Newsletter

Volume 50, Number 12

Inside This Issue

Joseph Chen, MD

CANS President

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

President's Message

I’m honored to serve you this year as CANS President. Congratulations are due to Dr. Javed Siddiqi, 2022 CANS President, for his extraordinary leadership and superb meeting held at the historic Mission Inn in Riverside on Jan 13-15. A number of particularly important topics were presented, including an overview of our organizational history, technical innovations, entrepreneurship, post-career planning, and a special section on mentorship, among other topics.

Winners of the resident prizes were John Yue for his presentation “Risk Factors For Prolonged Length of Stay After Traumatic Brain Injury;” Alexander Tenorio for his presentation “ The Impact of the Mexico-San Diego Border Wall Extension on Spinal Injuries;” and Adela Wu for her presentation “ Modifiers and or Disparities in Palliative and Supportive Care Timing and Utilization Among Neurosurgical Patients With Malignant Central Nervous System Tumors.” They and their faculty mentors are to be congratulated for their efforts.

From left to right: Joseph Chen, CANS President – John Yue, third prize winner – Alexander Tenorio, second prize winner – Adela Wu, first prize winner – Javed Siddiqi, outgoing CANS president.

A true giant of American neurosurgery was honored with the Byron Cone Pevehouse award: Dr. Lawrence Marshall. The long-time chair of Neurosurgery at UCSD has been a leader in neurotrauma research and has been instrumental in bringing the bolt ICP monitor and the pupillometer to our armamentarium. Dr. Marshall continues to be a brilliant intellect. He also shared with us his fond memories of our late Randy Smith.

The Ablin award winner was Fr. Gregory Boyle SJ, a transformative figure in Los Angeles, for his work in preventing gang violence. His work has saved many from tragedy and affirms the universal power of forgiveness and redemption.

One of my responsibilities as president is this editorial. My predecessors have been a remarkably erudite and articulate group who have shared many subtle insights on these pages. I hope you find some of my musings and personal opinions (not necessarily representative of CANS positions) of interest.

I have, in the past, only sparingly contributed to these pages because writing has often been a fraught and torturous experience for me. Perhaps it’s due to having malformed conceptions of the message I want to convey. Perhaps it’s due to the difficulties of being a hoarder of concepts with a garage and house too full of junk. But now, forced into this responsibility by our fearless editor, Dr. AbouSamra, I will test your patience this year.

School of Athens by Raphael

When I was a graduate student in neurophysiology, my student colleagues and I fell down a rabbit hole of reading historical, scientific texts – kind of a book club of science, among them the works of Darwin and Sherrington. We discussed the implications of D’Arcy Thompson and Dale Purves and the triumphs and failures of Bertrand Russell. I found one moment particularly galvanizing when a fellow student introduced me to – not a book – but a fresco by Raphael.

Painted in the early 16th century and situated in the Vatican, the School of Athens was meant in part to advance the concept of Catholic canon and theology as the concluding product of the western philosophical tradition. As one looks to the center of the image, two focal figures are depicted: one with his hand pointing up and the other with his outstretched hand extended to the ground in front of him. These are the figures of Plato and Aristotle. Plato’s upward hand symbolizes the primacy of the abstract and the unseeable. With his downward hand, Aristotle contradicts his master, figuratively saying that it is only through observation and study of the world that we may understand it. It was to be the Aristotelian approach that dominated for more than a millennium. Of course, as it turns out, it was Plato who was maybe more correct.

Details Plato and Aristotle in Raphael’s School of Athens.

The key failing of Aristotle and his heirs, including Roger Bacon, the Vienna Circle, and others, is a peculiar psychological phenomenon known as confirmation bias. Confirmation bias is the tendency for people to favor information that confirms their preexisting beliefs or hypotheses. People tend to interpret new information in a way that supports their existing beliefs and ignore or dismiss information that contradicts them. This can lead to distorted thinking and poor decision-making. Confirmation bias is a common cognitive bias that affects people from all walks of life and can be found in many areas, including politics, science, and personal relationships. It is a hard-wired trait in human brains – a vestige of an organ built for a different purpose.

In the history of medicine, confirmation biases have led to the promulgation of various nostrums, many of which, with hindsight, seem absurd – such as bloodletting, exorcisms, and useless medicines such as mercury and arsenic. In a more recent example, confirmation biases led eminences such as Halstead and his followers down a blind path of progressively more aggressive, disfiguring, and morbid approaches to cancer. As Siddhartha Mukherjee cogently tells in his book, the Emperor of All Maladies, those advocating for a more conservative treatment were ostracized and figuratively burned at stake, their results being ignored for over 30 years before becoming belatedly accepted.

I suspect that most of you can think of other similar situations in your journey through medicine and science. It is also inevitable that there are current treatments that many of us take for granted that, in time, will be exposed as useless, if not counterproductive. This has been our past and will be our future.

While the work of philosophers of science such as Karl Popper and W.V. Quine may show us to some extent the way out, there are certain things that are presently unknowable in as much as we do not have a complete picture of the physical systems that underlie our biology. This, in the background of the generational time scale of scientific progress, as discussed by Thomas Kuhn and others, should give us some modesty about our present understanding of those concepts that we hold dear, yet not dissuade us from our best Promethean aspirations.

Quote for the Month​ of December

Quote of the Month

” I want to make a New Year’s prayer, not a resolution. I’m praying for courage.
Susan Sontag

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Report

The 50th Annual CANS Meeting was held January 13-15, 2023, at the Historic Mission Inn, in Riverside, California. It was an unqualified success and one of the best in memory. Javed Siddiqi, our outgoing president, deserves a lot of the credit: his vision, determination, and hard work made it happen. It was nice that we had significant exhibitor support. The companies that exhibited are listed elsewhere in this newsletter. They added to the financial success of the meeting. Thank you.

The Board of Directors conducted our association business on Friday the 13th. Only good news to report. Nothing comes close to being considered bad luck.

The new Board of directors was voted in on Saturday, the 14th. They will be listed, as usual, at the end of this newsletter. But the new faces or people with new positions, are listed here:

 

President
Joseph Chen, MD
President-Elect
Ciara Harraher, MD
TreasurerSanjay Dhall, MD
Director North
Anthony DiGiorgio, DO, elected for his first term
Director North
Harminder Singh, MD, elected for his first term
Director North
Omid Hariri, DO, elected for his second term
Director North
Namath Hussain, MD, elected for his first term

The Nominating committee will be chaired by past president Javed Siddiqi, as specified by the Bylaws. It will have the following members: John Ratliff, MD; Kenneth Blumenfeld, MD, both from Northern California; Farbod Asgarzadie, MD; and Mark Linskey, MD, both from Southern California.

New members were voted in. They include:

Joel Beckett, MDLos Angeles
Lawrence Marshall, MDSan Diego
Stephen Shafizadeh, MDPalm Springs
Allen Ho, MDSan Francisco
Jessica Shields, MDPalm Springs

They are the new blood of CANS and are encouraged to be active and participate at every level.

CANS is on an excellent financial footing, as was reflected by outgoing treasurer Ciara Harraher, MD. report.

Adela Wu, MD, one of our residents’ board consultants and the 1st prize winner of residents’ presentations, wrote this month’s essay for “Women in Neurosurgery Column” about Motherhood and Pregnancy. It is a timely discussion. Hers was infused with optimism. We were fortunate to meet her daughter Aubrey, nine months old, who attended the meeting. Much like Dr. Siddiqi’s children Amman and Saira, she is a CANS baby.

Our president Joseph Chen appointed past president John Ratliff as a consultant to the board. In addition to serving CANS with distinction, John is finishing his tenure as chairman of the Washington committee and is about to take over as Chair of the CSNS. Clearly, John will bring significant experience to CANS Board.

Your editorial committee plans to feature some of the important topics discussed during the annual meeting in future newsletters.

We also plan to include two new columns in future newsletters: the first on Innovators in neurosurgery and the second labeled from the trenches, addressing various topics reflected in today’s practice. This month’s column was written by Ian Ross, MD, a member of the board of directors and one of the few remaining neurosurgeons who take calls regularly and practice “general neurosurgery,” taking care of all comers. We are fortunate that he agreed to join our Newsletter’s editorial committee.

Please see elsewhere in this newsletter an account describing the various sessions of CANS 50th Annual Meeting.

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.

Picture of Adela Wu, MD

Adela Wu, MD

Residency and Motherhood

Women in Neurosurgery

How do women in surgical fields approach pregnancy and motherhood? It is a question that has been the subject of several recent studies and news articles. And it was a question I asked myself when I applied to neurosurgery in 2018 as a female neurosurgery resident.

Surgical residency is long. For female residents, the typical training period often coincides with their years of fertility, as expressed eloquently by general surgeon Dr. Arghavan Salles in a widely-circulated editorial in TIME magazine. A survey conducted by Rangel et al. found that female surgeons had fewer children and were more likely to delay having children than their male counterparts. In addition, a person giving birth at age 35 is considered at an advanced maternal age. Had I waited to have my baby after I established a career as a junior attending, perhaps a mere two years after graduating from residency, I’d be considered advanced maternal age, where the risk of numerous complications, such as preeclampsia, gestational diabetes, and miscarriage, all jump significantly. On top of all that, I was also personally concerned with how I could be a good mother while still devoting time and energy to the job I’d worked towards for so long.

I’m fortunate that I had the right circumstances to plan for expanding my family in the middle of my neurosurgery residency. I had just started my research year at the time, curtailing most of my clinical obligations. For one, I could make all of my prenatal appointments on schedule rather than scrambling to the obstetrics office after a night shift, like I heard my friend in another surgical training program had to do. I was done with junior residency and with 30-hour in-house shifts.

I also felt tremendous support from my department, particularly from other women, the female neurosurgery attendings. When I was in my first trimester of pregnancy, Dr. Laura Prolo ensured that I was safely outside the operating room before the X-ray techs shot multiple scans. Dr. Melanie Hayden-Gephart made another resident whose wife was having and me child-customized infant knit caps. In the middle of an eight-hour spinal surgery, Dr. Kelly Mahaney gave me directions to the nearest lactation room and insisted that I scrub out for enough time to pump and hydrate myself. I was especially grateful when I attended my baby shower, and many female neurosurgery attendings, including Dr. Odette Harris, Dr. Ciara Harraher, Dr. Suzanne Tharin, Dr. Tene Cage, Dr. Corinna Zygourakis, Dr. Linda Xu, Dr. Prolo, and Dr. Mahaney, who didn’t have work obligations also supported and celebrated with me.

My daughter is almost nine months old now, and I am still learning from my mentors and the amazing mothers in my department. They are incredible people and models for balancing motherhood with a career when transitioning back to being on service and for the future. Through their experience, I navigated pregnancy, and now, through their example, I can envision how to approach motherhood as a woman in neurosurgery.

References:

Rangel EL, Castillo-Angeles M, Easter SR, Atkinson RB, Gosain A, Hu YY, Cooper Z, Dey T, Kim E. Incidence of Infertility and Pregnancy Complications in US Female Surgeons. JAMA Surg. 2021 Oct 1;156(10):905-915. doi: 10.1001/jamasurg.2021.3301. Erratum in: JAMA Surg. 2021 Oct 1;156(10):991. PMID: 34319353; PMCID: PMC9382914.

Salles, A. I Spent My Fertile Years Training to Be a Surgeon. Now, It Might Be Too Late for Me to Have a Baby. TIME. January 3, 2019.

Photo of the Month

The Photo was taken by Moustapha AbouSamra, MD on February 22, 2022 in Ventura, CA. iPhone X
The photo was taken by Moustapha AbouSamra, MD, on March 2, 2022, in Ventura, CA. iPhone X
The photo taken by Moustapha AbouSamra, MD, on January 5th, 2023 in Duarte, CA. iPhone XIII Pro
Picture of Ian Ross, MD

Ian Ross, MD

Medical “Malpractice” Woes

From The Trenches

I am sitting in pretty good seats, watching the Rose Bowl football game on January 2 (my neighbor scored some comp tickets at the last minute). I have been off all weekend. But it has not been a great holiday … I am worrying about a medical malpractice suit that might go to court later in the week.

Total bullshit. And I am looking at having to cancel a week and a half’s worth of office and surgery for something that I am pretty sure is going to go nowhere. But then again, when something goes to court, you never know. A text arrives from my lawyer. “Happy new year … Just got an offer for a free dismissal … No payments … I presume this meets with your approval.”

Yes!!!“ I promptly reply.

It starts to drizzle. The game is OK. I am not 100% invested in it … Penn State v Utah. And we get soaked walking home afterwards. My hip hurts. But hey, I have had worse days.                               

Five years earlier, I had been called to do a “mechanical thrombectomy” on an elderly lady with multiple co-morbidities. It was about 8 in the morning. I was already in the hospital. We got her to the angio-suite pronto and I was able, with some difficulty, to get up and access the embolus in the brain. It was not a thrombus (and thus not technically not going to be a thrombectomy procedure), rather a small piece of calcium/plaque that had broken off somewhere upstream and lodged in a proximal MCA branch. These bits of plaque can be dicey to remove. They do not come out easily, and as a result, if you are too aggressive, or have bad luck, the vessel can perforate. Sort of a no-win situation. I was not able to get the piece of calcium out, though my manipulations did manage to move the piece a little further downstream, opening some more proximal branches. Sadly, but predictably, she did not do well. About a year later a statement of claim arrived looking for damages. They claimed that I had been negligent because I had not prescribed recombinant tissue plasminogen activator (rtPA).

I never prescribe iv rtPA. The stroke neurologist is the one who does that; and he made the decision not to do so in this case. He is also getting sued. My lawyer pleaded with the judge in a preliminary hearing to drop me from the case, pointing out the fact that prescribing iv rtPA falls outside the scope of my practice. But the judge refused to dismiss it … saying that juries are best to decide these things. What a wimp! Then the guy had the nerve to invite my lawyer and me into his chambers (office). He showed us a photo of his dad, who had been a well-known cardio-thoracic surgeon. The photo was from a Time magazine article from the 1960s. Surely, I said, he understood from growing up with his father that things do not always turn out when doctors deal with very ill patients in high stakes situations. He looked and me and my lawyer and said that he was not aware of his father ever having had any complications.

This guy was living On the Good Ship Lollypop. We clearly were not going to get anywhere with him.

Over the subsequent year, my lawyer kept pointing out to the plaintiff’s lawyer that we would prove that the Stroke Team was set up in a way that precluded me from ever prescribing rtPA and that, furthermore, it would not have worked even if it had been given. Clot busting drugs are for blood clots and this lady had a piece of calcium that was blocking the flow.

When we got closer to the court date, my lawyer said that it would probably get thrown out as the plaintiff’s lawyer had not even qualified any expert witnesses to testify against me (there had been no discovery/deposition of her “experts”). The whole thing was bogus and mismanaged by an incompetent lawyer. But the plaintiff-sympathetic judge had not recognized this. I was getting tense.

I called the lawyer who managed my case a few days after the dismissal, to thank him for getting me a good litigator. I asked him how much it had cost to defend me to that point. He got back to me a few days later, $65,000.00 for the experts and legal fees. One year’s premium.

I think that MICRA had to be updated. It is not 1975 anymore; $250,000.00 is not what it used to be. But the sad fact is that with Assembly Bill 35, it is certain that the number of frivolous lawsuits is going to go up, with more incompetent attorneys taking shots. I do believe that the overall tort system remains unchanged, and that we will still usually prevail when the facts are on our side. But it is going to cost more time and money to deal with these headaches … not a great thing in this era of decreasing re-imbursement.

Picture of Deborah Henry, MD

Deborah Henry, MD

ChatGPT

Brain Waves

I first learned about ChatGPT a month ago when it was an answer to the LA Times crossword puzzle, which I complete religiously every morning in hopes that it will help prevent the Alzheimer’s disease that claimed my father’s life. Then I saw a series on ChatGPT running in the Dilbert cartoons, which I also enjoy because it’s like where I work. Next, ChatGPT showed up twice on the evening news-one episode, illustrating its ability to create detailed artwork with simple prompts and then being sold as original artwork, and then a second episode showing how it is being used/misused by students across the country (Stanford Daily).

So, what is ChatGPT, and why all the buzz? ChatGPT means “chat generated pre-trained transformer” and is a chatbot created by the San Francisco company OpenAI (AI stands for artificial intelligence). OpenAI released ChatGPT free to the public in November, and in five days, more than a million people signed up to test it. I checked today to see if I could try it out and received a ChatGPT message that they were at capacity. I tried again a few minutes later and received a differently worded message stating the same. The chatbot was at work.

Reading their website, I came across this example. The user part is what one would type into the chatbot. Next is the chatGPT’s answer:

User: what is Fermat’s little theorem

ChatGPT: Fermat’s Little Theorem states that if p is a prime number and a is an integer not divisible by p, then ap (a to the power p) is congruent to a modulo p. In other words, if we divide ap by p, the remainder is always a.

For example, if p=5 and a=2, then 25=32, and 32 divided by 5 has a remainder of 2. Therefore, 25 is congruent to 2 modulo 5, and Fermat’s Little Theorem holds for this case.

Fermat’s Little Theorem is often used in cryptography and other applications where it is necessary to perform modular arithmetic operations quickly and efficiently. It is also a useful tool for proving other theorems in number theory.

So how is ChatGPT doing this? My layman’s knowledge is that ChatGPT was trained using internet text databases, which it searched for all the information on Fermat’s Little Theorem. It then “intelligently” puts together an answer. If one typed “draw a blue puppy,” ChatGPT would search all types of artworks (apparently copyrighted or not) and generate its own image artwork of a blue puppy. None of the hundreds/thousands/millions of search sites are cited in the answer given.


Google (Alphabet, Inc) realizes that this will change search engines. Instead of getting a list of sites to research when one puts in the prompt, one will get the answer as illustrated above.

Why should we worry? For one, students can use ChatGPT to write essays, do artwork, solve math problems, etc. The Stanford Daily reported that in a recent survey that 17% of students said they used ChatGPT for their fall assignments and final exams and 5% of students said they submitted ChatGPT work as their own. This is like surveying doctors and asking if they made an operating error. It is likely to be an underestimation of the true numbers.

Not only will we have to find ways to use artificial intelligence like this in our education and develop new ways of assessment of everyone from an elementary school child to a medical student, but we have a new means for patients (and us) to find uncited information. I wish I had access to the system to see what it says about “how should I treat my glioblastoma?” Artificial intelligence is here. We need to find ways to stay ahead of the ethical and legal issues it will bring.

From CMA – A Year in Review

MICRA modernization

Facing another statewide ballot proposition that would have effectively eliminated MICRA’s cap on non-economic damages, CMA and Californians Allied for Patient Protection seized an opportunity to end one of the longest running political battles in California. The legislative deal (AB 35), which modernizes MICRA while preserving its underlying principles, has ushered in a new and sustained era of stability around malpractice liability.

Reproductive rights

After the Supreme Court’s Dobbs decision, CMA worked with the Future of Abortion Council to protect and expand access to reproductive health care in California, leading to 15 bills signed into law, $200 million in the state budget and the passage of Prop. 1 to enshrine abortion rights into California’s constitution.

Election victories

CMA member Jasmeet Bains, M.D., joined the California Assembly as its third physician legislator, while incumbent assemblymembers Joaquin Arambula, M.D., and Akilah Weber, M.D., were re-elected. At the federal level, representatives Ami Bera, M.D., and Raul Ruiz, M.D., were re-elected to Congress. CMA also saw its ballot measure positions reflected in election results, including the rejection of Prop. 29 (dialysis clinic requirements) and passage of Prop. 31 (ban on flavored tobacco).

Federal loan forgiveness

The U.S. Department of Education overhauled the Public Service Loan Forgiveness Program, including the specific fix that CMA advocated for that will allow all eligible California physicians to receive loan forgiveness.

Billing and burdens

CMA recouped more than $1 million last year (nearly $40 million over 14 years) on behalf of physician members through direct payor interventions. CMA also stopped Cigna’s burdensome modifier 25 policy.

Health IT

CMA achieved significant victories on health information technology issues by extending the COVID telehealth waivers into 2023; permanently extending key Medi-Cal telehealth payment parity; eliminating e-prescribing burdens (AB 852); and helping physicians comply with the new federal information blocking rule while protecting patients’ sensitive medical information (SB 1419).

Grassroots engagement

CMA saw unprecedented grassroots physician engagement, with nearly 4,000 messages sent to policymakers. These physician voices were key in helping to defeat AB 2060 (public member majority on Medical Board of California) and AB 2236 (allowing optometrists to perform surgical procedures).

Public Health Funding

CMA helped administer both the KidsVaxGrant ($22+ million) and COVID-19 Test to Treat Equity Grant ($59 million) programs, providing critical funding for community pediatric vaccinators, public health systems and community health centers.  

Community Health Centers

CMA saw rapid membership growth among community health centers, resulting in an expansion of our mode of practice forums and House of Delegates representation.

Retention payments

CMA helped secure $1.3 billion in the state budget to provide retention bonuses for many of California’s physicians and other health care workers to stabilize the health care workforce.

Universal health care

CMA successfully advocated for full-scope Medi-Cal coverage for all income-eligible Californians by January 1, 2024, making California the first state to expand its Medicaid program to provide full benefits to all eligible individuals regardless of age or documentation status.

Virtual grand rounds

CMA completed its 29th Virtual Grand Rounds webinar, providing critical COVID-19 continuing medical education to nearly 13,500 attendees while expanding topics to include other public health concerns such as long COVID, monkeypox and wildfire smoke.

CMA advocates for increased Medi-Cal access through the state budget

On January 10, 2023, Governor Gavin Newsom unveiled his $297 billion budget proposal for the 2023-24 fiscal year, which includes a plan to tax managed care organizations (MCO). The MCO tax, which allows the state to receive federal matching funds, had been in place for more than a decade and expired late last year. The California Medical Association (CMA) is urging the Governor’s administration to dedicate MCO tax revenues to raise Medi-Cal rates in order to provide access to care to the millions of Californians with Medical-Cal coverage.


DHCS finalizes Medi-Cal managed care contracts for 2024 and beyond

The California Department of Health Care Services (DHCS) has finalized an agreement with five commercial managed care plans to deliver Medi-Cal services in 21 counties across the state starting in January 2024. The plans include Blue Cross of California Partnership Plan (Anthem), Blue Shield of California Promise Health Plan, CHG Foundation d.b.a. Community Health Group Partnership Plan, Health Net Community Solutions, Inc. and Molina Healthcare of California.


Updated medical board notice to patients required effective January 1, 2023

Beginning January 1, 2023, all physicians licensed by the Medical Board of California must provide an updated “notice to consumers” that informs patients that physicians are licensed and regulated by the medical board and provides details about how patients can check the status of a license or file a complaint. Under the new regulation, the notice must be provided in a language understood by the patient or patient representative and include a QR code that leads to the board’s Notice to Consumer webpage.


Low volume prescribers can now request e-prescribing exemption

Low volume prescribers and health care practitioners that meet certain criteria can now request an exemption from California’s e-prescribing mandate, under a new law (AB 852) strongly supported by CMA. Under the new law, physicians are exempt from the e-prescribing mandate if they issue 100 prescriptions or less in a year; are practicing in an area affected by natural disaster, officially declared disaster or emergency zone; or are granted a waiver based on other extraordinary circumstances


CMS updates Medicare conversion factor; New fee schedule expected soon

When Congress passed its year-end omnibus legislation in the final days of 2022, it included a 2% Medicare physician payment cut for 2023. As a result, the Centers for Medicare and Medicare Services (CMS) has updated the 2023 conversion factor to $33.8872 for 2023. Noridian, California’s Medicare contractor, is expected to post the updated fee schedule by this weekend.


CMS extends deadline to apply for hardship exception to March 3, 2023

CMS has extended the extreme and uncontrollable circumstances application deadline for the 2022 performance year. Physicians and physician groups affected by the COVID-19 pandemic now have until March 3, 2023, to apply for a 2022 Medicare hardship exception. While COVID-19 flexibilities are still in place due to the public health emergency, the exceptions will not be automatically applied as they have been the past two years.


CMA to host webinar on new NP classifications

Assembly Bill 890 (Wood), signed into law in September 2020, created two new classifications of nurse practitioners (NPs) who can perform certain functions without standardized procedures and protocols in California. CMA is hosting a webinar on Thursday, February 23, 2023, to provide an overview of the law and regulations, explain under what circumstances 103 and 104 NPs can practice and where, and show how this may impact physicians and patients.


Save the Date: Join us in Sacramento on May 22 for CMA’s first annual health IT conference

Save the date and plan to join us on May 22, 2023, in Sacramento for the first annual CMA Health IT Conference, “Health IT: Powering Value-Based Care.” This event will bring together thought leaders from across California and the nation to explore the intersection of technology and payment reform. Registration is free for CMA members, and $250 for all other interested stakeholders.


CalHealthCares loan repayment application cycle opens next week

The next application cycle of the CalHealthCares Loan Repayment Program opens January 18, 2023. CalHealthCares provides loan repayment on educational debt for California physicians and dentists who provide care to Medi-Cal patients. Eligible physicians can apply for a loan repayment award of up to $300,000 in exchange for a five-year service obligation.


Save the Date: CMA’s Legislative Advocacy Day Is Back!

Save the date for the California Medical Association’s 49th Legislative Advocacy Day, happening on April 19, 2023, in Sacramento!

Attendees can expect to get hands-on experience and learn the nuts and bolts of advocating for their patients and profession.

  • Join your physician, medical student and resident colleagues at the SAFE Credit Union Convention Center in Sacramento.
  • Attendees will have the opportunity to meet and lobby legislators on priority health care issues and learn how to become an advocate for your patients and colleagues.
  • Registered attendees will receive a webinar training on legislation and policy affecting the practice of medicine on March 29.

How to attend:

This unique event is free of charge to all CMA physician members, residents and medical students. We look forward to seeing you!


Medicare physician fee schedule updated for 2023

When Congress passed its year-end omnibus legislation in the final days of 2022, it included a 2% Medicare physician payment cut for 2023. As a result, CMS updated the 2023 conversion factor to $33.8872 for 2023. Noridian—California’s Medicare contractor—has now updated its 2023 Medicare Physician Fee Schedule to reflect this change and has started releasing 2023 claims for payment.

Anthony M. DiGiorgio, DO, MHA, & Praveen V. Mummaneni, MD, MBA MEDPAGE TODAY, January 21, 2023

Death by 10,000 Clicks: The Electronic Health Record

https://www.medpagetoday.com/opinion/second-opinions/102722

Published with Permission from the authors.

Electronic health records (EHRs), once promised to revolutionize healthcare, are becoming a burden. We audited the EHR logs at our institution, University of California San Francisco, to examine the work of our neurosurgery residents and get a better understanding of the benefits and burdens. The results shocked us: the on-call residents spent 20 hours opens in a new tab or window logged into the EHR over a single shift.

When we shared these results with the residents, they weren’t surprised. They feel that EHR burden every day.

The Promise and Disappointment of EHRs
The EHR has plenty of benefits. Gone are the days of hunting for films in the radiology basement, searching the floors for that missing chart, or deciphering the infamously bad doctor handwriting. For patients who have a usual place of care, having quick access to their past records is valuable.

We considered whether perhaps this busywork had been replaced by more efficient EHR workflows. To see if this was the case, we examined what tasks the residents were doing when they were interacting with certain areas of the EHR. This “active time” (any time they spent moving the mouse or clicking the keyboard while in a patient chart) totaled 9 hours per shift but excluded computer activities outside of patient charts, most notably imaging review. This active time log revealed several inefficiencies, such as a daily average of 45 minutes spent searching for orders, reconciling orders, and navigating order decision support tools. This deep dive showed us that the scut work of old has been replaced with a worse EHR burden.

Our program is not unique in this regard. Surgery residents spend nearly 8 monthsopens in a new tab or windowof their 5-year training on the EHR. Residents routinely take EHR work out of the hospital, completing up to a thirdopens in a new tab or window of it from home. Non-surgical residents have it even worse, spending around 40% of their timeopens in a new tab or window on the EHR and only 12% of their time on direct patient care. Over 90% of residentsopens in a new tab or window say that documentation obligations are excessive, and that they take away from time with patients.

The EHR burden doesn’t just affect residents. It takes a trauma surgery attending 73 full 24-hour daysopens in a new tab or window to complete the required documentation for 1 year of billing alone. In ambulatory practices, physicians spendopens in a new tab or window 2 hours on the computer for every 1 hour of patient time. EHR use is linked to physician burnoutopens in a new tab or window, a problem that is costing billions of dollarsopens in a new tab or window in the U.S.

Many of the inefficiencies we found come from Medicare regulations. The appropriate use criteria programopens in a new tab or window is a good example. This was developed to reduce the unnecessary imaging ordered by physicians. When ordering a CT or MRI, the physician must click a few boxes to ensure the order is appropriate for the diagnosis. In our EHR audit, we found this added just a few minutes of computer time to the residents’ days. However, there’s no evidence that this regulation reduces unnecessary imaging. We believe it to be completely unnecessary. There are many more regulations that add a few minutes here and a few minutes there. It’s death by 10,000 clicks.

 

Steps to Relieve the Burden
Systematic identification of these inefficiencies is necessary to eliminate them. Our study, with its granular breakdown of EHR tasks, was just a start. There are many regulations around billing, coding, value-based reimbursement, and physician order entry that are adding to the EHR burden. Adding these numerous regulations was easy — identifying and eliminating them will be difficult. The Centers for Medicare & Medicaid Services “Patients Over Paperwork” initiative was a good start, as it reduced some of the documentation requirements for physician notes. That effort should be continued.

Some of the inefficiencies come from the EHR itself. Physicians often have little say into which EHR is selected and how it is set up. However, in physician-owned hospitalsopens in a new tab or window, where doctors have more input, their satisfaction with the EHR was improved and they reported more positive perceptions of time spent on documentation. Reversing the virtual banopens in a new tab or window on physician owned hospitals will give physicians more say in the purchasing of an EHR, shifting the market towards those that reduce the computer burden.

Of course, increasing advanced practice provider support helps offload the remaining EHR tasks. The Accreditation Council for Graduate Medical Education (ACGME) has encouraged thisopens in a new tab or window. However, mindless administrative tasks should be eliminated, not simply transferred to other employees. This shifting burden explains why healthcare must employ increasingly more workers to care for the same numberopens in a new tab or window of patients. Advanced practice providers don’t want to be saddled with mindless administrative tasks, either.

What doesn’t help are mandatory wellness programs, doctor appreciation days, or EHR training sessions. In fact, our data showed no improvement in EHR efficiency as trainees became more experienced. The problem comes not from a lack of mental fortitude, wellness, or ambition. It’s built into the system.

Conclusions
As neurosurgeons, we should advocate for policies that decrease administrative burdens. It is detracting from our trainees’ educational experience. Healthcare costs are increasing because of the inefficiencies that come with EHRs. We must be aware of this to protect our residents and to protect our industry. Continued involvement in advocacy is needed to reverse the ever-increasing EHR burden.

Anthony M. DiGiorgio, DO, MHA,  is an assistant professor in the Department of Neurological Surgery at University of California San Francisco, and affiliated faculty in the Institute for Health Policy Studies.

Praveen V. Mummaneni, MD, MBA,  is the Joan O’Reilly Endowed Professor and vice-chair of the Department of Neurological Surgery at University of California San Francisco.

 

Disclosures
DiGiorgio receives research funding from The Mercatus Institute.

Picture of Anthony M DiGiorgio, DO, MHA, FAANS

Anthony M DiGiorgio, DO, MHA, FAANS

Juggling tradeoffs

Academic Corner

Life is full of competing obligations.  This is no less true for the academic neurosurgeon.  My recent absence at most of this month’s CANS meeting showcased this in full.

I won’t get into the specifics, but there were many late nights, up with my wife and a United agent, rearranging
flights and calculating scenarios.

Occasionally I’ll have an opportunity to discuss this work-life balance with trainees and students.  It’s a unique challenge, and I always remind them to be thankful for it.  Not everyone is as privileged to have these quandaries.  We all worked incredibly hard to face this head-on. And the work doesn’t stop after residency.  The decision we made to sacrifice much of our 20s and 30s to medical training was a calculated tradeoff.  Those tradeoffs continue.

The challenge takes me back to a panel I attended as a resident on balancing work and life as an academic neurosurgeon.  The panel was full of giants in the field.  I was amazed that they struggled with such challenges as balancing a family, work, research, and other demands.  I admit I was a little disheartened by how many of them recounted their sacrifices over the years.  I’ve been fortunate to have extraordinary mentors, and I’ve noted how many of them emphasize family.

“You have to make the soccer games,” one mentor told me.

That sentence has stuck.  Now that I have two amazing kids, I truly see the wisdom.

I can’t do it alone.  I’m blessed to have a strong, flexible wife who won’t hesitate to turn a conference into a family vacation.

“Is CANS meeting in Riverside?” “Let’s turn that into a Disneyland trip!” she excitedly exclaims, planning it all out.

We both keep an eye on the meeting schedule, knowing that my CSNS obligations will require attending most AANS/CNS meetings and deciding which would make good family trips.    We enjoyed Austin in 2021; we are looking forward to both Los Angeles & DC.  CANS in San Diego was a blast, and my application to the Western Neurosurgical Society is pending.  Thankfully our kids travel well.

I’m also very fortunate to have supportive partners.  I take calls at two hospitals, so working out a schedule accommodating everyone’s needs isn’t always easy.  My partners who make these call schedules understand my requests, and there are few, if any, conflicts.  Even as junior faculty, these obligations are largely met.  I have a great job at a very supportive institution.

There are still sacrifices and not just my gray hairs.  I have missed many family dinners.  My daughter imitates me by playing on her toy laptop, telling me she’s working.  These are part of the tradeoffs.  As I tell the trainees, your work-life balance after residency is what you make it.  But there will be tradeoffs.  Not everyone will be blessed with such an amazing wife or understanding partners.  That makes the tradeoffs a bit more difficult.

I made a tradeoff in missing most of this month’s CANS meeting.  It wasn’t an easy one.  I had to cover, as the unaffiliated neurotrauma consultant, for the 49ers’ playoff game.  The last-minute change in the playoff medical coverage schedule made it necessary to scramble.  However, having to make those tradeoffs is a good problem to have.

Ian Ross, MD

History of Neurosurgery at Huntington Memorial Hospital

Historical Vignette

Huntington Memorial Hospital has had an active neurosurgical service for about 80 years. Early neurosurgical efforts are difficult to determine. The available records suggest that our first full-time neurosurgeon was C. Hunter Shelden who joined the medical staff in 1940. But World War II soon intervened, and Shelden signed up with the Navy. He moved to Bethesda, MD and worked in the Naval Hospital until returning to Pasadena in 1946 with Bob Pudenz, whom he had worked with in Maryland. Together, they developed a neurosurgery training program for the Navy (which trained several neurosurgeons before closing) and, eventually, Huntington Medical Research Institute (HMRI).

Shelden and Pudenz were thoughtful, forward-thinking individuals. Shelden’s lead article in JAMA in 1955 (Prevention, the only cure for head injury resulting from automobile accidents) proposed things like retractable seat belts, recessed steering wheels, reinforced roofs and rolls bars for cars. This had a huge impact, pun intended. Google “seat belt wiki.” Look at the article if you do not believe me. Pudenz was interested in hydrocephalus/shunt care. He invented the VA shunt procedure (determining it to work better than when the tube is placed in the vena cava) and designed and marketed a shunt system. I used his P-S (Pudenz-Shulte) shunt valve for my VP shunts for decades until it was recently taken off the market. It was a great valve. Shelden was interested in stereotactic surgery and was awarded a medal from NASA for a system that he developed with engineers and scientists at the Jet Propulsion Laboratory, which is just a few miles up the road in La Cañada. Imaging was also a passion, and Shelden was influential in having the first clinical MRI scanner in Southern California set up at HMRI (by strange acronymic coincidence).

For many years, the University of Southern California’s neurosurgery department maintained a strong clinical presence at Huntington, with residents rotating through, until they built their own private hospital. Ted Kurze and Robert Rand (from UCLA), early enthusiasts for the surgical microscope, were both on staff for a time. Joe Bogen, who did innovative work with the corpus callosotomy procedure, was too. His surgical experiences, and subsequent collaborations with Roger Sperry at Caltech (which is just down the road), were integral to the development of Sperry’s split-brain experiments, which led to his Nobel Prize for physiology in 1981.

Other neurosurgical pioneers have crossed our threshold. More recently, Adam Mamelak helped scientists at Caltech with a human single unit neuron recording initiative, by using modified depth electrodes already inserted into the brains of patients being worked up for intractable epilepsy. This work is on-going. And Jason Chu, a pediatric neurosurgeon from CHLA, has been actively involved in the development of fetoscopic spina bifida repair surgery at Huntington, literally one of the very first in the nation. There is, unfortunately, not enough space to recognize everyone.


All this has been possible, at least in part, because Huntington received a significant/lasting endowment from the Huntington family many years ago (hence the eponym) and has maintained extremely strong community support. The Board has recently elected to affiliate with Cedars Sinai, hoping to ensure a viable and indeed thriving healthcare presence in the community well into our still-new millennium.

Indeed, patient care for our community has been and remains a priority. We provide comprehensive stroke and trauma care, and full adult neurosurgical services. Excepting certain neonatal and fetal services, pediatric neurosurgery is no longer provided. But we do almost everything else. Bill Caton, a prodigious clinical force who recently passed away, made sure of that.

Changing Times

Editor’s note: I recently mentioned that EHR and the resulting decreased face time with patients contributed to my decision to retire when I did. Another factor was the rapidly increasing number of regulations that we, physicians, and surgeons, are subjected to. Below is a reprint of a letter I wrote to the late CANS Editor Randy Smith, published almost twelve years ago. It is slightly edited for clarity.

 

Letter to the editor
Moustapha AbouSamra, MD
CANS Newsletter Volume 38 Number 3 March 2011
Regulations and more regulations!
Are we regulating ourselves to death?

 

The evidence suggests that we are indeed subjected to more and more regulations that may lead to the demise of our noble profession.

 

I’ve been in private practice as a physician and a surgeon in my small coastal California community for almost thirty years; you’d think that I know what I am doing by now.

 

However, I am afraid that this is not the prevailing opinion: hospitals, governmental agencies, and even some of our medical organizations feel differently.

 

Instead of respecting the judgment of a more mature surgeon, we are told that “older surgeons” are more dangerous. Please read: “As Doctors Age, Worries About Their Ability Grow” by Laurie Tarkan, The New York Times, January 24, 2011. https://www.nytimes.com/2011/01/25/health/25doctors.html?smid=url-share

But there is always a different perspective:

https://www.nytimes.com/2023/01/17/opinion/letters/100-year-old-doctor.html?smid=nytcore-ios-share&referringSource=articleShare

 

I admit that there are “older” surgeons who should stop practicing, but I believe that most of us are perfectly capable of recognizing “our limits.” It is puzzling that we are expected to make life-and death-decisions daily, but we cannot be trusted to make decisions about our own abilities. Airlines pilots are quoted as an example of how we should be regulated, tested, and re-tested. Is taking a cognitive and physical screening exam annually after age 65 the way to go? Remember that we are also told that 65 is an arbitrary retirement age and that we should seriously think of working in one capacity or another beyond that since we are staying healthier and living longer.

 

With a few exceptions, physicians and surgeons are very careful and do, in fact, restrict their scope of practice to fit what they are most comfortable doing. We all see the wisdom of our elders, and we treasure their counsel. Our patients should feel similarly confident when seeking their expertise.

 

To further illustrate my point about regulations, please read: “Sleep Deprivation, Elective Surgical Procedures, and Informed Consent,” by Michael Nurok, M.D., Ph.D. et al., New England Journal of Medicine 2010; 363:257, December 30, 20107-2579. In this article, the authors suggest that a surgeon may not be capable of deciding whether or not he is impaired by sleep deprivation. I submit that most, if not all, surgeons will not drive while under the influence of alcohol or drugs and certainly will not operate if sleep deprived and impaired; consequently, a new informed consent on Monday morning following a weekend on call as Dr. Nurok recommended, is, in fact, not needed.

 

I agree that airline pilots are subject to many regulations and that aviation safety records are impressive; we should learn the basic lessons from that industry. But there is a vast difference between a pilot and a surgeon/physician. The pilot is trusted to operate a very complex but predictable machine that happens to carry humans; the surgeon/physician’s sole job is to deal with, interact and care for a fellow human being who is often in a vulnerable position and whose reactions are seldom predictable.

 

I do not think that any regulation is burdensome; I do believe, however, that since most regulations are aimed at the small percentage of colleagues that break the rules of common sense and professionalism, we should limit regulating the vast majority of hard-working and honest physicians. Instead, we should let them exercise their professional judgment. And if something must be regulated, I believe that allowing us to “police” ourselves is far more effective than being regulated by anybody else.

 

Losing mature and experienced physicians will be a travesty. And I am afraid that unwieldy regulations will lead to many perfectly qualified colleagues leaving our profession at a time when we need more physicians, not less.

CANS 50th Anniversary Meeting

Highlights

The meeting program included a variety of exciting topics chosen by Dr. Siddiqi. They included:

  • 50 Years of CANS, a short but fascinating presentation by our Historian Austin Colohan, MD
  • DEI in CANS, a well-researched presentation by board member Odette Harris, MD
  • Evolving Perspectives on Family Priorities in CANS, a touching perspective by Langston Holly, MD
  • Inclusion of Osteopathic Neurosurgeons in CANS, an informative presentation by Dan Miulli, DO
  • Neurosurgeons as innovators given by Javed Siddiqi, MD, Adela Wu, MD, John Adler, MD, Doug Ethell, Ph.D., and Alex Khalessi, MD.
  • Mark Linskey, MD, gave a comprehensive presentation about mentorship and its value from the perspective of the mentor, MD, and Saman Farr, DO, gave it from the mentee’s perspective.
  • Past president Praveen Mummaneni gave his perspective on the Value of CANS to its Membership.
  • And President Chen gave a talk on Generational Planning for CANS Leadership.
  • Also included were two concurrent sessions on financial/retirement planning, one for those in their early careers and the other for those in their late career.
  • A session that generated much interest was given jointly by Robert Fessinger, a Medical Malpractice Defense Attorney, and Doug Shin, General Counsel for the Cooperative of American Physicians. They agreed that AB 35 is generally not in the best interest of physicians and that it is particularly of concern to neurosurgeons. The audience seemed to agree. Further, most attendees felt that consultation by CMA with CANS should have preceded the finalization of this compromise with the trial lawyers. Our president-elect, who is a newly elected member of the CMA Board of Trustees, will discuss this further at their next Board meeting.
  • Congressman Ted Lieu, California 36th District, participated in CANS 50th Anniversary celebration by sending a congratulatory video message.

Two highlights of the meeting included the awarding of the following:

  • The George Ablin Public Service Award to Father Gregory Boyle, founder of Homeboy Industries. Father Boyle could not attend in person because of the torrential rain; it made his drive hazardous. We plan to feature him in a future newsletter.

The Byron Cone Pevehouse Distinguished Service Award was awarded to Lawrence Marshall from UCSD.

In addition to being supremely qualified for all his accomplishments – please see highlights of his CV below – Dr. Marshall is an amazing storyteller. He regaled us with interesting stories but concentrated on a fond remembrance of our departed friend Randy Smith. He also imparted some advice that he gave his students and staff over the years.

  • If you don’t know the answer. Say, I don’t know.
  • Pay attention.
  • If you don’t know the solution. Say, I will figure it out.
  • Go and figure it out.

During the banquet, President Javed Siddiqi gave a warm speech and passed on the gavel to President Joseph Chen. Here are some excerpts from Dr. Siddiqi’s speech.

“I will let posterity judge my term as CANS President, but I can say without hesitation that this 50th anniversary meeting has been a great success–I want to acknowledge all the people that made it so.  I want to start by thanking our fantastic exhibitors, without whom we could not have this meeting.  There are many exhibitors at this meeting who responded with a quick, unqualified, YES, when I called them to participate; others had to deal with their corporate

bureaucracies, but never gave up when the process seemed arduous.  Thanks to Dr. Marco Lee, Dr. Brian Gantwerker, and other CANS board members whose sweat equity was invaluable in bringing their contacts to the table.   Emily Schile did a great job in coordinating our varied efforts, sometimes against significant odds.  Because of space limitations in this hall, we have a select group of exhibitors with us tonight—will all our exhibitors present please stand and be acknowledged.  Thank you for supporting this meeting.  Thank you Emily! Please be seated.  ….

This meeting has been very well attended, and actually this banquet was sold out–we were only limited by space; not by interest.  As it was my Presidential prerogative to choose the annual meeting location, I want to point out that this is the first CANS meeting in our half-century, in this part of California, which is my unsubtle way to highlight the great academic and clinical work ALSO being done far from the madding crowds of California’s big cities, in this Inland Empire, a previously sleepy hollow that now has FOUR medical schools, three neurosurgery residency programs, 4 neurology residency programs, and multiple teaching hospitals.  When I look around this room, and see multiple individuals whom I consider my mentors, and an even greater number of my mentees– residents and neurosurgeon graduates–I feel a sense of pride and gratitude by what the Inland Empire has contributed to neurosurgery in California, and across our country.  If you are a member of my faculty, a neurosurgeon graduate of my residency programs, or my current resident, please stand and be recognized for your service to this community, and thus to California and wherever you practice currently.  Thank you for putting the IE on the neurosurgical map, and for sharing my destiny.”

 

 Sunday was largely dedicated to the residents. President Chen already announced the award winners in his message. But in reality, all were winners, and their efforts were appreciated. It was a robust session:

John Yue, MD, The University of California, San Francisco, California

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

Peyton Nisson, MD, Cedars-Sinai

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

Tejas Karnati, MD, University of California, Davis

“Biomechanical evaluations of 2-level arthroplasty, overstuffed, hybrid, and 2-level fusion constructs in the cervical spine with a mobile-core arthroplasty device.”

Kunal Patel, MD, University of California, Los Angeles

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

Recurrent Glioblastoma.”

Adela Wu, M.D., Stanford Department of Neurosurgery

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

Angie Zhang, MD, University of California, Irvine

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

Maxwell Marino, DO, Riverside University Health System Medical Center

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

Alexander Tenorio, M.D., University of California, San Diego

“The impact of the Mexico-San Diego border wall extension on spinal injuries.”

Saman Sizdahkhani, MD, University of Southern California

“Intra-operative Exposure to Botulinum Neurotoxin-A Significantly Reduces the Rate of Clinical

Vasospasm in Bypass Grafts”

 

There were also three rapid-fire presentations:

John Yue, MD, University of California, San Francisco

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

Anzhela Moskalik, MD, University of California, Davis

“One and Two-Level Robotic MIS TLIF Demonstrates as Improvement in Alignment Parameters as well as Quality of Life.”

Jose Castillo, MD, University of California, Davis

“Ten-Year Outcomes of Cervicogenic Headaches After Anterior Cervical Disc Arthroplasty: Post Hoc Analysis of Multicenter Randomized Clinical Trial.”

 

Highlights of Dr. Marshall’s CV:

  • Whole career at UC San Diego – 1975 – present

1975-79, Assistant Professor of Surgery in Residence

  • 1979, Associate Professor Surgery in Residence
  • 1980-84, Associate Professor of Surgery
  • 1984-2005, Professor of Surgery
  • 2005 – present, Distinguished University Professor of Surgery
  • 1994 Program Director, UCSD Residency Training Program
  • 1995 – 2010, Chief Division of Neurological Surgery
    • Second Division Chief succeeding the founder, John Alksne, MD
  • 1999 Director of Neurotrauma, Children’s Hospital of SD
  • 1973 – 2008
    • 161 Peer review research articles and clinical papers
    • 84 Book Chapters
    • 3 Monographs/Booklets
    • >500 Presentations/Lectures
  • 1977 – 2004
    • Continuously funded for trauma research (TBI & SCI)
      • NIH
        • Including RO1 & NO1 & RCT
      • Private Foundations
      • Pharmaceutical Industry
    • An internationally known expert in adult and pediatric traumatic brain and spinal cord injury
      • National Advisor, Department of Emergency Medical Services, HHS
      • One of the founders of the National NIH Trauma Coma Data Bank
      • 1986, Chairman, Committee on Head Injury Program Review, HHS
      • 1979 – present, Committee on Trauma, American College of Surgeons
      • 1987 – present, Research Committee, National Head Injury Foundation, Inc Professional Division
      • 1988 – present, Trauma Care Task Force, Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
      • 1989 – present, Director at Large, Board of Directors, National Head Injury Foundation

Major force in the establishment of geographic central nervous system trauma centers in the US

CANS MISSION STATEMENT

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

Picture of Brian Gantwerker, MD

Brian Gantwerker, MD

Raise the Tide

Private Practice Corner

“Nothing in the Golden Rule says that others will treat us as we have treated them. It only says that we must treat others in a way that we would want to be treated.”

Rosa Parks

Starting a practice in the early 2010s was not entirely insane.

Reimbursements were still decent, and most physicians were in group practices, not hospital-employed.  I had seen others before me both fail and succeed in multiple iterations.  I have spoken before about the people who influenced me while I was in Ohio, and of course, at Barrow, where herding cats was made an art form.

Here I wanted to do something where I could really show patients what it meant to be cared for.  My wife and I had a dinner table conversation, she was pregnant with our son then, and we decided to go for it. We started carpetbagging at first, covering both hospitals in the San Fernando Valley and the West Side of Los Angeles and Santa Monica. 

The pressure was immense, and Medicare was not cooperating.  A paperwork glitch in the online portal PECOS prevented my application from going forward, and Medicare refused to start paying me.  At the time, I had to get my Congressman Ted Lieu involved, who thankfully helped convince whichever major-domo of the fiefdom to delete the old application and pay my outstanding claims once I got verified.

As we hired staff, I had a long conversation with my wife.  I had never run a business, let alone run an office.  She had been the practice manager of a very well-known dental practice.  In other words, she was VERY qualified, and I had zero experience. 

She taught me a lot, starting with how to act.  She regaled me with stories of inappropriate comments made to her and the other forms of disrespect shown to her and her coworkers.  We both understood there is no room nor reason for any of that behavior in any form, especially in our workplace.  We wanted to make it a safe space and give our staff a feeling of belonging so they can concentrate on being as good as they can be.

Seeing staff’s potential and individual strengths and fostering their personality traits rather than forcing them into a corporate mold have been one of the best parts of this job.  We have always encouraged our staff to be themselves.  One of our staff, a young African-American lady, had a lot of body art.  She asked if we wanted her to cover up. 

We both said absolutely not.  “Just be you.” 

Now, this does not mean come to work in whatever is in the closet but bring you and who you are to work.  I also started saying that my staff “works WITH me” and not “FOR me.”

 

This also meant investing in their productivity.  So, we bought computers we knew would last.  In fact, we just replaced our coordinator’s 10-year-old Mac only because a certain cloud drive program was no longer supported on the OS.  (This also meant we got to keep taking the depreciation until we throw it out).

We encouraged the staff to come in and make suggestions.  And really, listen to how we can make their job easier.  Some of the best suggestions for efficiency have come from our staff.  One of them was investing in decent desktop scanners, which increased their ability to capture chart data in 1/5 the time. 

Now, when things are not working, we have had to let staff go.  As my friend and dentist said, “things are just not working out,” and you must do what’s best for the business.  Treating even a termed employee with respect is always the best bet.  Feelings will be hurt but maintaining professionalism at all times and in all things.  But letting someone go, for me at least, was not easy.  When things become tense with other staff or enormous mistakes are made, someone’s employment with you should be carefully considered.

There are other things that can help as well.  In full disclosure, I spoke to my coordinator, who has been with me for eight years in this next part.  She said that showing appreciation for their work really elevates staff.  This could mean, at the end of the day, saying, “great job” or “you really handled that in an expert manner.”  Giving kudos is a solid way to make your staff feel like you see their effort.

The last thing is support.  There have been moments, especially with the pandemic, where incredible amounts of tension have been in the office with patients, especially those that were not compliant with masking during the harshest times.  Because of the initial time we all remember this when there were freezer trucks parked outside of hospitals, and there were 6-7 patients in the ICU on ECMO because their lungs didn’t work anymore, all we had were face coverings – for better or worse.  We would politely ask patients to pull their masks up or wear one and maintain social distancing.  There were patients who would become irate or leave in a whirl of anger.  But we maintained our practice of being careful and have kept the staff safe.

In fact, I only got COVID because I went to Chicago and have thankfully recovered (highly NOT recommended, by the way).

Supporting your staff and making their safety and efficacy your priority will keep you in business, rather than running through former baristas and other inexperienced people who look at a job taking care of patients as the same as getting someone a latte.  It isn’t, and patients deserve better. 

Our staff also deserves an environment where we can bring out their best, be themselves, and support their own families.  The practice mantra was, is, and should always be: “if you succeed, we succeed.”

Adela Wu, MD, and Lauren Stone MD Residents Consultants to the CANS Board

Reflections on CANS Annual Meetings

Residents Corner

Adela Wu:

2023 began on a high note with the spectacular 50th anniversary of CANS and the annual meeting in Riverside, California, on January 13-15. This was my first time attending this event, and it was even more special as I could enjoy the weekend with my family, see my friends and colleagues, and meet neurosurgeons I had only virtually interacted with over Zoom meetings or email previously. 

Saturday was a buffet of amazing presentations by field leaders throughout the day. We were all treated to brilliant insights and captivating stories from the very beginning. The first plenary session of that day resonated with me, in particular. In deference to CANS’s major milestone this year–its 50th anniversary–the speakers’ session focused on both the history and the future of CANS. I loved learning about the inception of CANS from the board historian, Dr. Colohan, and the importance and legacy of advocacy in this society. Dr. Harris then shared her incredible story — indeed, what were the odds of a Black female astronaut and a Black female neurosurgeon walking into the same room? Her presentation highlighted the current landscape of minority group representation in neurosurgery and in the medical field as a whole, along with salient pearls of wisdom about how we could all increase awareness of and access to the biomedical sciences. As a new mom, I also found myself riveted by Dr. Holly’s talk. He spoke about work-life balance and neurosurgery’s changing lens on family priorities. One of the images I remember most was a photo he modified from a placard hung on a baseball field: “Parents: Your Kids are Watching” to “Neurosurgeons: Your Kids are Watching.” I will keep this in mind as my daughter grows up and sees my work and the life I lead. Finally, Dr. Miuli gave a fascinating and important talk on the history and inclusion of osteopathic neurosurgeons in CANS and in California. Overall, the plenary session set the tone for the rest of the conference, which was entertaining and educational for us residents. I am so grateful and fortunate for the opportunity to participate in this event and organization!

Lauren Stone:

The annual CANS meeting is a concentrated forum on neurosurgery’s most critical issues.  As a resident, the value of this meeting is difficult to overstate.  This year’s agenda consisted of updates, lectures, and discussions of topics including Medicare reimbursement, medical malpractice, financial planning, and product innovation, to name a few.  Trainees, non-physician experts, and attendings from all career stages participate in these sessions, building a rich, nuanced discourse.  For example, the AB35 session included a formal presentation by expert lawyers and open discussion from CANS members.  This brought forward perspectives from academic and private practice surgeons who iterated the likely impact of AB35 on their practice. 


This discussion exemplified a powerful concept in action = maintaining the standards of our profession requires neurosurgeons to retain a voice at all levels of government politics.  AB35 is a microcosm of the reason for neurosurgical surveillance over general medical malpractice laws.  The effects of stacked, higher noneconomic damage caps and the renegotiated attorney contingency fee that have now taken effect in California will echo forward when the current generation of residents graduate into junior attendingdom.  This is the value of attending CANS as a resident: we will ultimately bridge today’s organized neurosurgery into tomorrow.  The annual CANS meeting is thus practical, pertinent, and an investment in the future quality of neurosurgical practice in California.

Tidbits January

Tidbits January

January 1 – HAPPY NEW YEAR! January first was not always celebrated as the start of the New Year. Julius Caesar created the Julian calendar in 46 BCE by adding 90 days to the year, starting the year on January first in honor of Janus. Before that, the year began in late March, with the first full moon after the spring equinox. In ancient Rome, New Year’s celebrations consisted of gifts, decorations, and sacrifices to Janus. The Council of Tours abolished January 1 as the start of the new year in 567. Pope Gregory XIII later restored January 1 as New Year’s Day with the implementation of the Gregorian calendar in 1582. The American colonies eventually adopted the holiday in 1752.

Walter Cunningham aboard Apollo 7 in 1968. Credit…NASA

January 3 – The 118th Congress was sworn in … not exactly. But we know that it has 149 women, a record-setting. Women of color also break a record, with 58. The House has the first Gen-Z lawmaker, Democrat Maxwell Frost from Florida’s 10th Congressional District. And Democrat Marcy Kaptur becomes the longest-serving woman in Congress, representing Maryland’s 9th Congressional District for her 21st term.

January 3 – Walter Cunningham, an Apollo 7 astronaut, died in Houston. He was 90. A physicist and a former Marine pilot, he joined Captain Walter M. Schirra Jr. of the Navy and Major Donn F. Eisele of the Air Force in a virtually flawless 11-day mission in October 1968. They completed 163 orbits of the Earth in a reconstructed space capsule with many safety modifications after the launching-pad fire that killed three astronauts twenty-one months earlier. They became the first NASA astronauts to appear on television from space. Mr. Cunningham wrote in his memoir “The All-American Boys:”  “We carried the nation’s hope with us … Twenty-one months before, a fire on the very pad from which we launched had killed three of our teammates. One more setback now, and the prospects of landing a man on the moon before 1970 would be gone forever.”

Walter Cunningham aboard Apollo 7 in 1968. Credit…NASA

January 4 – National Spaghetti Day. Yummy!

January 5 – The World Health Organization is warning that a new COVID-19 subvariant, XBB.1.5, is the most transmissible yet. Roughly 75 percent of new cases in the northeastern United States at the moment are cases of this subvariant. Let us not let our guards down.

January 6 – A mob attacked and desecrated the Capitol of our Nation two years ago. There is no agreement on what its nature was. Was it a riot, an insurrection, a sedition, a treason? The courts are still deciding. However, since its main objective was to stop the count of the electoral ballots of the 2020 presidential election, I think it was an assault on our Democracy. I will always remember what I was doing on that day, much like I remember what I was doing on 9/11, when President Kennedy was assassinated, and when we landed on the moon.

January 9 – More than 7000 Nurses went on Strike in New York City, protesting understaffing and poor working conditions resulting in a patient safety decline. Zulma Gutierrez, 42, an intensive care unit nurse at Montefiore, who went on strike, said, “I feel that hospital administrators are hypocrites … They’re going home making millions, and we’re going home with guilt.”

January 9 – The atmospheric rivers hit California. Ventura County was particularly affected. Strawberries count among the top industries in the counties; many fields were covered with silt and debris due to flooding causing millions of dollars of lost crops.

Ventura beach was covered with debris following the storm. Photo from the VC Star

Flooding from the Santa Clara River covered strawberry fields near Ventura in a layer of silt and gravel. Photo from the VC Star

Ventura beach was covered with debris following the storm. Photo from the VC Star

This aerial view shows the Capitola Pier, built in 1857, damaged after recent storms in Capitola. Getty Images

This aerial view shows the Capitola Pier, built in 1857, damaged after recent storms in Capitola. Getty Images

January 10 – Abbot Receives FDA 510(k) Clearance for the First Rapid Handheld Blood Test for Concussions. According to Abbott:

  • The test will help evaluate mild traumatic brain injury (TBI) and produces a result within 15 minutes; it will be run on Abbott’s i-STAT™ Alinity™ handheld device. The test simultaneously measures biomarkers UCH-L1 and GFAP, proteins found in the blood after a concussion or head trauma.
  • Having a blood test available could help eliminate wait time in the emergency room and reduce the number of unnecessary CT scans by up to 40%.

January 12 – A comet named C/2022 E3 (ZFT) was discovered on March 2, 2022, by astronomers using the Zwicky Transient Facility’s wide-field survey camera at the Palomar Observatory in San Diego County, California, made an appearance in the night sky on January 12, for the first time in 50,000 years.

Lloyd Morrisett, left, with Lloyd Morrisett the Muppet, on the set of “Sesame Street” in 2019. Credit…Gil Vaknin/PBS

January 15 – Lloyd Morrisett, a psychologist whose young daughter’s viewing habits inspired the creation of the revolutionary children’s educational television program “Sesame Street” and whose fund-raising helped get it off the ground in 1969, died on Jan. 15 at his home in San Diego. He was 93. I love Sesame Street!
Lloyd Morrisett, left, with Lloyd Morrisett the Muppet, on the set of “Sesame Street” in 2019. Credit…Gil Vaknin/PBS

January 16 – Martin Luther King Day

January 16 – A new study found that walking in a park or along a lake may reduce the need for medication for anxiety, asthma, depression, high blood pressure, or insomnia. The study, published in the Journal of Occupational & Environmental Medicine, interviewed approximately 6,000 random people in three of the largest cities in Finland about their use of green and blue spaces within a kilometer of their homes. Green spaces included forests, gardens, parks, moors, natural grasslands, wetlands, zoos, and even cemeteries. Blue spaces included lakes, rivers, and the sea. I am fortunate to live by the Pacific Ocean.

Erchana Murray-Bartlett crossed the finish line at the Pillars of Wisdom at the Tan Track in Melbourne on January 16, 2023.

January 16 – Erchana Murray-Bartlett, 32, from Australia, completed 150 marathons in 150 days, running 3,900 miles from Cape York, Queensland, in the country’s northern tip to the southern city of Melbourne, setting a new world record. Murray-Bartlett completed her run to raise awareness of the threats to Australia’s biodiversity. She raised more than 118,000 Australian dollars ($82,130) for the Wilderness Society, with all profits going towards conserving Australia’s native animals. Exhilarating. Bravo!

Erchana Murray-Bartlett crossed the finish line at the Pillars of Wisdom at the Tan Track in Melbourne on January 16, 2023.

December 17 – The birthrate plunged in China for the first time last year, resulting in a  population decline for the first time in decades. This is a dramatic turn in a country that once sought to control such growth through a one-child policy. Does social engineering ever work?

January 17 – Dr. George Q. Daley, dean of the faculty of medicine at Harvard, indicated that Harvard Medical School would no longer submit information to the U.S. News & World Report’s medical school ranking. Harvard held the top spot on the latest ranking of medical schools for research. He indicated, “Rankings cannot meaningfully reflect the high aspirations for educational excellence, graduate preparedness, and compassionate and equitable patient care that we strive to foster in our medical education program.” Amen.

January 18 – The San Francisco district attorney said that her office had issued an arrest warrant for Mr. Shannon Collier Gwin, 71, who runs the Foster-Gwin Gallery in the city’s Financial District, based on evidence from an investigation by the San Francisco Police Department. She said he was charged with misdemeanor battery “for the alleged intentional and unlawful spraying of water on and around a woman experiencing homelessness.” “Mr. Gwin will face appropriate consequences for his actions.” Mr. Gwin was undoubtedly frustrated, but where is his humanity?

January 22 – Lunar New Year, also known as Spring Festival, is widely celebrated among Asian Americans. It is now an unpaid state holiday in California. It typically falls on the second new moon after the winter solstice. Governor Gavin Newsom said that declaring Lunar New Year a state holiday is a way to “acknowledge the diversity and cultural significance Asian Americans bring to California.” Year of the Rabbit. Eat “Longevity noodles – Stir-fried Ginger Scallion Lobster Yi Mein.” They symbolize long life. According to tradition, the chef can’t cut the noodle strands, and each strand needs to be eaten whole. Don’t break it before you eat it.

January 24 – The Golden Raspberry Awards – the Razzies – nominated Actress Ryan Kiera Armstrong, 12, for worst actress for her performance in “Firestarter.” The “Razzies” bills itself as celebrating cinema’s best of the worst. Once again, where is their humanity?

January 26 – Senior U.S. District Judge William Shubb in Sacramento blocked a California law that sought to penalize doctors who spread “misinformation or disinformation” about COVID-19 while he considers a pair of lawsuits challenging it on free speech grounds. He ruled that Assembly Bill 2098, which was signed last October by California Governor Gavin Newsom, was too vague for doctors to know what kind of statements might put them at risk of being penalized.”COVID-19 is a quickly evolving area of science that in many aspects eludes consensus,” he wrote. Really, your honor?

January 27 – International Holocaust Remembrance Day, a day to honor the victims and survivors of the Holocaust. Let us not forget!

January 27 – Congressman Jake Auchincloss (D-MA) delivered a speech on the House floor. It was written entirely by ChatGPT. No comments. Please read “Brain Waves” in this issue.

January 28 – The new AI chatbot tool recently passed law exams in four courses at the University of Minnesota and another exam at the University of Pennsylvania’s Wharton School of Business. After completing 95 multiple-choice questions and 12 essay questions, the bot performed on average at the level of a C+ student, achieving a low but passing grade in all four courses. ChatGPT fared better during a business management course exam at Wharton, earning a B to B- grade. No comments. Please read “Brain Waves” in this issue.

January 30 – National Croissant Day.

EXHIBITORS

THANK YOU EXHIBITORS!

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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  • Comments can be sent to the editor, Moustapha AbouSamra, M.D., at mabousamra@aol.com

or to the CANS office emily@cans1.org.

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CANS Board of Directors

CANS Board of Directors