the periodic payment of damages.

The Health Coalition on Liability and Access, of which Katie O. Orrico, Esq., AANS/CNS senior vice president for health policy and advocacy is vice president, issued a press release expressing support for the bill.

Click here to read the press release.

  • Start the New Year Off by Contributing to NeurosurgeryPAC

In 2022, NeurosurgeryPAC raised $212,000 from neurosurgeons across the country, falling short of its $250,000 annual fundraising goal. These funds allowed NeurosurgeryPAC to support candidates who supported neurosurgery’s 2022 policy agenda, contributing $247,000 to 68 federal candidates, evenly split between democrats and republicans.

Congratulations to California and Nevada neurosurgeons, the 2022 Leibrock State Leadership Award winners, for the most contributions and the highest percentage of participation in NeurosurgeryPAC, respectively. 

NeurosurgeryPAC is a nonpartisan political action committee that does not base its decisions on party affiliation but focuses on candidates’ voting records and campaign pledges. Click here for more information about NeurosurgeryPAC, including the list of 2022 donors, candidates receiving NeurosurgeryPAC support and more about the PAC in action.

To make your 2023 contribution, use the online donation option by logging into  MyAANS.org, going to the online fundraising website or texting “AANSPAC” to 71777.

Editor’s Note: AANS members who are citizens of the United States and pay dues or have voting privileges may contribute to NeurosurgeryPAC, as may AANS candidate members. All contributions must be drawn on personal accounts and any corporate contributions to NeurosurgeryPAC will be used for administrative expenses and other activities permissible under federal law. Contributions are not tax-deductible. Federal law requires NeurosurgeryPAC to use its best efforts to collect and report the name, mailing address, occupation and the name of the employer of every individual whose contributions exceed $200 in a calendar year.

  • Neurosurgery Lauds Proposed Rule to Streamline Prior Authorization

The Regulatory Relief Coalition (RRC), of which the AANS and the CNS are leaders, issued a press release lauding the Centers for Medicare & Medicaid Services (CMS) for its recently released proposed rule. The proposal — which applies to Medicare Advantage, Medicaid managed care, Children’s Health Insurance Program and federal Marketplace qualified health plans — closely aligns with the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018),legislation that unanimously passed the House by voice vote on Sept. 14, 2022. In the release, John K. Ratliff, MD, FAANS, former chair of the AANS/CNS Washington Committee, stated:

“Patients and physicians are thrilled that the proposed rule paves the way for commonsense, necessary, and appropriate changes to prior authorization in Medicare Advantage and other government health programs. Congress should take action before the end of this year and codify these vital principles by passing the Improving Seniors’ Timely Access to Care Act.”

CMS published a second proposal to address additional issues related to prior authorization in the Medicare Advantage program. Taken together, the proposed rules:

  • Aim to advance interoperability and improve prior authorization processes by requiring health plans to adopt electronic prior authorization;

  • Require plans to make prior authorization decisions within 72 hours for urgent requests and seven calendar days for others;

  • Ensure that prior authorization approvals remain valid for a patient’s entire course of treatment;

  • Mandate that Medicare Advantage plans follow traditional Medicare’s national and local coverage policies and stipulate that coverage determinations must be reviewed by professionals with relevant experience;

  • Support efforts, such as gold carding, to waive or modify prior authorization requirements based on provider performance; and

  • Compel health plans to publicly report the use of prior authorization, including information on delays and denials.

Subsequently, on behalf of the Alliance of Specialty Medicine, Katie O. Orrico, Esq., AANS/CNS senior vice president for health policy and advocacy, attended a stakeholder roundtable convened by the Department of Health and Human Services and CMS. The roundtable was organized by CMS Administrator Chiquita Brooks LaSure, U.S. Surgeon General Vivek H. Murthy, MD, and other senior CMS officials, allowing participants to share their experiences with prior authorization. Also attending on behalf of the American Hospital Association was neurosurgeon James B. Chadduck, MD, FAANS.

Click here to read the Alliance’s press release about the roundtable.

  • Neurosurgeon Pens Op-Ed on Prior Authorization

On Jan. 3, The American Spectator published an op-ed by AANS/CNS Communications and Public Relations Committee member Richard Menger, MD, MPA, Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN. Titled “Insurance Companies Use Stalling Tactics to Save Themselves Money,” the authors discuss health care provider burnout from the cumbersome prior authorization process required by insurance companies to perform surgery agreed upon by patient and surgeon. The article concludes with the authors asking Congress to take action and pass legislation to streamline prior authorization in Medicare Advantage.

  • Neurosurgery Raises Concerns about MedPAC Primary Care Payment Proposals

Recently, the AANS and the CNS joined the Alliance of Specialty Medicine in a letter to the Medicare Payment Advisory Commission (MedPAC) expressing concerns with policy options to boost primary care reimbursement. The proposals continue to prioritize primary care over specialty care, and the letter urges MedPAC to consider alternative means of increasing interest in primary care.

Click here to read the letter.

  • Neurosurgery Responds to CMS RFI on National Provider Directory

The AANS and the CNS joined the Alliance of Specialty Medicine in responding to a Centers for Medicare & Medicaid Services (CMS) Request for Information (RFI). The RFI sought input from the public about establishing a National Directory of Healthcare Providers & Services that could serve as a “centralized data hub” for health care providers nationwide. 

The letter supports CMS’s goal of making more accurate and up-to-date directory information about providers available to the public in an easier-to-use format. The letter identifies two areas that could benefit from the adoption of a centralized provider directory:

  • Identifying and tracking physicians’ specialty and payer contracts; and 

  • Prior authorization processes.

Click here to read the letter.

Jacob Young, Ilona Garner & Anthony DiGiorgio

History of Neurosurgery at UCSF

Historical Vignette

The first neurosurgical case at what would become UC San Francisco was a cerebellar decompression performed in 1912 by Dr. Howard Naffziger. Naffziger, born in 1884, was a medical student when the 1906 earthquake struck San Francisco. That gave him an early introduction to trauma surgery as he assisted in caring for victims of the quake. In 1911 he moved to Baltimore to train under Harvey Cushing, returning to UC in 1912 and immediately putting his training to use for neurosurgical patients.  Between 1917 and 1919, he accompanied Cushing to Europe as part of the Allied war effort, serving as an officer in the Medical Corps.  He returned to UC again in 1919, and the neurosurgical service grew rapidly under his watch, with trainees arriving in the 1920s and the neurosurgical residency program established in 1934. In 1947, after serving as the chair of the Department of Surgery, Naffziger ultimately became the first Chair of the Division of Neurological Surgery at UCSF. However, the distinction between a “division” and a “department” of neurosurgery was largely semantic at that time.  Under Naffziger’s leadership, the department cultivated a reputation for surgical excellence and research productivity.  Naffziger retired in 1951 before being appointed as a member of the Regents of the University of California by Governor Earl Warren.  Under the next two chairs, Edwin Boldrey and John Adams, the department continued to grow, pioneering research in EEG, stereotactic surgery, and cerebral physiology.

With the retirement of Adams in 1968, the department recruited Charles B. Wilson – then just 39 years old – from the University of Kentucky to be the next chair.  He had a particular interest in brain tumors and immediately launched a Clinical Chemotherapy Service, which introduced BCNU to the treatment arsenal for patients with recurrent gliomas and ultimately expanded to include animal models for the biological investigation of brain tumor treatments. This program ultimately became the Brain Tumor Research Center (BTRC), which rapidly grew into the largest brain tumor treatment and research program in the country. Wilson was known for his work ethic, surgical advances, and high expectations, and it was under his leadership that the UCSF Department of Neurological Surgery became the foremost clinical practice, training program, and research center for neurosurgery in the country.  Under his guidance, the department trained 14 future chairs of other neurosurgery programs across the country, such as Neil Martin, Robert Spetzler, Phil Gutin, Nicholas Barbaro and Dong Kim.

Of course, Wilson trained his own successor and, in 1997, Mitchel S. Berger took over as department chair and director of the Brain Tumor Research Center, ushering in a new era of unparalleled growth and excellence. Since 2000, the Department has been #1 in NIH funding for academic neurosurgery, boasting the top research productivity for residents and faculty in the country. It has maintained the #1 NIH spot every year since.  The BTRC obtained the first Specialized Program of Research Excellence (SPORE) grant for brain tumors in 2002, and this has been consistently renewed every four years since. The Department grew to over 60 full-time clinical and basic science faculty members and several satellite clinics across the Bay Area.  Berger recruited leading experts in every subspecialty of neurosurgery and ensured that they interacted with basic scientists who were focused on research questions that would lead to improved therapies for patients.  He also focused on quality and safety on a national level.  The residency program was one of the first to have trainees complete a quality and safety project.  It also achieved the top rank in Doximity during this time.

Dr. Edward F. Chang became the 7th chairman in Department history in 2020.  As someone who has been at UCSF since medical school, he recognizes how extraordinary the institution is.  He envisions leading a department of surgeon-scientists that can push the boundaries in innovation.  Shortly after taking over as chair, the UCSF Department of Neurosurgery became simultaneously ranked #1 in the US News and World Report rankings, #1 in NIH funding for neurosurgery departments, and the residency program was ranked #1 by Doximity.  The program remains as strong as ever, continuing to lead the field in research, clinical care, and resident education.

References:

  • Dolan B, Garner I & Porter D. A History of Neurological Surgery at UCSF, 1912 – 2015.  https://escholarship.org/uc/item/5fx51314
  • UCSF Department of Neurosurgery. Edward Chang: A New Vision for Neurosurgery. https://neurosurgery.ucsf.edu/edward-chang-new-vision-neurosurgery
Dr. Berger & Dr. Chang at a department event in 2022 (Courtesy of UCSF Department of Neurological Surgery)

From CMA

Physician legislators to discuss state’s health care priorities at CMA’s Legislative Advocacy Day

Join us in Sacramento on Wednesday, April 19, 2023, for the 49th annual CMA Legislative Advocacy Day. Attendees will hear directly from our physicians in the state legislature about the state’s priorities for health access. CMA will host a panel discussion with Assemblymembers Joaquin Arambula, M.D.; Jasmeet Bains, M.D.; and Akilah Weber, M.D.; with CMA Council on Legislation Chair Kelly McCue, M.D., as our moderator.

CMA and more than 100 physician orgs unite to support prior auth reforms

CMA joined the American Medical Association and more than 100 leading medical societies to voice support for the meaningful prior authorization reforms proposed by the Centers for Medicare and Medicaid Services that will increase access to medically necessary care.

CMA seeking nominations for Justice, Equity, Diversity and Inclusion Committees

CMA is currently seeking physician members to serve a two-year term (2023-2025) on the Justice, Equity, Diversity and Inclusion (JEDI) Committee. CMA’s committees and councils provide key input to the Board of Trustees to guide the association as it sets new policies. The deadline to submit an application or nomination is Monday, March 6, 2023.

Picture of Brian Gantwerker, MD

Brian Gantwerker, MD

My Constant Companion

Boundaries aren't all bad. That's why there are walls around mental institutions.
Peggy Noonan

Private Practice Corner

Being of use in this life is an important thing.  Living a meaningful life is a big aspiration of mine.  One of the factors in choosing my career was having a positive impact on patients.  Intervening constructively, either with my expertise or doing an operation to prevent death or disability, was a positive thing to do. 

While you hopefully save lives and prevent deficits in private practice, you must build a business. 

It became clear early on that to build a business, you had to show patients and referring physicians that you are good at what you do.  And the only way to do that, at least initially, is to be on call.  When I first opened my practice in 2011, I was on call at a few hospitals and covered my practice 24/7.  It was exhausting.  A few hospitals did not remunerate for taking calls, which was offset by a good payer mix.

Trying to keep costs down, I used a VOIP system called Vonage, which is now defunct.  Not able to afford an “operator,” the phone was forwarded to a separate line at night to our home office.  I would wake up hearing the dreadful ring at all hours.  Then to impress the ER or whoever was calling me, I would pick up the phone myself. Of course, it would also forward a special alert to my phone to act as a backup.

Being available became an obsession for me. 

In residency, we were taught to “never say no.”  This reminds me of a few different occasions when an outside hospital sent us a fixed and dilated patient, only to be declared dead within a few hours of morning rounds after thousands and thousands of dollars were spent to transfer the poor unfortunate soul by chopper or ambulance.  And on top of that, the family, having been told that “we” could save them by the referring ER or doctor, were understandably upset that nothing could be done for their loved one. 

We would, without fail, have a patient come in late Friday when an outside surgeon would send their complication to our center because they were going out of town and their partner was not comfortable handling the CSF pouring out of their ACDF patient’s neck. 

I was exhausted, not just because I had to admit and work the patients up, but then bear the verbal blast I got from my attending as he or she shot the messenger.  Being able to say no at that point was unattainable.

So, I carried that with me as we got the practice up and running.  The referring doctors became familiar with me and my work, and thankfully we began to grow. 

As I started to see patients on the Westside of Los Angeles, I would frequently hopscotch back and forth between my San Fernando Valley and Santa Monica locations. I would frequently get home late and not see my son until after he was down for the night. 

This went on for years, and I started seeing fewer well-insured patients and sicker and more underinsured patients as the mix shifted seismically in both areas.  Managed care had seeped into every crevice and brought more acute patients and a less likely chance of getting paid.

I still loved my work, but my frustration grew.  The medical directors for the HMOs were making 6-7 figures while a 9–11-hour operation for an undiagnosed metastasis in the thoracic spine, making a patient more and more myelopathic over two months while their doctor thought they were just anemic gets one paid less than it costs to fix a bumper.  After a few of those, a fundamental paradigm shift began within me. 

Whereas we were all trained to do good work and be ethical and were told that we would make a good living, it became obvious that things had changed.  We are still well paid, and US physicians are among the highest paid among most countries, but we also carry the most amount of medical school debt amongst all countries. 

I started noticing reimbursements tanking, payer mixes worsening, and payers coming up with new and creative ways of not paying.  As my frustration turned to concern, I realized I had to change.  Changing my practice also led me to unlearn many things I had been taught that “just were.”

Here are some of the “old” truths and “new” truths I’ve learned:

Old: Be on-call at as many hospitals and take as many insurances as possible.

New: Be selective where you take calls, do it near where you live, and be careful which payers you take.

Old: Take on ALL cases, even when you are not on-call.

New: Take cases on ONLY when you are on-call.

Old: Never, ever fire patients, no matter what.

New: If a patient relationship is not working, don’t force it and let it go (when appropriate).

Caveat – not all these things will work for you or even be appropriate.  Always do things in the best interest of your patients, but very close behind, keeping you and your family together spiritually and emotionally should also be there.  Nothing will make you feel as empty as when you have a lot of money and no one with whom to share it.

One final thought:  the most successful people in our business are not businesspeople at all – they do the right thing for the patient AND their families.  Sometimes that means not taking the patient on at all and letting the on-call person be the one who takes care of them.

From AMA

CMS takes big steps to fix prior authorization in Medicare Advantage

Physicians are backing proposals on prior authorization from the Centers for Medicare & Medicaid Services (CMS). Learn why the AMA and nearly 120 physician organizations strongly support proposed reforms.

How Minnesota is fighting physician burnout with one key query

Intrusive questions on state licensing applications deterred physicians from getting care they need. The Minnesota Medical Association prodded the state medical board into making a change. See why the AMA says it’s a change all medical boards should emulate.

How the AMA is taking on scope creep in 2023

Dozens of pending state bills aim to expand nonphysicians’ scope of practice and remove physicians from patient care teams. Get details on the legislation and learn how the AMA is helping state medical associations fight back.

IN THE NEWS THIS WEEK

What doctors wish patients knew now about COVID-19 risk and age

As SARS-CoV-2 evolves, age remains an important risk factor for severe COVID-19 outcomes. An intensive care physician shares how age affects outcomes.


8 reasons patients don’t take their medications

Patients don’t take medications as prescribed about half the time. Learn what’s stopping them.

Amid political divisions, physicians unify to protect patients

Physicians gather in the nation’s capital to press for fixes to Medicare payment, prior authorization and other priorities. Learn how physicians’ priorities are finding bipartisan support in a deeply divided D.C.

AMPAC Candidate Workshop

March 31 – April 2

Make the leap from the exam room to the campaign trail. Learn how to run a winning political campaign with in-person training at the Candidate Workshop at the AMA offices in Washington, DC. Learn more or register now!

Picture of Antony DiGiorgio, DO

Antony DiGiorgio, DO

ChatGPT is Going to Change Healthcare, Just Not How You Think

Academic Corner

I can now pass the US Medical Licensing Examination.  A group showed that ChatGPT could pass the USMLE with no prior training.  It wasn’t a perfect score, but it passed.  Thus, the latest round of the “replacing doctors with AI” discussion has been circulating in the mainstream media.  However, like IBM’s Watson before, replacing doctors with ChatGPT is bound to lead to underwhelming results. 

For those unfamiliar, ChatGPT is an AI-based chatbot that will respond to relatively complex prompts with narratives.  It was trained on all knowledge available on the internet.  Its algorithms then answer prompts using that data.  Thus, it provides canned, broad, middle-of-the-road answers.  Try going to the ChatGPT website (chat.openai.com/chat) and asking it what to do for a glioblastoma or spinal cord injury. 

When asked a medical question, ChatGPT responds like a WebMD page.  It will hedge, provide generic advice and, of course, recommend consulting a physician.  It cannot capture all the subtle nuance that goes into surgical decision-making.  It can’t capture the unspoken body language a patient conveys, responding in a way that makes us human.  The technology isn’t ready to replace humans.

The problems behind replacing doctors with AI are regulatory as well.  The FDA has strict guidelines around devices that provide diagnoses and treatment recommendations.  They require new approval for any updates to the software that may alter the diagnosis or treatments.  However, with AI, the software is continuously updating.  There are no mechanisms currently in place for the FDA to ensure that the AI isn’t drifting into algorithms that could endanger patients. 

AI could benefit healthcare right now, without additional regulatory clearance, by reducing physicians’ administrative burden.  Instead of asking it to diagnose a disease or recommend treatment, ask it to provide the CPT codes for your op report (I’ve tried this).  It does a very good job off the bat.  With a little training, the AI can easily provide real-time CPT for both op-notes and E&M.  These functions don’t require the same level of FDA regulatory oversight because the AI isn’t making diagnoses or treatment decisions.

AI could be integrated into EHR to reduce the amount of time physicians are tethered to the computer.  Imagine the clinical note being populated as the patient is speaking.  The AI provides predictive text as it learns your typical documentation patterns.  It could also start filling out orders for you, associating ICD and CPT codes, and ensuring the documentation was appropriate for the CDI staff.  The reduction in clicks and computer time would be astronomical.  Physicians could return to focusing on the patient, having face-to-face conversations, and not being tethered to a computer.

The administrative bloat could be reversed with well-trained AI.  Before physicians are replaced, AI could replace coders, CDI staff, and massive data entry jobs.  Physicians should embrace these changes, knowing they will only enhance our job security by returning us from the keyboard to the bedside.  We should make our voices heard and work with AI developers to guide them along this path.  Replacing physicians with AI grabs the headlines among the public, but replacing administrators is where the technology will be truly transformative.

However, in closing, I’ll demonstrate another function of ChatGPT, more amusing than useful: using its ability to craft responses with different types of prose.  Thus, I give you a microdiscectomy as explained by Dr. Suess:

Oh, let me tell you about a procedure quite grand,
A lumbar microdisc, it’s oh so in demand!

It’s a procedure, you see, for a disc in the back,
That’s causing the patient quite a bit of flack.

The surgeon will make a very small cut,
And use a microscope, like a detective with a magnifying strut.

He’ll remove the herniated part of the disc,
And close up the cut with a tiny little stitch.

The patient will wake up feeling so fine,
With less pain and discomfort, they’ll feel just divine!

No need for a hospital stay, they’ll go home that same day,
And in a few weeks, they’ll be back to their normal way.

So if you have a disc that’s giving you trouble,
A lumbar microdisc may just be the perfect double!

Trust in your surgeon and have no fear,
They’ll make your back feel just right, my dear!

CANS MISSION STATEMENT

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

Picture of Adela Wu, MD

Adela Wu, MD

What We Do in Hard Moments

Residents Corner

As a neurosurgery resident seeing consults on night float for the first time, I knew this shift would be tough—beep, beep, beep. The sound of the pager startled me. Beep, beep, beep. A consult for a 53-year-old man who was found down and arrived comatose at the emergency department.

I saw a room full of activity in the trauma bay and immediately suspected that this was my patient, a thin Asian man lying still on a small bed surrounded by IV lines. I quickly went to his bedside and examined him just before the ED doctors prepared to intubate him. Opening his eyelids for him, I saw big, sluggish pupils. His body jerked and flexed on the narrow gurney when I stimulated him. No family members had arrived yet, and we wheeled him to the scanner. After imaging revealed a large intracranial bleed, the chief neurosurgery resident and attending quickly made the decision to take him to the operating room. While staff rearranged monitors for transport, I grabbed a razor and shaved off this man’s hair, marking the left side of his scalp for surgery. During the surgery, my attending removed nearly half of the man’s skull to relieve pressure on the swelling brain. Our patient was stable for now.

However, when his condition deteriorated over several days, and he never recovered consciousness, we arranged a family meeting to discuss the next steps. The conference room contained a long table where the doctors, social worker, and interpreter sat along one side, facing the patient’s wife, numerous siblings, and two adult children. Confronting imminent death for the first time as a junior resident, I could feel a lump rising in my throat and reflexively focused on clinical facts at first. His family was overwhelmed with the news that further treatments would be futile, and several started sobbing. I was grateful when my attending also found time to join, explaining the injury and prognosis. They seemed to understand better, with a second round of explanations and repeated information. 

When I applied for residency, I knew that neurosurgeons cared for patients facing some of the worst moments of their lives. In fact, I wanted to take on that role, training to perform life-altering surgeries. Yet, I didn’t fully understand then that neurosurgeons were also present during other hard moments. Moments when we must tell people their father isn’t a candidate for further surgical intervention. Moments when families face making the most difficult decisions for their loved ones. 

The patient’s wife was too tearful and distraught to communicate her questions clearly, so his daughter asked what our team thought about her father’s trajectory. Meanwhile, the medical interpreter was translating rapidly into Vietnamese. We held eye contact with each family member during the interpretation. It is known, maybe even common sense, that difficult conversations like this “goals of care” family meeting rely on establishing rapport and gaining trust with patients and families. Too often, particularly for those from racial and ethnic minorities, people may have a wariness, sometimes even vitriol, towards doctors and the healthcare system for “giving up” on their family members. I’ve witnessed some families demanding transfer to a different hospital for a second opinion and some families calling physicians “killers.”

Fortunately, our team had been in contact daily with this family, and I knew his children well. They came almost every evening after work to spend time at their father’s bedside. They knew that our team did everything we could for him. While this “goals of care” meeting was extremely difficult for them, they still graciously expressed gratitude for his medical care. 

By the meeting’s end, his children thanked us and made a special request according to their Buddhist cultural customs. So, we promised to return their dad’s skull bone flap. The least I could do for them was procure the bone from the pathology department. It arrived in a biohazard zip bag, which I pinned to the front of his patient gown. This way, he could be “whole” for his burial and pass peacefully to the afterlife. This way, his family could be at peace, as well.

Tidbits February

Tidbits February

The first Boeing 747 at the plant in Washington State in September 1968. Agence France-Presse — Getty Images

February 1 – Boeing delivered its final 747 jumbo jet airplane, the 1,574th built in Washington state. Since its first flight in 1969, the giant 747 has been a commercial aircraft capable of carrying nearly 500 passengers, a cargo plane, a transport for NASA’s space shuttles, and even the Air Force One presidential aircraft. It revolutionized travel. But over the past 15 years, Boeing and its European rival Airbus have introduced more profitable and fuel-efficient wide-body planes, with only two engines to maintain instead of the 747′s four. This was an iconic plane. I was fortunate to have experienced flying in one and to have toured the Boeing factory where it was made.

 

February 2 – According to the Xerces Society, a conservation group, this year’s annual Western Monarch Count showed a bump to more than 335,479 butterflies. While the numbers increased in Santa Barbara County, San Luis Obispo County, and the Bay Area, they decreased in Ventura, LA, and Orange Counties. This is the second increase in so many years. However, estimates in the 1980s put the state’s population in the millions. The Monarch population has since plummeted by more than 95%. Scientists attribute the decline to habitat loss and degradation, pesticide use, and the changing climate.

Milkweed attracts a Monarch Butterfly at a native plant nursery in Ventura County. Juan Carlo/The Star

February 2 – Groundhog Day. When Punxsutawney Phil spots his shadow. This determines whether we can expect six more weeks of winter or early spring; his accuracy has been a hit or miss. We know that most of the country is experiencing a severe ice storm, with temperatures dropping to new lows and wind chill recorded at minus 108 degrees in Mount Washington, New Hampshire, the lowest level on record in the United States. My grandchildren’s school in Austin was canceled for the fourth day in a row.

February 5 – A powerful predawn 7.8 earthquake hit a large swath of southern Türkiye and northwestern Syria while the area was experiencing a winter storm and the temperatures were near freezing. The epicenter was Kahramanmaraş, a

town northeast of the major urban center of Gaziantep. The quake was felt in faraway Lebanon, Jordan, Israel, Egypt, Cyprus, Iraq, Georgia, and Armenia. According to the United States Geological Survey – USGS, It’s the strongest earthquake the country has experienced in more than 80 years. A second and a separate 7.5 earthquake hit the area nine hours later. Widespread damage and more than 48,000 fatalities were reported. The number of injured and dead is expected to rise as many are still trapped under collapsed buildings in this densely populated area. A major humanitarian disaster is unfolding. Türkiye sits atop the Anatolian Plate, a block of the Earth’s crust that is slowly rotating counterclockwise and shifting west at about an inch a year. The Anatolian Plate is near the Eurasian, Arabian, African, and Aegean Plates.

AP Photo/Ghaith Alsayed

February 7 – Baby girl Aya, born under the rubble of the earthquake that hit Türkiye and Syria, receives treatment in an incubator at a hospital in Afrin, Syria.

February 9 – The town of Antakya, Türkiye, a historic town, is totally destroyed

February 12 – Superbowl. Regardless of your level of interest in this game, it was fascinating to see brothers Jason Kelce,  a center on the Philadelphia Eagles, and Travis Kelce, a tight end on the Kansas City Chiefs, play against each other for the Lombardi trophy. Also interesting was seeing their mother, Donna’s expressions. At least they were not on the field simultaneously since they both play on offense. According to the Pro Football Hall of Fame, Donna is now the first mother to have two sons play against each other in the Super Bowl. Another first was the Navy pregame flyover, which was conducted by an all-woman team of aviators to celebrate 50 years of women in the Navy aviation. 
AP-Photo/Hussein Malla

September 13 – New York State ends its requirement that masks be worn in health care settings, including hospitals and nursing homes. After that, such facilities can set their own masking rules. The move aligns the state’s guidance with the Centers for Disease Control and Prevention, which lifted the federal mandate requiring masks in healthcare facilities in September.

February 14 – Valentine’s Day was celebrated everywhere, even in Saudi Arabia, where Valentine’s Day was previously banned under a decree from the Saudi Committee of Promotion of Virtue and Prevention of Vice, known as the religious police. Red roses, pink balloons, giant teddy bears, and heart-shaped chocolates filled the streets of the kingdom’s shops and restaurants to celebrate. 

Meanwhile, in the US, The San Antonio Zoo offered a special Valentine’s Day greeting for exes who won’t bug off. For $10, the zoo will name a cockroach after your not-so-special someone and feed it to an animal – a cold but direct message that you’re no longer interested. On its website, the San Antonio Zoo says that the annual “Cry Me a Cockroach” fundraiser will “support the zoo’s vision of securing a future for wildlife in Texas and around the world.” Those not into bugs can choose a vegetable for $5 or a rodent for $25 instead.

A Ukrainian serviceman in Kramatorsk walks with a balloon and flowers he bought for Valentine’s Day.

February 14 – According to prime minister Chris Hipkins, Cyclone Gabrielle is the worst storm to hit New Zealand this century. New Zealand is in a national state of emergency. The cyclone batters the North Island of New Zealand, with floods trapping people on roofs, thousands displaced, and landslides destroying homes in what officials have described as an “unprecedented” natural disaster. A national state of emergency has been declared for only the third time in New Zealand’s history. Climate Change Minister James Shaw said of the cyclone, “This is climate change,” and went on to say, “the lost decades that we spent bickering and arguing about whether climate change was real or not, whether it was caused by humans or not, whether it was bad or not, whether we should do something about it or not.” At least New Zealand has a Climate Change Portfolio in its cabinet.

February 14 –  The UCLA SETI group – Search for Extraterrestrial Intelligence – launched “Are we alone in the universe?” a citizen-science effort. No formal training or scientific background is needed. Like most scientists in the SETI community, team leader Jean-Luc Margot readily admits that finding conclusive proof of intelligence beyond Earth is an extremely long shot. No sign of civilization has been found in any space mission so far. Yet Margot thinks that it is entirely possible that something else is out there in this 13.7 billion-year-old universe. The Truth is Out There!

February 15 – More than one million people are now homeless because of the earthquake that hit Türkiye and Syria.

Sergey Ponomarev for The New York Times

February 16 – A rescued 17-year-old, a “miracle girl,” was found alive underneath the debris in Türkiye 248 hours after the February 6 quake. This was later followed by that of two others, ages 30 and 12, who told rescuers that there were more people buried nearby: Miracles and Race against the clock.

But miraculously, rescue workers are still pulling people trapped under the rubble for more than one week, alive!

 

 

Ismail Coskun/Ihlas News Agency, via Reuters

February 18 – Jimmy Carter, the 39th President of the US, and at 98, the longest-living president, chose hospice care at home after a series of hospitalizations for undisclosed reasons. He had previously suffered from metastatic melanoma to the brain. President Carter is considered by many as our best former president. He was also known for his “malaise speech,” delivered on July 15, 1979, during the energy crisis.

February 19 – In 1942, during World War II, President Franklin Delano Roosevelt signed Executive Order 9066, enabling military authorities to designate military areas from which “any or all persons may be excluded.” This led shortly after to the internment of Japanese Americans. Japanese immigrants gained/regained the right to become U.S. citizens in 1952. 

February 19—In 1923, the Supreme Court decided the  United States v. Bhagat Singh Thind case. It said that Thind, an Indian Sikh who identified himself as Indo-European, could not become a U.S. citizen because Thind was not a “white person” under U.S. law, and only “free white persons” could become citizens. The decision was based on the 1790 naturalization law limiting citizenship to “free white persons.” The court decided “white person” meant “persons of the Caucasian Race.” It was not until 1946 that the US Congress made natives of India eligible for U.S. citizenship.

February 20 – Presidents’ Day – The Federal Government officially designates it as Washington’s Birthday. His actual birthdate is February 22, 1732. Lincoln’s? February 12, 1809.

Numbered boards in a cemetery in Antakya, where unidentified earthquake victims have been laid to rest. Emin Ozmen The New York Times

February 20 – A few hours after Türkiye called off its search and rescue operations, two weeks after the powerful earthquake, another powerful 6.4 quake hit the same region, causing additional fatalities, injury, fear, and misery. So far in Türkiye alone, 1.7 million people are displaced, almost 900,000 people are living in tents and containers, almost 140,000 buildings have collapsed, and 115,000 people have been injured. 

February 20 – When ChatGPT was asked, “What is the best hospital in the United States?” the artificial intelligence-powered chatbot offered ten hospitals highly ranked by other sources and publications. However, the answer was qualified with the following statement: “It is difficult to definitively say which hospital is the ‘best’ in the United States as this can vary depending on the specific needs and preferences of the patient, the medical condition being treated, and other factors.” Smart AI!

February 21 – Mardi Gras, French for Fat Tuesday: The first American Mardi Gras took place on March 3, 1699, when French explorers Pierre Le Moyne d’Iberville and Sieur de Bienville landed near present-day New Orleans, Louisiana. They held a small celebration, dubbing their landing spot Point du Mardi Gras.

February 21 – Vanderbilt University’s Peabody School apologized to students for using artificial intelligence to write an email about a mass shooting at another Michigan State University. This line was at the end of the school’s email: “Paraphrase from OpenAI’s ChatGPT AI language model, personal communication, February 15, 2023.” It was written in smaller font. Following an outcry from students, the associate dean of Peabody, Nicole Joseph, one of the three signatories of the original email, sent an apology note the next day. She said that using ChatGPT was “poor judgment.”

February 22 – Ash Wednesday. Fasting and prayer are done to remember and reflect Jesus Christ’s fasting in the wilderness. Lent lasts 40 days. Sundays are not counted, so actually, 46 days. The observance of Lent dates back to the 4th century. During the 5th-9th centuries, strict fasting during Lent was customary. Meat and fish are forbidden, but one meal a day is allowed. Even though I am Muslim, I have observed Lent since I married Joanie, a Roman Catholic. I figure this would count in the eyes of God instead of fasting from sunrise to sunset during Ramadan. This year I am giving up cheese and wine.

February 22 – The FDA issued a draft “guidance” on how companies should identify plant-based products that are marketed and sold as alternatives to dairy milk, such as almond, oat, or soy milk.  According to the draft guidance, any plant-based milk product with the word “milk” in its name should include a statement explaining how it compares with dairy milk. In the future, the label on alternative kinds of milk could state, for example, “contains lower amounts of vitamin D and calcium than milk” or “contains less protein than milk.”

Svitlana kneels next to the coffin of her husband Serhii, 48, during his funeral in Tarasivka village, near Kyiv. AP Photo/Emilio Morenatti

February 24 – Marks the first Anniversary of the Russian invasion of Ukraine. Vice President Kamala Harris said in a speech at the Munich Security Conference: “the United States had formally determined that Russian forces had committed crimes against humanity in Ukraine.”

February 24 – Major League Baseball Spring Training for the 2023 season begins.Yeah!

February 24 – The Drug Enforcement Administration plans to reinstate a longstanding federal requirement that a doctor must see patients in person at least once to get an initial prescription for drugs with the most potential for abuse, such as Vicodin, OxyContin, Adderall, and Ritalin. This requirement was waived during the  COVID-19 pandemic. Refills could still be prescribed over telehealth appointments.

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Calendar

California Medical Association’s 49th Legislative Advocacy Day, on April 19, 2023, in Sacramento
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
CANS, Annual Meeting, January 12-14, 2024 – Northern CA TBD

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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CANS Board of Directors

CANS Board of Directors