It is my pleasure to announce that the 2023 CANS Annual Meeting venue has been chosen as the Mission Inn Hotel & Spa in Riverside, California. This is a historic choice for our organization, as this will be the first-ever CANS Annual Meeting in the “Inland Empire” region of southern California. The Mission Inn is a 4-star/diamond hotel, which is a designated historic landmark, generally considered the largest Mission Revival Style building in the United States. Located 16 miles from Ontario International Airport (ONT), and 45 miles from John Wayne Orange County Airport (SNA), this venue should be an easy flight or drive for all our membership.
The current Mission Inn Hotel & Spa began as an adobe boarding house in 1876, and evolved to a full-service hotel by 1903, when the “Mission Wing” was added, incorporating architectural elements from over 20 different California missions, making it especially meaningful to families with kids who did their “mission project” in primary school. The Wright Brothers took their first flight in 1903, which left an indelible mark on the Inn’s future as the Miller family that owned the establishment became aviation enthusiasts. As the hotel’s popularity grew, three additional wings were added, and supplemented with valuable items from near and far, including artwork, furniture, and religious relics. According to their website, Mission Inn “still houses the oldest bell in Christendom, dating back to 1247.” Overall, while walking the property, patrons can look for and appreciate the 800 bells displayed in various locations.
While I am the latest CANS President to also be a private pilot, I will surely not be the last. Pilots, and all those who dream of flight in our skies, and in space, will find special aviation references at the Mission Inn. Part of the Hotel is dedicated to aviators, with its “Fliers’ Wall” that opened in 1932, and currently home to over 150 copper wings representing notable aviators and aviation groups, including Amelia Earhart (1936), Charles Lindbergh (1994), the Women Air Service Pilots (2001), Buzz Aldrin (2009), and Tuskegee Airmen (2012).
Other than serving as a backdrop for some of Hollywood’s earliest films (“Idiot’s Delight”, “Man in the Iron Mask”, etc.), the Mission Inn boasts an impressive list of “A-list” celebrities who stayed there, including Harry Houdini, Ginger Rogers, Bette Davis, Clark Gable, Cary Grant, Barbara Streisand, and Drew Barrymore to name a few. The hotel also managed to host the politically powerful reflecting the status quo, social reformers advocating change to the status quo, and the intellectuals and pioneers who moved the nation and the world. The Mission Inn’s famous guestlist includes at least ten U.S. presidents; Pat and Richard Nixon were married there, and Nancy and Ronald Reagan honeymooned there.
Numerous captains of industry (Henry Ford, Andrew Carnegie, John D. Rockefeller), pioneers in journalism (William Randolph Hearst, Joseph Pulitzer), and naturalists (John Muir) were guests at the Mission Inn. Attending the 2023 CANS Annual Meeting will also allow our members and their families to walk the ground tread by civil rights icons Susan B. Anthony, Helen Keller, and Booker T. Washington. To commemorate the 100th anniversary of his visit, a permanent bust of Booker T. Washington was unveiled in the hotel’s grand entrance in 2014, with many of his descendants present to honor his legacy. CANS members are encouraged to explore the option to take the docent’s tour of this property, palpating history by actually walking the precise path taken by Washington and others. Albert Einstein was a notable guest, details of whose stay we may want to explore.
If all the above has not convinced you, perhaps all CANS followers of Harry Potter and Lord of the Rings will surely be attracted to the Mission Inn’s narrow passages, medieval style, five-story rotunda, stained-glass windows, castle towers, minarets, flying buttresses, Mediterranean domes, pedestrian sky bridge, and even a Cloister Wing (with catacombs)! A great time will be had by all in this modern-day castle. Do plan to attend, and let’s make this a family event, the most fun CANS Annual Meeting since medieval times (or at least the last 50 years). See you there!
On March 19, Flo, Stephen, Christine, Mike Smith, and their family held a celebration of life memorial for our colleague, friend and founding editor Randall M. Smith, at the Women’s Beach Club in San Diego. It was a beautiful and warm affair. Randy was remembered lovingly by family, friends, colleagues, neighbors, and ex-patients. Neurosurgery was well represented both in person and on zoom. Randy was an amazing and unique man. His contributions to organized Neurosurgery are unequalled. Rest in Peace, my friend!
In this issue we will continue our monthly column of women in Neurosurgery. This month we are privileged to have Deborah Benzil, Vice Chair of Neurosurgery at the Cleveland Clinic write about her experiences and personal perspective. As a recognized leader in our field, her contribution is very valuable to all of us.
Starting this month, we will have a medical students’ corner, a first for our newsletter. Shivum Desai MS-III whose enthusiasm impressed me very much, reached out to me at the encouragement of his mentor Omid Hariri. He will introduce this column this month by discussing how he became interested in neurosurgery. He plans to write in future columns about experiences that cemented his interest.
I bring your attention to the fact that “trauma” was what led both future doctor Desai and Leader Benzil to choose neurosurgery. Treating patients with traumatic brain injuries in the Emergency Departments continues to be a service only neurosurgeons can provide, giving us a significant advantage as we deal with hospitals.
Also new this month is an essay by a CANS Board of Directors member who is not on the editorial team. Board members work hard to keep CANS on track and their perspective is very valuable. Ian Ross from Pasadena, a Director-South, recalls a specific incident that led him to reminisce about the pandemic and the last two years, striking an optimistic note. Neurosurgeons are eternal optimist, I’d say.
Finally, a quick history about National Doctors’ Day, March 30.
Thank you to all physicians and neurosurgeons for what you do!
The biggest news in the world now is the invasion of Ukraine, a democratic country, by Russia, an autocratic country controlled by Vladimir Putin, a dictator and I’d say a sociopath. This unprovoked invasion characterized by atrocities and war crimes, including deliberate attacks on healthcare facilities, has resulted so far in untold injuries, deaths, and misery. More than 3.7 million Ukrainians have fled to neighboring countries, and a significant number of Ukrainians are internally displaced. This terrible war is now in its second month. The end is not in sight.
The world, led by the US and the NATO alliance, with a few exceptions mostly from countries that are controlled by autocrats, have come together to help Ukraine. They are having to balance being forceful against this terrible aggressor and avoiding an escalation that may trigger WWIII. It is my firm belief that Good will eventually prevail against Evil.
It is good to see how welcoming and supportive neighboring countries have been to the Ukrainian immigrants. It is also good to see the wide-spread indignation of ordinary European citizens, and of citizens from around the world as they witness the atrocities to which the innocent Ukrainians have been subjected.
Our non-political, scientific National organizations, the AANS and the CNS were quick to issue unprecedented statements of support for the Ukrainian people and of condemnation of Russia’s aggression. Even the WFNS, an umbrella organization of dozens of regional and state neurosurgical societies, issued a similar statement. The AANS statement reminded the reader that, at least in part, the organization felt committed to make a statement because it “is an international organization which, for over 90 years, has been dedicated to education, research, treatment, and advocacy related to diseases of the brain and spine; conditions which constitute many of humanity’s most common, consequential and debilitating afflictions.”
Although I totally endorse the support of Ukraine, and the condemnation of Russia, I wonder where the indignation was when people in my country of birth – Syria – suffered at least as much misery as the Ukrainians, and probably much more. Yes, and ironically the suffering of Syrians was at the hand of the same dictator – Putin, who supported one of the world’s worst pariahs, Bashar Al Assad, another dictator and sociopath.
I was troubled when I heard “well meaning” reporters describe the Ukrainians as “civilized people like us,” and not “like people from Syria, Iraq or Afghanistan.” Really, Syrians are not civilized? This is news to me. There is a lot of bigotry, and there is both overt and covert racism in the world. The different standard applied to the Ukrainians from Europe and the Syrians from the Middle East, demonstrates this bigotry, which has become crystal clear. Some of Ukraine’s neighbors who are welcoming the Ukrainian refugees with open arms, closed their borders to Syrians and other refugees from the Middle East.
Shouldn’t people, whether from Ukraine or Syria, be treated as human beings? Or should they be treated differently based on someone’s idea of how civilized they are? Shouldn’t we try to save them all? Shouldn’t we work diligently to prevent them all from suffering neurological injuries? According to Amnesty International, there are currently an estimated 25.9 million refugees in the world, half are children. At least 1.4 million especially vulnerable refugees need resettlement. Should we at least hope that the open-arm treatment of Ukrainian refugees be extended to all of them?
There are many bad regimes in the world and there are many millions of internally displaced people or who were forced to become refugees; they are not being treated kindly by their own governments, nor by the world community. Please see our own State Department report about regimes that are known to have committed genocide against portions of their own population. https://www.state.gov/2021-report-to-congress-pursuant-to-section-5-of-the-elie-wiesel-genocide-and-atrocities-prevention-act-of-2018
Four of our five children attended the Thacher School, an exceptional boarding school in Ojai, California. The school motto is Honor. Fairness. Kindness. Truth. Oh, how I wish that this motto could be universally accepted and applied; let me say that I am not naïve, and I don’t believe in pipe dreams. However, when it comes to our professional organizations, I expect Fairness to be a basic principle. And fairness requires treating people with the same standard.
Organizations like the AANS and CNS have as members people like me who were born in countries that can be labeled as “uncivilized.” And the WFNS has many societies under its umbrella that represent countries and even continents, which are not usually considered “civilized.” So, I feel that they were unfair, inconsistent, and even hypocritical – inadvertent hypocrisy is hypocrisy nonetheless – when they jumped to support the Ukrainians and to condemn the Russians, but never lifted a finger when the Russians used cluster bombs to kill and maim Syrian civilians including women and children. They were not concerned either about the millions and millions of other refugees or about the genocide committed in some troubled areas under the watchful eye of the world; our National Neurosurgical Societies remained silent on this subject.
I believe that the AANS, CNS, and WFNS should stick to their scientific and medical missions. And unless they are willing to apply the same principles and standards to all people who suffer at the hands of aggressors in this dangerous world, they should stay away from political issues like the Russian war against Ukraine, despite its humanitarian dimension.
I also wish that our non-political, scientific societies consider adopting the Thacher motto: Honor. Fairness. Kindness. Truth
Speak your mind, even if your voice shakes.
-Ruth Bader Ginsburg
My wife and I are sitting in a medical clinic late on a Saturday afternoon in a small town in eastern Switzerland. We are on a ski vacation, but I sprained my knee a couple of days ago and still have a limp. The room is bright and spotless, on an otherwise gray winter day. A husband-and-wife physician team, Elisabeth and Clemens Neumeier, run it. Dr. Elisabeth was the one who took my initial information and gave me my appointment time. The examining room is white with glass cabinets and polished chrome. The walls are decorated with modern art resembling Jackson Pollock, painted by their artist son.
Yet, despite the pristine setting and the welcome, I am anxious, and my heart is pounding. And it is not because of my knee. I’m a neurosurgeon, I already know it’s not that bad.
I startle to the sound of Elisabeth tearing open a small white package the size of a candy bar; she removes the contents and asks me to pull down my mask. With blistering efficiency, she directs a tiny pipe-cleaner through my nostril into the back of my throat. I gag, then cough and sneeze. Sound familiar? A couple of quick maneuvers later, and my rapid antigen test is “cooking” on the white linoleum countertop in front of us. The same maneuver is performed on Cathy, my wife. Now, we wait.
I twiddle my fingers for a few minutes, then get up, and peek a look at the little white test kits. I almost faint when I see blue streaks. I focus my eyes and notice that the blue streaks are adjacent to a letter C. The area beside the letter T remains white. Elisabeth’s English is slightly better than my fractured German. She is down the hall, and I softly ask if the tests are normal; she says that we must wait a bit longer. I presume that C is for control and T is for test, but can only truly exhale when she returns, smiling, and presents us with two negative Covid-Zertifikate. We can return home to California.
The result – and the moment—have become routine. And that is monumental. Two years ago, many of us thought we were going to die, at least that was the thought of many in the medical profession. Only a few weeks earlier, we had blithely joked about the “beer virus,” and Cathy had thrown a big party for my sixtieth birthday. On March 11, WHO declared the novel coronavirus outbreak a global pandemic, and the U.S. soon shut down. People were dying all around us, there was no cure in sight, and not even enough personal protective equipment for hospital personnel treating infected patients, let alone everyone else. It was terrifying.
I always thought that watching men walk on the moon in the summer of 1969 was going to be the coolest event in my lifetime. But the progress that we have made fighting the coronavirus over the last two years, while it may seem less dramatic, is no less impressive. We went from no vaccine to worldwide introduction of effective vaccines within about nine months. The vaccines, especially the mRNA vaccines, are remarkably good at preventing severe infections and death. Ramping up production and administration to the point where billions of doses have been administered over the last year has been unprecedented. In very short order, we have also learned much about how the virus propagates and makes people sick. Effective antibody and antiviral treatments have been developed. It’s still a deadly disease, but mostly for those who are unvaccinated (by choice or circumstance), with no prior immunity from infection, and individuals whose immune systems are compromised. We have even learned ways to mitigate the virus’s spread. These are not small things.
Like everyone, I have very significant COVID fatigue. I get irritated that, for the foreseeable future, I am going to have to wear a mask in the hospital. I still can’t enter the US, at least via a commercial airplane flight, without a negative COVID test. And the virus has not gone away. Indeed, one of my patients recently died of COVID-19. He was forty-eight and didn’t think getting vaccinated was a good idea. We are not at the end of the COVID tunnel, but the light is there. The incredible human response to a viral pandemic gives me hope. It shows us that big problems can be solved. We just need to put our collective minds to solving them.
Who would have thought a girl growing up in rural Maryland, in a community where there were more farm animals than library books, would become a neurosurgeon, and Vice Chair at the Cleveland Clinic? The road traveled was tortuous and difficult. It is both rewarding and frustrating to appreciate the challenges, the progress and the significant hurdles that still remain for this specialty, to which I have given my sweat, blood, and tears.
July 4, 1983. A 16-year-old waterskiing on the Chesapeake Bay skittered his skis smacking his head against a submerged rock. At first, he felt fine, but then rapidly declined. A trauma helicopter transported him to Shock Trauma in Baltimore. The stat CT scan took more than 30 minutes, but the first slice of the temporal fossa revealed a massive epidural hematoma and emergency surgery ensued. My brand-new white shoes were permanently stained when I drilled the burr hole that released the blood clot and ultimately saved his life. By the next morning, the teenager was asking to go home. He recalled none of the drama that had unfolded, but I would never forget. Up to that point, I knew little about neurosurgery and had no interest in it as a specialty- now I was hooked. Little did I understand the challenges that lay ahead.
Neurosurgery circa 1983
Most neurosurgeons of today would hardly recognize the neurosurgical world of 1983:
My first enormous challenge was to achieve a residency training position. It never dawned on me that I might fail. Resident interviews were horrendous:
There were also uncomfortable moments specifically to being a female interacting with men in powerful positions-enough said. Eventually, I was landed a position at Brown University/Rhode Island Hospital.
Residency Years (1985-94)
Brown was an amazing place to train- Providence perfect host for my young family. These were transformative times within neurosurgery with MRIs, coiling, Gamma Knife, and molecular biology. However, complex spine was not part of neurosurgery.
These were the days before resident evaluations, direct supervision, duty hour restrictions, or program requirements. There were constant challenges including:
Incredible progress has been made in all of these in today’s training environments.
There was the added strain of being the first and only female in the program. Then, neurosurgery included pornographic images in the call room and many lectures, as well as routine comments about female patients’ physical attributes. Then I announced my pregnancy! Despite the passage of time, still few programs have paid maternity leave and there remains no “good” time for a neurosurgeon to plan pregnancy/childbirth.
In 1994, the concept of a two-career family was still atypical with the daunting task of finding simultaneous jobs and taking care of 2 young children. Health Maintenance Organizations (HMOs) were on the rise, physician reimbursement declining and medical malpractice rates soaring.
I struggled to find balance during this period. The pressure to grow a practice, gain academic credentials, and compete “with the boys” conflicted significantly with needing reliable time for family and my own personal health, neglected for years. Predatory individuals were common in neurosurgery- junior faculty were often the victims of unethical practices. Neurosurgery departments were lucrative and powerful, making those at the top untouchable. The most important lesson learned was the power of the patient: if you do the right thing and care for your patients, they will become your strength and free marketing.
Being competent and relevant required me to learn new techniques and add to my surgical repertoire. This included mastering spine instrumentation, minimally invasive techniques, and embracing innovation. I swiftly learned how important the “business of neurosurgery” – equal to learning surgical technique and patient care. I gained roles within organized neurosurgery with a springboard into leadership positions. Increased visibility allowed me to mentor and support the amazing next generation of women and forward-thinking men.
At Columbia University College of Physicians and Surgeons I collaborated with the resident team to develop a comprehensive socioeconomic education curriculum. My clinical practice flourished, and organized neurosurgery offered many leadership opportunities. In 2018, I became the Vice Chair of Neurosurgery the Cleveland Clinic. Here I continue patient care but have increased opportunity to teach and train an outstanding resident team as well as apply the strategic and leadership skills honed throughout my career. Three decades into my career, I have found reasonable balance between work, family, friends, and my own needs.
Women in Neurosurgery (WINS)
The evolution of women neurosurgeons-in numbers, acquisition of leadership roles, and acceptance-is as significant to me as any of the technological innovations. WINS was launched after a small number of women residents sat together during a luncheon. Many women declined early involvement in the organization out of fear of retribution. In fact, I kept my own leadership role a secret.
Women have and continue to transform neurosurgery in many traditional ways through research, innovation, clinical/technical excellence, teaching/education, leadership/administration, and socioeconomic/advocacy/fiduciary expertise.
Women also challenge the status quo, ask different questions, provide alternative perspectives, and think differently, adding to the evolution of our specialty. Being a part of WINS as well as working with individual female neurosurgeons is essential. They are my dear friends, my sisters-in-arms. Today’s generation will carry the torch to places I could not dream of in 1983 or 1994, or even today as I savor the last years of my long career.
And in the end…
Tomorrow’s world of neurosurgery has the potential to positively impact patients through change that we cannot yet even imagine. Perhaps somewhere there is an undergrad or a medical student who will encounter a 16-year-old trauma patient, or similar, whose world will tilt as mine did decades ago.
There I was, standing in the middle of a busy freeway, past midnight, in downtown Los Angeles, blood covering my hands. Just minutes before, I was driving home from a celebratory dinner with a car filled with family and friends. I noticed several cars stopped ahead in the middle of the busy freeway. As I drove by, I could see a man, trying his hardest, pounding on the chest of another individual laid on the ground. In that moment something came over me and, without thinking, I immediately pulled my car over and jumped out. I ran over to victim’s body, jumped down on his chest, and began CPR. After that, the combination of my CPR training and adrenaline took over, and the rest was just a blur.
From a young age I always envisioned a career in law enforcement. Such a career choice stemmed from my deep desire to help others when they needed help and protection the most. But, after that harrowing night on the freeway, I knew my career path had changed forever. Yet, I still did not know that I would aspire to become a neurosurgeon until several months later, when I found myself next to my father’s hospital bed, praying he would wake up from his traumatic brain injury. It was only after this humbling experience that I finally found my calling, neurosurgery …
However, my father’s surgeon was quick to warn me. He told me to ask myself why I so desperately desired to pursue a career in which favorable outcomes can be rare and recovery periods are painstaking. Fortunately, my response to his question is the same reason which continues to fuel my unrelenting desire to achieve the career of my dreams: I want to change and save people’s lives. Because if it had not been for a neurosurgeon, my childhood mentor would have suffered from brain cancer and my own father might not be alive today.
Fortunately, I found my motivation to be strong and unwavering and it could have not come at a better time. After my father was discharged from the hospital, I found it difficult to not only help nurse him back to health, but also return to college, and work two jobs at the same time.
But my newfound passion kept me focused and always wanting more. Today, that same motivation has helped me overcome countless adversities in medical school and continues to push me relentlessly, stopping me from ever accepting anything less than perfection from myself. During my didactic medical training I went through many ups and downs. Initially, my dedication to my extracurricular activities, coupled with my drive to succeed academically, proved difficult. But eventually I concluded that viewing my failures as what they are is not beneficial. Today, every stumble I experience I choose to view as a teaching moment, a perspective which I plan to carry with me as an aspiring neurosurgeon.
Neurosurgery is a specialty marred by both peaks and valleys. Fortunately, I was able to experience such ups and downs, firsthand, through difficult times in my life. But it is because of these difficult experiences that I am driven to help others in similar situations. I use these experiences and lessons to motivate me daily, so I continue to grow as a medical student and future neurosurgical resident.
John Hanbery (1919-1996) attended Stanford Medical School and did his Neurosurgical training at the Montreal Neurologic Institute with Wilder Penfield and William Cone. In 1954 he was recruited to Stanford as an assistant professor of neurosurgery in the Department of Surgery. He was the driving force to establish the Stanford neurosurgical residency-training program which was established and certified in 1961. He became the inaugural Professor and Executive Head of the Division of Neurosurgery in 1964. At that time the program accepted one trainee per year for a 6 year post internship program which consisted of four years of clinical training in neurosurgery (two at the University Hospital, one at the Palo Alto VA and one at the Santa Clara Valley Medical Center). Additionally there were 6 months of Neurology training at the Institute of Neurology in Queens Square, England and 6 months of Neuropathology training with the eminent Lucien Rubinstein at Stanford. There was one year of dedicated research time included in the training program. Dr. Hanbery retired in 1989.
Gerald D. Silverberg was named acting head of the Division of Neurosurgery at the time of Hanbery’s retirement. He had trained in Neurosurgery at Stanford with Hanbery. While on the faculty he was the micro surgeon and was known for his work on the use of deep hypothermia and cardiac arrest for the treatment of giant cerebral aneurysms. He was instrumental in obtaining Departmental status for Neurosurgery at Stanford in 1990. He also charted a course for encouraging subspecialty practice of Neurosurgery at Stanford. He initially started as the acting chair and then formally was appointed as permanent chair of the newly formed Department after the formal search was terminated by the Dean due to financial constraints and opinion of the Dean that the internal candidate was suitable. This triggered a protest by Francis K. Conley, a full professor within the department. Allegations of conduct and behavior reminiscent of sexual harassment were raised against the school and the Dean felt pressure to rescind his appointment and instead appointed Lawrence M. Shuer as acting Chair on March 20, 1992.
Dr. Shuer trained under Hanbery, Silverberg and Conley and kept the department together during the turbulent times. He successfully appealed an adverse action proposal from the Neurosurgical RRC to place the program on probation for lack of a permanent chair. Ultimately, a national search resulted in Gary K Steinberg to be selected as the Chair of the Department on December 1, 1995.
Under Dr. Steinberg the Department grew exponentially from 5 clinical faculty to 59 faculty in clinical and research positions. During that period, Stanford’s infrastructure grew with the addition of new Adult, Children’s, VA and County Hospitals. The Department now has faculty to cover the subspecialty areas of Cerebrovascular, Neuro-interventional, Functional, Neuro-oncology, Stereotactic Radiosurgery, Skull Base, Epilepsy, Spine, Trauma, Peripheral Nerve and Pediatric disciplines. The training program has grown to train three residents a year for a total of 7 years with the internship incorporated into the training program. The residents rotate through the Adult, Children’s, County, V.A. and Redwood City Kaiser Hospitals. There are now two dedicated years for research in the middle of the training schedule. There are also post residency fellowships in Cerebrovascular, Neuro-interventional, Radiosurgery, Skull Base, Spine and Pediatric Neurosurgery.
Dr. Steinberg stepped down as Chair in 2020 and Michael Lim was recruited to be Chair. Dr. Lim was a Hopkins Med School graduate who trained in Neurosurgery at Stanford. He then went on to become a very accomplished researcher, teacher and clinician at Hopkins. Dr. Lim continues to foster excellence in Neurosurgery through Clinical care, Research and Education. The department performs over 4,000 neurosurgical operations each year. The faculty and trainees are among the most diverse for any Neurosurgical Department in North America.
Stanford Neurosurgery Department 2021
One of the first things to learn when starting private practice while you are breathing the fresh air of independence and freedom, is you have to pay your own bills. Frequently, people striking out in practice have no clue how money comes in, nor where to get it. Income, if you are coming from employment, will immediately take a nosedive, even with your obligatory 3 months of emergency cash stash. Surgeons will undoubtedly enter full freak-out mode when they are trying to get their income stream going.
Most surgeons, including myself, will sign up for each and every insurance plan – usually without reading their agreement. The contracting agent will swear up and down that the contract “is boiler plate.” And sure, it looks great. Many times, payers will lure you in with a multiple of Medicare, say 110%. This sounds really great. (I have since become aware neurosurgeons are now accepting a fraction of Medicare – don’t be that person).
You work, you send a clean claim with the right CPT codes, within 30-45 business days you get paid! Why doesn’t everyone do it this way? They secretly mock their colleagues who don’t take all the insurances, smiling knowingly as they wait for that tsunami of cash to wash upon their shores.
Except – it never comes.
They have been doing 60-70 cases a month and humming along. Doing great. Then they look at something called their “accounts receivable” or “AR.” That. Number. Is. Big. The corresponding amount in your banking account gets smaller and smaller as its mirror twin gets bigger. In fact, there starts to be a full-on inverse correlation between the two.
What’s going on? Where’s the money? Mental images of your second home on Lake Tahoe fade back into the ether. Then, worries start about making the mortgage payment on your first home. The answer comes in that those promises from the payers to pay you ON TIME and at your contracted rate ring hollow.
The point is, simply signing contracts with payers almost never equals payments. Now, the reasons are legion that insurance companies can and do get away with legalized thievery. I would be happy to share an adult beverage with whomever is reading this and talk over the methods they have used and are using.
Truth is there is almost no full-proof inoculation to give your business to make them pay. There are companies that can and do pursue these companies, but it will take years to recoup a fraction of it.
Having worked with a few companies that will pursue, successfully, unpaid claims from insurers, I have seen that the battle is usually long, may take years, but in the end something is better than nothing. It also is extremely helpful to notify your patients that you need their help. Instruct them to file a dispute with the office of the insurance commissioner (http://www.insurance.ca.gov/01-consumers/101-help/), stating they got care from you, but the payer will not pay you.
How do you keep on/survive? Eventually, you find that dropping some insurers is good to keep you and the practice healthy. You also need to be aware of stipulations of AB72 and the carve out for emergency care. Familiarize yourself with the after-hours, weekend, and office hours disruption codes and their required documentation that you are entitled to bill when you are on-call:
Procedure code and Description
99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service
99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic
99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to the basic service. It involves the physician interrupting his or her care of another patient to deal with an emergency.
99060 Service (or services) provided, out of the office, on an emergency basis, in addition to basic service which disrupts other scheduled office services.
The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified. These codes have a Status Indicator of “B” in the National Physician Fee Schedule (NPFS). Consistent with CMS, Medica considers these codes not eligible for reimbursement.
These are add-on codes used for commercial and private insurers, not for Medi-Cal and Medicare plans. For Medicare Advantage plans, you could try to bill them as well. The No Surprises Act, which started as a bipartisan legislation forged in Congress and unfortunately unilaterally altered by some rather anti-medical folks at HHS, will undoubtedly make things difficult for not just private practice but even employed physicians. Until it is settled, the future is somewhat uncertain. Now, more than ever surgeons must bill correctly and accurately to make sure the remuneration obtained is correct.
I learned quickly that taking all insurers is helpful in the short term, and not a viable long-term strategy as you will be crushed by your outstanding accounts. Even in contracted situations, I have waited for almost 10 months to get paid. Eventually, you will find out which insurers cooperate the best in your locality as well as where you can find your best efforts rewarded.
It is important to know that insurers really only want is a race to the bottom, to get the best price. This is reasonable if you are a multi-billion-dollar behemoth and swings in revenue spook shareholders. But when you are carving out a spot, it is important to be savvy, bill correctly and ethically, and be prepared to wait. Getting your happy and satisfied patients involved to complain is perhaps the best leverage you could hope or ask for.
And lastly – never believe you and your hard work are worth less.
I’m hoping my first column convinced you, the CANS readership, of the value of social media. If so, I bring you a short guide for entering the Twitterverse.
Creating an account is easy. Go to Twitter.com and click the “sign up” button. You can use your phone number or email address to sign up. I recommend uploading a profile photo. Choose something that will be recognizable when it’s shrunk to 1cm diameter on a smart phone.
The symbols and terminology of Twitter can take some getting used to. The timeline is your home screen. This is where the Twitter algorithm shows you what’s going on. It is mostly populated by tweets (and re-tweets) from people you follow. The symbols at the bottom of any tweet allow you to comment (the speech bubble), re-tweet (the recycling symbol) or like (the heart button) the tweet.
Commenting on a tweet leaves a public response. Your comment can show up on the timeline of anyone who follows you, allowing them to see the original tweet as well. It will also show up for anyone who views the original tweet as well. A re-tweet simply shows that tweet to any of your followers. When you hit the re-tweet button, it gives an option to quote re-tweet, which just allows you to comment with your re-tweet. A “like” simply shows that you liked the post and will help Twitter’s algorithm.
The ampersat (@) denotes an account. By submitting a tweet with an “@” and account name, you are tagging a person in that tweet. They will be alerted, and the tweet could show up on their followers’ timelines. The hashtag (#) denotes a keyword for a tweet. It helps Twitter track trending topics and for tweets to show up in searches. I often tag my tweets with #MedTwitter and #neurosurgery. If you search for a term on Twitter (glioblastoma or Ukraine, for example), posts with those hashtags will result.
Now search for some accounts to follow. CANS is @CANeuroSurgeons. The CSNS is @councilsns. The AANS is @AANSNeuro. The CNS is @CNS_Update. The neurosurgery DC office is @neurosurgery (account run by the venerable Katie Orrico, who also has her own account, @KatieOrrico).
CANS stalwarts John Ratliff (@JohnRatliffMD), Sanjay Dhall (@spineNeuro), Brian Gantwerker (@cscla), Arvin Wali (@ArvinWaliMD), Ciara Harraher (@SantaCruzNeuro) & Kenneth Blumenfeld (@KenBlumenfeld) are all on Twitter. I’m @DrDiGiorgio (shameless self-promotion here). Following these accounts will lead to Twitter suggesting more accounts for you to follow. Many prominent neurosurgeons, programs (@NeurosurgUCSF), organizations (@AANSCNStrauma & @spinesection) and journals (@TheJNS & @Neurosurgery CNS) have accounts that Twitter will eventually suggest for you. Give them a follow and tailor your account to what you enjoy.
Finally, try posting something. If you want to share an article, many journal websites have a link to tweet an article directly on the site. Just look for the little bird button. You can track how many people have seen your tweet and how many have followed the link. Soon you’ll be reading articles you might not have otherwise seen and having conversations with new colleagues. Maybe you’ll even go viral one day.
Satellite Image From NASA
March 31 is Cesar Chavez Day. The national holiday honors the civil rights activism of the late labor organizer. Without Chavez, California’s farm workers wouldn’t have fair wages, lunch breaks and access to toilets or clean water in the fields.
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CSNS Spring Meeting, April 28-29, 2022, Philadelphia, PA
AANS: Annual Meeting, April 29-May 2, 2022, Philadelphia, PA
Neurosurgical Society of America: Annual Meeting, June 12-15, 2022, Maui, HI
Rocky Mountain Neurosurgical Society: Ann. Meet., June 18-20, 2022, Coeur D’Alene, ID
New England Neurosurgical Society: Annual Meeting, June 23-25, 2022, Chatham, MA
Western Neurosurgical Society: Annual Meeting, September 9-12, 2022, Kona, Hawai’i, HI
CSNS Fall Meeting October 7-9, 2022 San Francisco, CA
CNS Annual Meeting October, 9-15, 2022 San Francisco
CANS, Annual Meeting, January 13-15, 2023 – Riverside, CA The Mission Inn
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