Menu
CANS President
CANS Influence on our National Organizations
August is upon us, and school will start again. July has been the month of the interns, with the expected chaos of dropped balls and nonsensical inquiries. Year by year, it seems to devolve more and more. Is it that things are really getting worse? Or is it that I’m getting old and crotchety? History teaches us that it is probably the latter.
Congratulations are due to the new CANS fellows. These are in no particular order Dr. John Yue, UCSF; Dr. Yagmur Muftuoglu, UCLA; Dr. Paras Salva, RUHS; and Dr. John Choi, Stanford. We have been excited about having the fellows and look forward to having a productive interaction with them. Please expect their contributions in the coming year.
Honorifics, titles, and other labels
Within hierarchical organizational structures, the number and gradation of titles reflect the structure’s rigidity. Perhaps no social structure is more rigidly enforced than in the military, where rank is integral to the command and control structure – an essential part of the organization’s operational integrity. Lines of control are, therefore, clean and unambiguous such that the coordinated might of a military arm can be wielded with greater strength given the unity of action of many individual soldiers.
It is not difficult to see analogous hierarchies often defined or denoted by titles and honorifics in other areas of society. Within the strict social confines of societies with a caste system, there may be clear distinctions of pedigree, speech, dress, and behavior between those with higher and lower social rank. The proximate motive of enforcement of such systems is often to merely ensure its self-perpetuation with knightships granted to a select few in the gentleman caste, lordships to the nobility, and kingships for the royals.
In Europe, with the rise of enlightenment republicanism and the weakening of the aristocracy, a different form of hierarchical organization began to emerge. This was the rise of meritocracy, broadly defined. A flattening of class structure did not accompany this, but merely the replacement of one hierarchy, defined by hereditary privileges, with one that is ostensibly based on accomplishment.
These accomplishments may take various forms, including performance on examinations, contributions to a discipline of science or literature, development of technical or business skills, etc. With this new hierarchy, a raft of new titles may come to the fore, replacing aristocratic honorifics with other titles resulting in an apparent meritocratic stratification of power based on rank and qualification. An amusing modern symptom of the premium placed on the hallmarks of the meritocratic system is the title and qualification bloat seen on email signatures within large organizations. The meaning of the three, four, and sometimes five-letter degrees and certifications are sometimes a mystery to me, as is the scale, or lack thereof, of the “directorships”, committee memberships, and chiefdoms.
Yet sometimes, the titles are different from what they appear. As Thomas Hardy’s Stoke family revealed in Tess of the D’Urbervilles, titles can be bought and sold. What is different, however, in the modern age is that the titles can be mass-produced as well.
So, witness the case of the diminishing title of “Doctor.” The title’s origins come from one of the Latin words for “teacher,” docere, sharing the same roots as the term “indoctrinate”. The title had been associated with elite education within universities, first with theology and then
spreading to other disciplines, including medicine. Eventually, those who trained in the medical arts at university were called “doctors.” This was in distinction to the barber-surgeons who trained in apprenticeships and to this day in the British system are referred to as “Mister.” Since the mid-1800s, however, the common use of the term “doctor” in the United States has been reserved for physicians and surgeons.
The medical profession has also been an exemplar of very strict training regimens to conform to the highest standards of scientific practice to cultivate the public’s trust. As such, the title of “doctor” came to have a particular meaning in common parlance.
Other “doctors,” such as those of dentistry, podiatry, pharmacy, psychology, optometry, etc. seem to have used the term within the scope of their particular profession without much controversy. This is likely due to the relatively small overlap between these limited and specialized services and what we would consider medical services. Interestingly, our legal colleagues, the Juris Doctors, have generally been referred to as “counsel,” disposing of the use of the term doctor in almost all professional and academic settings.
Recently, a case of a nurse practitioner running a clinic along the Central Coast has attracted substantial attention. In possession of a DNP, the nurse had taken to be called “doctor,” employing the title on the practice website as part of her patient testimonials. This was brought to the attention of the California Department of Consumer Affairs through the Medical Board of California. The nurse practitioner was fined and prohibited from the use of the title. Subsequently, a suit has been filed against the State of California by three relatively new DNP individuals represented by the Pacific Legal Foundation, a libertarian non-profit organization. It is likely that this suit, filed in US District Court as a first amendment and equal protection issue, will work its way through the litigation process for a few years.
During this period, we should take some time to think about what the possible outcomes are and how we should react as a profession.
The encroachment of advanced practice nurses upon the scope of physicians and the resulting conflict hinges on some salient key points:
1: There is a large overlap, especially in primary care services, where nursing doctorates can substantially replace the bulk of work that MDs and DOs have performed.
2: The basic formational aspects of the nursing profession differ substantially from that of the physician or surgeon. This hinges on the process of diagnostics. Diagnostics are not part of the basic training of nurses. Nurses are trained in the arts of medical assessment, the delivery of interventions, and the reassessment of the effectiveness of delivered interventions. As such, the arts of differential diagnosis are not part of basic nursing education. The result is that NPs tend to rely more on specialists to make relatively simple diagnoses.
3: The certification examination process for NPs is relatively lax, requiring a passing score on a 150-question, 3-hour multiple-choice examination.
4: Classical economics teaches us that the value of any commodity is directly related to its relative abundance and scarcity in relation to its need. Things that we have the greatest need for, such as the air we breathe, are, for the most part, free. Gold, by contrast, is costly despite its relatively frivolous common use. By expanding the supply of doctorate-level nursing certificates, which assume the same label as physicians and surgeons, we may expect a depreciation in the value of the medical degree, at least in settings where there is substantial real competition from nursing doctorates, such as in primary care, women’s health and anesthesia.
I believe that the nursing profession will likely prevail in its legal challenge. The enforcement of what to the general public may appear to be arbitrary standards of use of a title and entrance to a particular profession, for which many have mixed views, will likely be subordinated to free speech and individual determination issues. Further, the nursing profession has the advantage of superior organization and larger membership. Yet, I don’t think this is anything that those of us in the medical profession should be afraid of. So long as we offer substantial unique value by virtue of our standards, training, and expertise, we will be needed.
Ultimately, there needs to be a better substitute for cultivating our individual value to the care of patients than relying on a title to do work on its own. Recently, I corresponded with our Newsletter editor, Dr. AbouSamra, on the topic of his recent editorial on the choice of footwear in the White House and appropriate attire, and related to him this story:
A couple of years ago, I was walking through a hospital ward where I was stopped by a nurse who asked me if I was there to draw blood for a particular patient. I realized then that the only people who were wearing white coats were the phlebotomists and the nursing supervisors. I decided then to keep my white coats in the closet. The patients still know that I’m their neurosurgeon.
Let me know what you think. Write us a letter, and we’ll publish it.
CANS Newsletter Editor
As noted in our president’s message, we have four new resident consultants as of July 1, 2024. Dr. John Yue from UCSF; Dr. Yagmur Muftuoglu from UCLA; Dr. Paras Salva from RUHS; and Dr. John Choi from Stanford. Congratulations, and good luck! The four resident consultants who completed their term on June 30, 2024, were: Lauren Stone, Saman Sizdakhani, Saman Farr, and Adela Wu served admirably and indicated to me that the experience was valuable to them. To make this experience even more valuable, our president is directing us to formalize the process so that these dedicated residents will learn even more during their tenure on the board. In addition to learning more, studying specific socio-economic issues may be expected in the hope that they may produce one or more white papers that might be considered for publication.
In this issue, please note the follow-up on Alex Tenorio’s efforts to bring the increase in neurological injuries due to the increase in border wall height to National attention. Alex is to be commended.
Also, in this issue, please read the letter of CMA President Donaldo M. Hernandez, MD, FACP, in which he commands the California Medical Association (CMA), the Coalition to Protect Access to Care, and state leaders, particularly Governor Newsom, on the Medi-Cal Managed Care Organization (MCO) Tax legislation. An internal discussion at our Board revealed that only some agree. Although we should strongly support CMA, our interests – California Neurosurgeons and CMA – may not always be aligned.
The historical Vignette in this issue is about the history of Neurosurgery in the Coachella Valley. Our former president Javed Siddiqi who wrote the vignette played and continues to play a major role in delivering high-quality care to the residents of this typically underserved area and providing neurosurgical education at residency and fellowship levels; the course over the years was not always smooth.
Ian Ross, author of “From the Trenches” Corner, makes an important point: the need for humor and levity in our lives as neurosurgeons who otherwise deal with very serious issues. His choice of “Funny” included a subject never previously addressed in these pages; He assured me that Mrs. Ross, a lawyer, approved.
Deborah Henry discussed the desire/need to level the playing field in football and sports in general. Will we ever be able to do that? And will we solve the difficult question of affirmative action in college admission? Please read “Changing Times.”
Also included in this issue are all the regular columns.
As always, my editorial committee and I welcome all suggestions and criticism. Please e-mail me at mabousamra@aol.com or call me at 805-701-7007 if you prefer to discuss any issue directly with me.
I hope you will enjoy this issue.
Dear friends and colleagues,
With Governor Gavin Newsom’s signature on the Medi-Cal Managed Care Organization (MCO) Tax legislation, it’s official: California is entering a new era by committing to historic investments in Medi-Cal and our health care system.
I could not be prouder of the California Medical Association (CMA), the Coalition to Protect Access to Care and state leaders for seizing this opportunity on behalf of California patients.
You can find all the information about the passage of this bill and the agreement to invest new revenue in our health care system in our fact sheet and on the CMA website, but to summarize, the reinstatement of the MCO Tax will raise $19.4 billion, the majority of which will be invested in Medi-Cal. That money will go toward increasing reimbursement rates for Medi-Cal primary and specialty care, supporting behavioral health and family planning, training hundreds of additional physicians annually and a whole host of other needs in our health care system.
Needless to say, it’s a big deal.
The new law includes significant investments throughout our health care infrastructure, including long-overdue reimbursement rate increases, which will be the largest ever in state history.
Over the past several years, we’ve seen massive expansions in eligibility and benefits for Medi-Cal – and rightfully so, as Medi-Cal provides essential health services for roughly a third of Californians, including some of our most vulnerable patients. But the missing piece was always funding to back up these expansions. How could we provide health care to all while still ranking 47th in the country for Medicaid reimbursement rates?
Those days are over with these rates increases, which begin with primary care, maternity care and non-specialty behavioral health in 2024 and expand further in 2025. The rate increases will go a long way toward increasing provider participation in the Medi-Cal program and will greatly bolster access and equity in our health care system.
I would like to extend a big thank you to our physician members, Dustin Corcoran (our CMA CEO), and everyone who made this happen – from physicians and patients who shared their stories to the staff, coalition members and lawmakers who negotiated this deal with us. But most importantly, I want to thank the health care providers who care for Medi-Cal patients and demonstrate why it’s such a vital program.
There are remaining details that need to be ironed out for the 2025 calendar year, and we look forward to working on those in the coming months. But in the meantime, I hope we can take stock and appreciate this monumental achievement.
Best wishes for a healthy future.
Professor & Chair, Dept of Surgery/Neurosurgery, California University of Science & Medicine
History of Neurosurgery in the Coachella Valley, 1977-2023
Tertiary Care Hospitals:
The Coachella Valley has four hospitals: Eisenhower Medical Center and three Desert Care Network hospitals (Desert Regional Medical Center, JFK Memorial Medical Center, and Hi-Desert Medical Center). JFK is a Primary Stroke Center (effective January 2019) and a Level IV trauma center (effective September 2021), and Hi-Desert Medical Center has an Acute Stroke Ready status (effective January 2021) and a Level IV trauma center (effective December 2022). This brief (and inevitably incomplete) history of neurosurgery in the Coachella Valley is largely restricted to the two largest medical centers that have historically had comprehensive neurosurgical capabilities: Desert Care Network’s Desert Regional Medical Center (DRMC), a Level 1 trauma center, and the only Comprehensive Stroke Center in Palm Springs; and Eisenhower Medical Center (EMC), a primary stroke center and Level IV trauma center in Rancho Mirage. DRMC is a for-profit Tenet hospital with corporate headquarters in Dallas; EMC is a stand-alone, not-for-profit hospital. The story of neurosurgery in the Coachella Valley is compelling and intimately linked in its destiny with the history of hospital-based neurology. Because it is the only facility with a history of neurosurgery and neurology residency programs, this narrative is largely about DRMC, about which I have first-hand knowledge and in which I have significant sweat equity: not unlike institutions and communities that have advances and setbacks, it is my opinion that the scope and comprehensiveness of clinical neuroscience practice at DRMC peaked by 2017. Advances and setbacks are not unusual in any important effort, and the Coachella Valley has seen its share of both; while my own faculty had a relatively small turnover, it remains uncontroversial that DRMC’s original attrition in 2004, which resulted in my own Group’s arrival in Palm Springs, was among the most impactful changes in the neurological history of the Coachella Valley. In 2023, my medical group starts our twentieth year in Palm Springs; what the future holds for neurosurgery in the Coachella Valley is anyone’s guess, but the community has grown accustomed to a high standard of neurosurgical and neurological care.
Neurosurgeon Pioneers:
I heard a story that Dr. Ralph Cloward was once invited to Palm Springs to assess a patient with a complete spinal cord injury; assuming this is not apocryphal, he returned to Hawaii without being able to help the patient. Multiple neurosurgeons have vacationed or retired in Palm Springs, but Dr. Ali Tahmouresie was the first full-time neurosurgeon in the Coachella Valley, receiving his DRMC privileges in August 1977; Dr. Ahmet Oygar followed him in March 1979, and Dr. John “Jack” Thompson in February 1980. Primary care physicians often assisted These early neurosurgeons in their cases, some of whom retain fond memories of this role. At EMC, the first neurosurgeon was also Dr. Ali Tahmouresie, who recruited Dr. Shahin Etebar, who in turn expanded his practice to include Drs. Farhad Limonadi and Alfred Shen. Dr. Limonadi and Dr. Shen continue to serve EMC patients to this day admirably and to grow their practice. As was the norm then, the above-listed six neurosurgeons were credentialed to practice at DRMC and EMC.
Much of the rest of this story is predicated with the pronoun “I” because the story is, to a great extent, my own story and the comprehensive team I personally recruited to Palm Springs; it is also largely about DRMC. There is also some description below of neurology and neurocritical care, as these services were built in tandem with neurosurgery and provided the core of what was historically an unprecedentedly strong clinical science foundation in the Coachella Valley.
Arrowhead Neurosurgical Medical Group (ANMG) in Palm Springs:
In 2004, Arrowhead Neurosurgical Medical Group, my own team, was invited to build neurosurgery at DRMC after an unanticipated loss of their neurosurgery coverage with one-day notice. Naturally, the highest priority for then DRMC CEO, Truman Gates, was to patch the neurosurgery gap for trauma coverage left by departed neurosurgeons; accordingly, he reached out to me for a stop-gap measure to avoid going on diversion for what was then the only trauma center in the Coachella Valley. I agreed to personally provide temporary neurosurgery coverage to DRMC for
a fixed number of days to help what I considered an extension of my community, 45 minutes east of my home in Redlands. While the trauma patients from DRMC could have been transferred to me at Arrowhead Regional Medical Center (ARMC), my primary concern was for the trauma victims who could have poor outcomes from any transfer-related delays in their treatment. My initial agreement with the DRMC administrator was to take care of business till they could get their locums coverage in order, giving hospital leadership time to reimagine their future. I was given emergency privileges the next day. I found myself at a hospital I had never previously entered and where I had none of the support systems—residents, fellows, NPs, reliable colleagues, etc.—to which I was accustomed from my academic practice at Arrowhead Regional Medical Center and Riverside University Health System Medical Center (RUHS), both teaching hospitals. After a few days of being the only practicing neurosurgeon at DRMC, I was asked by the CEO if I was interested in re-building their neurosurgery program. My answer was ‘no.’
As an academic neurosurgeon with a “County” practice originating at Arrowhead Regional Medical Center, sixty miles west of Palm Springs, my primary interest was teaching the residents from the AOA-accredited ARMC neurosurgery residency program, which I had founded in 1999, for which I was the Program Director. As a community hospital, with the exception of the Trauma Physicians and Emergency Medicine Group, the prevailing practice paradigm at DRMC was unsurprisingly solo private practice; this practice paradigm was anathema to me. Further discussions with DRMC leadership led to my describing my preconditions for long-term participation in their neurosurgery program: I was open to expanding my academic paradigm from ARMC & RUHS to Palm Springs but not to adopting the prevailing private practice paradigm in Palm Springs; I was also not interested in being the next neurosurgeon to pull out of DRMC, perpetuating the revolving door that existed over the prior decade, implying institutional limitations causing recurring cycles of dissatisfaction by otherwise intelligent and well-trained neurosurgeons. I expressed an interest in building all clinical neurosciences and not neurosurgery in isolation (because that formula had already failed repeatedly). I doodled for the CEO on one piece of paper my vision of comprehensive neurosciences, which included neurosurgery, neurocritical care, neurology, and neuro intervention, buttressed by neurology and neurosurgery residency and fellowship training programs, all housed in a hospital-based institute. To my surprise, my expansive vision was accepted, and DRMC embarked on a multi-year journey to evolve into what became the most comprehensive neurosciences program under one umbrella, and under one leadership, in the Coachella Valley and in the region more broadly.
Led by me and supported by medical staff leadership and a succession of DRMC CEOs (Truman Gates, Barry Dykes, Karolee Sowle, Ken Wheat, Carolyn Caldwell, and Michele Finney), the hospital benefitted from the development (from scratch) of new and comprehensive Neurology, Neuro Critical Care, Neurointervention, and Neurosurgery services, all based at the Institute of Clinical Orthopedics & Neurosciences (ICON), a 1206(d) hospital-based clinic which I founded, and named. (The “Arthritis Institute” preceded ICON, but the four orthopedic surgeons practicing there had agreed to allow me to reinvent them as “ICON,” which would add neuroscience to the mix, foster spine collaborations between neurosurgery and ortho spine services, and they appreciated that the “O” in ICON preceded the “N,” reflecting the historical chronology). By winning a Tenet-wide grant competition with a prize of $5 million, reinforced by a $1 million grant from the Desert Health Care District (DHCD), and a similar amount matched by my own non-profit research and education foundation, Arrowhead Neuroscience Foundation (ANF), did the trick to start DRMC off to a running start for what was the new clinical neurosciences “service-line.” With my neurosurgery and neurology team in place, the hospital was rapidly elevated to Primary Stroke Center designation. The DHCD and ANF funds were used at my discretion to fund neurocritical care and neurointerventional fellowship programs, which attracted qualified faculty interested in teaching; all boats were rising together. Multiple current CANS neurosurgeons, and several neurologists, benefited from residency and fellowship training at DRMC and served the local community in the process, thus fulfilling the hospital and community’s interest in retaining the subspecialists that our programs attracted—the clinical neurosciences orchestra was something to behold, and unprecedented in the history of the Coachella Valley. The primary deliverable for my DHCD grant required successful accreditation of DRMC as a Comprehensive Stroke Center (CSC)—we achieved this in 2012, making DRMC the first CSC in Riverside & San Bernardino Counties. Over the past decade, DRMC has successfully been reaccredited as a CSC several times, which may be my team’s most self-evident and enduring institutional legacy.
As the above developments occurred at DRMC, EMC became a Primary Stroke Center and fluctuated between 2 to 3 neurosurgeons who primarily served their catchment area with dedication. EMC also became a teaching hospital with multiple residency and fellowship programs; however, neurosurgery and neurology were not among those residency programs. Other than rare but cordial interactions, there was no direct interaction between my DRMC
neurosurgery or neurology teams and our EMC counterparts; indeed, none of the DRMC neurosurgeons and neurologists from my team were credentialed at EMC because of my strong belief that we came to this dance with Tenet, so would remain committed to DRMC through the end of the party. Among ten CANS Neurosurgeons recruited by me to DRMC included some individuals who retired from there, some who moved on to other pastures, and some who continue to serve the population of the Coachella Valley to this day; but all made enduring contributions, and include: Dr. Anthony Alastra, Dr. Blake Berman, Dr. Vladimir Cortez, Dr. Silvio Hoshek, Dr. Deependra Mahato, Dr. Rosalinda Menoni, Dr. Jerry Noel, Dr. Michael Schiraldi, Dr. Emilio Tayag, and Dr. Margaret Wacker. (Photo below)
Neurosurgery Residency Training in Palm Springs:
From 2005 thru 2015, up to five neurosurgery residents per year rotated with my team at DRMC as an extension of the AOA-accredited residency program at ARMC. These were the first-ever residents to train at DRMC. In the process of incorporating them formally, the hospital’s Governing Board (at my request) formally declared itself a teaching hospital in 2005, allowing the creation of a Graduate Medical Education Committee, which I led; this GMEC formed the underpinnings required for GME credibility a decade later, when in 2015, DRMC launched five residency programs, among them Neurology and Neurosurgery, both led by myself and by the neurosurgery and neurology faculty I recruited to Palm Springs. As DRMC was new to graduate medical education, and with its large proportion of MediCare-eligible patients, it was in the enviable position to qualify for virtual full reimbursement for its GME-related expenses from the Centers for Medicare & Medicaid Services (CMS). Because DRMC leadership insisted on my being their founding neurosurgery residency program director, I reluctantly stepped down from that same position at the ARMC Neurosurgery Residency program (which I had founded in 1999 and which I remained committed to). I took the helm of the new DRMC Neurosurgery residency program. (My role as ARMC and RUHS Chief of Neurosurgery did not change). I recruited an outstanding neuro intensivist, Dr. Glenn Fischberg, the founding Neurology residency program director and the anchor for the newly created neurocritical care unit (where our neurology and neurosurgery residents rotated). All clinical neurosciences programs were under my leadership. At the peak of my Group’s presence in Palm Springs, we had 21 neurosurgeons and neurologists, with varying subspecialty interests, who would train multiple neurosurgery and neurology residents at DRMC—the community hospital which had zero hospital-based neurosurgeons and neurologists in 2004, now was buzzing with all things neuro!
The ARMC neurosurgery residents who had rotated at DRMC for a decade prior to 2015, were repatriated to ARMC as DRMC’s inaugural neurosurgery resident class started on 7/1/2015. Over two dozen ARMC residents received a very important part of their education at DRMC from 2005-2015. By July 2023, DRMC has contributed to educating approximately 38 total neurosurgeons and 16 neurologists. While EMC also evolved into a teaching hospital in the last decade, by the time of this writing, they did not have a Neurology or Neurosurgery residency program or stated ambitions to acquire them.
Fluctuations in Early Achievements & GME Rules:
In recent years, there have been fluctuations in clinical neurosciences and associated residency programs in the Coachella Valley, many of which can be attributed to impossible accreditation requirements imposed by the ACGME. Other than the standard flux in manpower in neurology and neurosurgery that happens anywhere, the greatest change in neurology faculty occurred after my Group’s neurology and neurocritical care contract was terminated in 2020; this had serious consequences on the neurology residency program, which underwent faculty and program director changes as a result of our contract termination, adding stresses beyond what was already inflicted by the COVID-19 pandemic. In 2021, DRMC voluntarily withdrew from the ACGME accreditation for its neurology residency program; fortunately, all the neurology residents were placed in other programs, which benefited from a funding transfer from DRMC to support the expenses associated with those residents’ salary and benefits. My neurosurgery group withdrew from ICON, the institute I founded, named and led for over a decade. As multiple former neurology faculty departed and neurosurgery priorities for the institution changed, the hospital became dependent on locums physicians in neurology, neuro intervention, neurocritical care, and neurosurgery to maintain its comprehensive stroke and trauma center coverage. The neuro ICU program founded by Siddiqi and Fischberg was taken over by medical intensivists, returning to the paradigm that was in place before I arrived there in 2004; the neurosurgery and neuro intervention services found themselves in a period of instability and uncertainty as multiple transient physicians, physician groups, and locums tenens doctors passed through (albeit this was partly a result of my insistence that my neuro interventionalists would only take call when my own neurosurgeons were concurrently on call, because of several negative experiences with transient neurosurgeons who refused to see or treat ruptured aneurysms at this Comprehensive Stroke Center because their experience was limited to spine surgery).
Graduate Medical Education in the USA was transitioning from two long-standing residency accreditation bodies, the AOA and ACGME, to only the ACGME, in a process that started in 2015 and ended in 2020. Approximately one thousand AOA-accredited residency programs in the USA were asked to close down or join the approximately 10,000 ACGME-accredited residency programs; both organizations agreed that the AOA-accredited programs would have to apply for ACGME accreditation and would not be grandfathered (irrespective of how long they had existed prior to the new rule). The AOA would end its residency accreditation role by 2020.
Due to the national accreditation transition from AOA to ACGME, the DRMC Neurosurgery residency program applied to ACGME to transition. Despite the acknowledgment of meeting the neurosurgery-specific requirements, the DRMC neurosurgery residency program was denied ACGME accreditation based on “institutional limitations” that proved too steep a hill to climb. Three of these “institutional limitations” included: 1) lack of certain other residency programs at DRMC; 2) off-site rotations more than 25 miles from Palm Springs; and 3) dependence on virtual (vs. in-person) didactics.
A major area for improvement in our application to ACGME was the absence of Anesthesia, General Surgery, Radiology, and Pediatrics residency programs at DRMC. While the first two of these programs were anticipated, getting them started by the ACGME deadline was not practical. (Interestingly, DRMC has received ACGME approval for the General Surgery residency program recently, but alas too late to benefit the neurosurgery residency program).
Under AOA accreditation, the DRMC Neurosurgery residents were permitted to rotate at various sites for subspecialty exposure, including Arrowhead Regional Medical Center, Children’s Hospital of Los Angeles, Kaiser Anaheim, Naval Medical Center San Diego, and Redlands Community Hospital. These sites provided outstanding educational exposure to the residents, DRMC funded local housing so the residents did not have any financial hardship, and residents appreciated the exposure to a huge and diverse faculty. While our residents and faculty felt the diverse exposure was a major strength of the DRMC Neurosurgery residency program, this proved to be a serious deficiency for the ACGME, which promulgated a new rule that no new ACGME resident could rotate at sites more than 25 miles from the base hospital (despite many established ACGME neurosurgery residency programs having rotations in Europe and Africa!); extant programs were exempted the new requirement. Since there is largely sand within 25 miles of Palm Springs, it was impossible to convert DRMC into the only neurosurgery residency program in California that would train its neurosurgery residents exclusively at its base hospital.
A third ACGME criticism of the DRMC Neurosurgery residency program was our use of Zoom for virtual didactics sessions because it was not possible for us to force residents to return from distant rotations to the base hospital for in-
person teaching sessions. ACGME declared the lack of in-person didactics a major deficiency, potentially depriving the cohesiveness among the residents that would occur with in-person meetings. Interestingly, the spread of COVID-19 proved that Zoom was the ideal way to keep residents and faculty connected, and the technology that DRMC was criticized for became the norm in all ACGME residency programs and continues to this day after COVID-19 is behind us. Essentially, the DRMC Neurosurgery residency program was too far ahead of its time in the use of technology for virtual teaching sessions.
Clearly, ACGME accreditation proved a bridge too far for the DRMC Neurosurgery residency program. With AOA approval, and DRMC administration support, the difficult decision was made in 2020 to “train out” the remaining ten neurosurgery residents, not replace them as they graduate, and to allow the program to fade away voluntarily—this process will be completed in 2026 when the residency program will end as the last of the AOA-accredited neurosurgery residencies in the USA; these fourteen wonderful neurosurgery residents, all CANS members in good standing, are truly the last of the Mohicans and will always represent the historical contribution to California neurosurgery training by the Coachella Valley.
Final Chapter in DRMC Neurosurgery Residency Program:
In the last year, the DRMC Neurosurgery residency program reached its final evolution: with AOA approval, and support from DRMC CEO Michele Finney, and ARMC CEO William Gilbert, the residency program was formally closed at DRMC, and ARMC accepted the program for what will be its last three years; six neurosurgeons were graduated from DRMC. As anyone who understands the complexity of GME will know, moving a residency program is a complex kabuki, requiring the buy-in of numerous stakeholders. The AOA had only one condition in their support of the relocation: that I remain as the Program Director for the remaining term of the program. Effective 7/1/2023, what started as the DRMC Neurosurgery Residency Program on 7/1/2015, underwent a name change to the “ARMC Neurosurgery Residency Program,” and the base hospital moved from Palm Springs to Colton; a small number of residents continued to rotate at DRMC as that institution was still committed to their education. In some ways, we have come full circle: the first neurosurgery residents at DRMC were from ARMC; the final DRMC residents are now ARMC residents—while much changed, much remained the same. The remaining eight ARMC Neurosurgery residents will not be replaced as they graduate over the coming years. 
Closing Thoughts:
In closing out this brief history, I am eternally grateful to the DRMC and ARMC leadership for their continued support for the remaining neurosurgery residents training out, as they will spread across the country and make us all proud. By 2026, the DRMC and ARMC well-wishers, our neurosurgery core faculty at the multiple sites listed earlier, as well as our well-wishers in the community and CANS more broadly, will be able to take pride in graduating 14 neurosurgeons—an achievement unlikely to be emulated in the future of the Coachella Valley, but which will be the benchmark against which all neurosurgery achievements in the Coachella Valley should be judged. The “ARMC Neurosurgery Residency
Program” aspires to produce highly competent neurosurgeons for our nation’s needs; these eight residents hail from seven different states, reflecting the truly national contributions made by our residency program, institutions, and faculty. We expect to continue our 100% post-graduate fellowship rate, which we are uniquely proud of. The history of the DRMC Neurosurgery Residency Program, and now the ARMC Neurosurgery Residency Program, is inextricably linked with the history of CANS.
As I write this (as an eternal optimist), looking back at the golden period of steady growth in what became the most comprehensive clinical neuroscience services in the history of the Coachella Valley and taking pride in what we were able to achieve there over nineteen years, I remain hopeful that future hospital and community leaders will revive clinical neurosciences to their former glory as outstanding neurosurgeons and neurologists continue to make the Coachella Valley their home.
CMS Publishes Program Year 2022 Open Payments Data
Today, the Centers for Medicare & Medicaid Services (CMS) published Open Payments Program Year 2022 data, along with newly submitted and updated payment records for previous program years. The data is accessible at https://openpaymentsdata.cms.gov/.
Open Payments is a national disclosure program that promotes transparency and accountability by making information about the financial relationships between applicable manufacturers and group purchasing organizations (GPOs) and certain healthcare providers available to the public. Because of this program the American public has much more transparent insight into the nation’s healthcare system.
Drug and medical device companies are held accountable by law to report certain financial relationships for the purpose of the Open Payments program. Healthcare providers have a voluntary role in Open Payments and my review, affirm or if necessary, dispute data that has been reported about them.
Program Year 2022 Summary
For Program Year 2022, CMS published $12.59 billion in payments and ownership and investment interests made by applicable manufacturers and GPOs to physicians, physician assistants, advanced practice nurses and teaching hospitals. This amount is comprised of 14.11 million records attributable to 588,514 physicians, 271,682 non-physician practitioner (NPPs), and 1,240 teaching hospitals.
Payments are reported in three payment categories: general payments, research payments, and ownership or investment interests. Payments in the three major reporting categories for Program Year 2022 are:
Over the last seven years, 80.66 million records amounting to $68.44 billion have been published through the Open Payments program.
The Program Year 2022 data publication is the second Open Payments publication that includes data about physician assistants and advanced practice nurses. In Program Year 2022 physicians received 67.27% of the combined number of general and research payment records; physician assistants and NPPs received 31.64% of payment records, and teaching hospitals received 1.08% of payment records.
Although physicians and NPPs receive the majority of general and research payments, they did not receive the largest monetary totals. Teaching hospitals received the highest dollar value of payments in Program Year 2022; 49.42% of the dollar value for Program Year 2022 was attributed to teaching hospitals, 47.43% was attributed to physicians and only
3.15% of the dollar value was attributed to physician assistants and advanced nurse practitioners. These trends are consistent with the Program Year 2021 data.
The Open Payments data will be refreshed in early 2024 to reflect any updates made to the data since this publication. To explore the data visit the Open Payments Search Tool.
Additional Information
Covered Recipient Post Publication Review and Dispute Availability
Covered recipients have until December 31, 2023, to review and affirm, or, if necessary, dispute, records attributed to them that were submitted in Calendar Year 2023. Action taken on the data between now and December 31, 2023, will be reflected in the annual data refresh or in a later publication. In order to participate in review and dispute activities, covered recipients must be registered in the Open Payments system. For more information about registration and the review and dispute process visit the Open Payments Covered Recipients page.
Archived Data
Data publication occurs for five years from the first publication of the program year data. After a program year reaches its fifth full year of data publication, it is closed and archived. Program Years 2013 – 2015 are archived and are not displayed on the Search Tool. More information about the archiving process and the archived data is available on the Open Payments Archived Datasets page.
Contact Us
For program related questions including registration, review and dispute and data submission questions contact our Help Desk at openpayments@cms.hhs.gov or by phone at 1-855-326-8366 (TTY Line: 1-844-649-2766). The Help Desk is open Monday through Friday, from 9:00am – 5:00pm (ET), excluding federal holidays. Please note that all press inquiries should be submitted to the CMS’ Press Office.
Decisions
“The most basic of all decisions is who shall decide.” –Thomas Sowell
“To assume all the knowledge to be given to a single mind…is to disregard everything that is important and significant in the real world.” -FA Hayek
After my piece last month, I had been discussing the “single-payer” system with anyone unfortunate enough to come within earshot. My wife has been especially tolerant of my rantings, even more so given that she only wants to focus on the upcoming women’s World Cup (Go Zambia!).
However, I had an interesting conversation with a prominent spine surgeon who favored “single-payer.” His reasoning was that it could decrease the amount of crazy, unindicated spine surgery in the community. This took me back to some basic economic, even philosophical, decision-making questions. My thoughts on this are largely influenced by FA Hayek’s “The Use of Knowledge in Society” and Thomas Sowell’s Knowledge and Decisions (from which the above quotes are taken).
Using the example of spine surgery, some decisions are relatively easy, but most are not. This is clear when we present a case at any spine course or conference. There will be twice as many opinions as people in the room. In a single case example, prominent spine surgeons recommend everything from a minimally invasive laminectomy to a T10-pelvis fusion.
So, suppose a room of highly trained experts can’t agree on what’s to be done. How can we expect a government bureaucracy to formulate a payment scheme to prevent unindicated surgery? I fully agree that there is too much crazy, unindicated spine surgery. Creating a “single payer” system in hopes that, by controlling payment, the government can control healthcare utilization is the essence of the decision-making problem highlighted by Hayek and Sowell.
To a lesser degree, we deal with this in our current third-party payment setup. Insurance companies, those third parties to which Sowell refers, don’t have all the information we, the patient & surgeon, have. The patient knows what the symptoms are and how badly they want relief. The surgeon knows what is possible in his or her hands. The insurance company, acting with imperfect information, takes the decision away from the patient-physician relationship. If we are frustrated with how insurance companies act, imagine how a single-payer government bureaucracy will act when it tries to ensure that no unindicated surgery is done.
At least there are multiple insurance agencies. They can change their payment policies much easier than a governmental bureaucracy could. If enough people get fed up with a “single-payer,” there are at least a few other options. More competition in the insurance market would improve matters, bringing the decision-making closer to the patient/physician locus. However, “single-payer” means decisions are made by one entity, controlled by unelected bureaucrats far removed from the patient/physician relationship.
Who will set the rules on what surgery is ok for what condition? Who will decide who sets those rules? How will the “single-payer” approve of surgery? Will approval be based just on associated CPT codes, making over-utilization even easier than it is now? Or will spine surgeons be forced to submit imaging for approval, creating an even more onerous prior-auth process? Will clinical notes be reviewed? How will emerging technologies be incorporated? What about if an administration gained control and decided spine surgery was over-paid anyway and slashed reimbursement across the board?
Again, Sowell puts it more eloquently than I can:
The advantages of market institutions over government institutions are not so much in their particular characteristics as institutions but in the fact that people can usually make a better choice out of numerous options than by following a single prescribed process.
A “single-payer” would have a single prescribed process. This is how it works when filing taxes or getting a driver’s license.
Taken to the opposite extreme, imagine there were no third-party payments. A patient had to bring in a duffel bag (or briefcase if you’re of Sicilian heritage like me) full of money for their surgery. The decision to do surgery, and the type of procedure, would be entirely between the patient and the physician. There would be no governmental body or third-party payer to convince of the necessity of the ultimate decision.
In this hypothetical world, will every decision, made independent of third parties, be correct? Of course not. However, in the aggregate, the millions of individual patient-physician decisions will lead to better outcomes than a single, heavy-handed governmental decision-maker. This is the argument of Hayek and Sowell. It doesn’t matter if the economic decision is an indication for spine surgery or the price of soybeans; decentralized decisions will, on aggregate, have better results than a single prescriptive plan enforced by the state’s power.
That hypothetical world free of third-party payers in medicine will never exist. That’s why people cede some decision-making power to insurance companies. Decreasing the heavy-handed tactics of the insurance companies is a topic for another day (the answer is more decentralization and more patient control). However, using a “single-payer” system to task the government with reducing the amount of unindicated spine surgery takes even more control away from the individual patient-physician interaction. This is not something we should advocate for.
Diversion Control Division
MATE Act Training Requirements
Dear Practitioner,
As mandated by Congress, medical practitioners have a new role to help patients fighting to sustain recovery and prevent opioid overdoses. All Practitioners, with the exception of Veterinarians, submitting a new DEA Registration Application or renewing a current DEA Registration must attest to completing 8-hours of training to treat patients overcoming opioid use disorder.
Complete instructions and an overview video are available on DEA’s Diversion Control website, and we encourage you to take a moment to review these important new requirements.
If you have any questions, feel free to contact the Policy Section at ODLP@dea.gov.
Eating Humble Pie and how to be a Colleague
“Criticism may not be agreeable, but it is necessary. It fulfills the same function as pain in the human body. It calls attention to an unhealthy state of things.” –Winston Churchill
Despite reports of people leaving in droves in California, a steady stream of physicians are beginning or moving their careers here. Although I suspect there will be more retirements than new physicians moving in in the near term, the long-term outlook is for the population of California to grow, and the demand for physicians will follow. Whatever the flavor of physicians that come to the Golden State – employed, academic, insurance-employed, or even private-practice consolidations, we will always compete for patients with each other. As neurosurgeons, we have been selected for a voracious appetite for work, a penchant for self-criticism, and an absolute demand for perfection.
In short, we are all sociopathic workaholics in some regard. We oftentimes struggle to get along, partly because we are always in competition – with ourselves, each other, and our mentors.
Because there has been a constant current of neurosurgeons and other specialties consolidating, breaking apart, and re-forming, one never knows when we will be on the same team with people we don’t necessarily like. More loosely, when working in a community with a high density of patients and, therefore, cases, patients will undoubtedly be getting more than one opinion. Patients may also show up in your ER or doorstep after surgery by another neurosurgeon (orthopedic spine surgeon or even interventional pain physician) for a second opinion, revision, or complication. In private practice, many of us pride ourselves on fixing our own issues. One of my favorite things about my community is that most neurosurgeons are acutely aware and accountable for their postoperative complications. We all face, at one time, or another, a case we did our best on, and things don’t go right.
Early in my career, I had a patient with focal scoliosis and a large extruded disc in the upper lumbar spine. Try as I might, problem after problem happened. At one point, the patient did get transferred to another local surgeon at a higher level of care during a holiday weekend. Feeling awful, I thanked the surgeon and put my tail between my legs. I followed up with that surgeon, and the patient required no further operations. The surgeon was not accusatory but was gracious and collegial. He knew I had done my best, but the snowball effect of problems kept growing. The patient is doing well, and no further actions were taken by anyone. It was humbling, and frankly, I still think about the case, but not sure what I would have done differently other than doing a huge operation for a single-level disc protrusion – and there is no guarantee the patient would have gone for it.
When you deal with patients who get a second opinion, especially in an urgent matter, there is a sense of dread. Did I recommend the right thing? What if something bad happens as they are leaving the office while they are on the way? What if the other surgeon thinks what I want to do is nuts? These are all my questions, and possibly some of you taking the time to read this have had, whether in private or other modes of practice. These healthy self-doubts keep me on my toes but may add to my gastric distress.
In large urban areas, there are bound to be patients who want to and, in many cases, should get a second opinion on their situation. I have eaten crow, just like anyone else has in their career. It’s a bitter desert after a big, filling meal of hubris sometimes. Trying to operate with a sense of humbleness when I tackle any case, especially high-profile patients, and family members of physicians in my community, in the end, they are all treated with the same considerations, but my sphincter tone is noticeably higher in all phases of care. I feel like they are my family member – my mom or dad, brother, sister, wife, and so forth.
One cannot control when a patient seeks a second opinion, and in many cases, it is absolutely for the best and not a criticism of you or your abilities per se. One also cannot control if a colleague deviates from professional standards. Being fairly certain it has happened to all of us, it is safe to say it is unwise to do. Unless they have called you, the other
surgeon seeing the patient is uncertain of the why’s and the what’s of what you want to or have done and should allow for the very real possibility that you knew what you were doing. There are those, of course, in the community who cannot help themselves.
Some quite talented surgeons are quizzically still insecure enough to badmouth colleagues or even say things that may cause an action to be filed against the prior surgeon. This is not to say bad behavior and bad choices should not be rubber-stamped or not called out. We have arenas for that – imperfect as they are. No one likes having a case “fall out” at an M&M conference. It is a place where we can discuss what went wrong and why. You often did your best, and no one looked at you crosswise. Other times, your epic failure is displayed for everyone to see, and your colleague may not be kind. More often than not, the criticisms are constructive and help us improve.
What is not and should not be normalized is doing the Ickey Shuffle in front of another surgeon you have “won” against in the battle of patient trust. A patient has every right to change surgeons at any time, and there are many reasons why. Most surgeons have lost a case to another surgeon at some time or another. It is an awkward moment for both surgeons. How collegial surgeons act when this occurs speaks volumes on both ends of the baton. As most surgeons mature, they have had both happen, often more than once.
It only lowers everyone’s to the lowest base and drives us further apart when surgeons speak ill of other surgeons. With reimbursement cuts, aggressive anti-doctor rhetoric, and corporate tiger sharks circling our boat, it helps none of us other than giving someone a very short and quite empty-in-the-end ego boost. We cannot afford that kind of animosity. Many of us do not call each other friends, but we would do well to put our collegiality and cooperation above the need to feed our egos. The only entities that win in those situations are the administrators and, sometimes, the lawyers.
CMA-sponsored bill to reform prior authorization advances out of Assembly Health Committee
A bill sponsored by the California Medical Association (CMA) that would reform the prior authorization process advanced out of the Assembly Health Committee on July 11. SB 598, authored by Senator Nancy Skinner, would institute a one-year “gold card” exemption program from prior authorization requirements for physicians who have at least a 90% prior authorization approval rate. The bill would also allow physicians to have appeals of their prior authorization denials reviewed by a licensed health professional of the same or similar specialty.
DHCS publishes Medi-Cal Managed Care Plan Transition Policy Guide
The Department of Health Care Services (DHCS) recently updated its 2024 MCP Transition Policy Guide to include a table that lists Medi-Cal managed care plan changes slated to take effect January 1, 2024, and relevant transition-related policies by county. Physicians are encouraged to review the table to see what changes are coming to their counties.
CMA and DHCS host webinar on Medi-Cal managed care plan transition on Aug. 10
Earlier this year, DHCS reached an agreement with five commercial managed care plans to deliver Medi-Cal services in 21 counties across the state starting in January 2024. CMA is hosting a free webinar with DHCS on August 10, 2023, to help physicians understand and prepare for the transition
California Supreme Court rules CMA can sue Aetna Health under Unfair Competition Law
CMA has achieved a significant victory for providers, consumers and public interest advocates in the case of California Medical Association v. Aetna Health of California Inc. The California Supreme Court ruled unanimously in favor of CMA, confirming the organization’s legal standing to sue Aetna Health for alleged violations of the Unfair Competition Law.
Physicians must use HIPAA compliant video communications tools for telehealth by August 10
When the COVID-19 public health emergency expired on May 11, 2023, the U.S. Health and Human Services Office for Civil Rights (OCR) announced the end of flexibilities that allowed physicians to utilize remote communication technologies for telehealth services that did not fully comply with HIPAA rules. OCR provided a 90-calendar day transition period for covered health care providers to come into compliance with the HIPAA rules for telehealth.
California physicians can now apply for federal public service loan forgiveness
The U.S. Department of Education’s updated Public Service Loan Forgiveness program launched on July 1, 2023, and will now allow eligible California physicians to participate in the program, despite our state prohibitions on physician employment by private non-profit hospitals, clinics, foundations and other health care entities.
Physicians who had temporary Medicare provider access during PHE must complete CMS-855 application
During the COVID-19 public health emergency (PHE), physicians and other providers who previously would have had to complete a CMS-855 Medicare enrollment application were granted temporary provider transaction access numbers, or PTANs. The lifting of the PHE on May 11 means that physicians and other providers who had relied on temporary PTANs for their Medicare enrollment will have to revert back to the normal process of completing a CMS-855 enrollment application.
Affirmative Action and Foreign Medical Graduates
On June 29, 2023, the United States Supreme Court struck down “Affirmative Action” in college admissions. Chief Justice John Roberts, speaking for the conservative majority, said that for too long, universities have “concluded, wrongly, that the touchstone of an individual’s identity is not challenges bested, skills built, or lessons learned but the color of their skin. Our constitutional history does not tolerate that choice.” There were two cases before the Court. The Harvard case was ironically filed on behalf of an “Asian American” minority student. The ruling effectively overturned 45 years of precedent.
President Joe Biden immediately said he “strongly, strongly” disagreed with the court’s ruling. He urged colleges to seek other routes to diversity rather than let the ruling “be the last word.
“Affirmative Action” has undoubtedly helped many African Americans attend elite colleges and accomplish their educational dreams, a fact that we should celebrate. Former President Obama said that affirmative action “allowed generations of students like Michelle and me to prove we belonged. Now it’s up to all of us to give young people the opportunities they deserve — and help students everywhere benefit from new perspectives.”
This is a very difficult topic to discuss. I strongly believe in “Diversity” and what it adds to every aspect of our Nation’s life. But I have reservations regarding weighing only race, ethnicity, or gender in deciding on admitting an individual student to college. Each applicant should be considered individually and on his or her merit. And I believe this principle should apply to everything in our “National Life.” Admission to residency training generally and in Neurosurgery is no exception.
I recently read an article titled “Why My Application Is Routinely Screened Out.” By Priyanka Bakhtiani, MD. https://opmed.doximity.com/articles/why-my-application-is-routinely-screened-out
Dr. Bakhtiani is an accomplished pediatric endocrinologist at the Children’s Hospital Los Angeles, CA, specializing in the endocrine care of children after cancer therapy. At the completion of her medical school in India, she “applied to 36 programs for residency, and on the very first day of application review,” … she “got rejection letters from 20.” This is common for International Medical Graduates (IMG). I had a similar experience when applying for a neurosurgical residency in 1973. Then, I justified that my applications were rejected because returning American-born GIs were given preference; I accepted this fact and supported it. But I am afraid that, in retrospect, this was not the only reason. Similar reasons may be factors in college admission decisions if “Affirmative Action” was eliminated.
In her article, Dr. Bakhtiani indicated she is “one of many IMGs and FMGs here. One in every four physicians in the U.S. is an IMG, and the AAMC reported that 42.3% of hospitalists in the U.S. were IMGs in 2013. We are a critical part of the health care system and contribute significantly to scientific development, research, and most importantly, quality patient care, with fewer patients dying in our care than in that of U.S graduates.” I am one of these IMGs.
Dr. Bakhtiani, who was not offered a residency position when she first applied, was fortunate to get an “observer-ship,” during which her skills and dedication were noticed. Then she was offered a residency position. She was also fortunate to receive an H1B visa. Her husband failed to receive such a visa simultaneously and had to return to India for a year.
This brings me back to affirmative action; like race in college admission, national origin should not be the only factor considered in residency training. This may not be as obvious in neurosurgery, but we face a shortage in most areas of medicine, and IMGs are part of the solution. The AMA predicts a shortage of up to 124,000 physicians in the U.S. by 2034, primarily impacting most underserved and disparate populations in America.
I admit that Affirmative action in college admission and the treatment of IMGs are not one and the same, but there are many similarities.
So, shouldn’t merit be the most important criterion in selecting candidates for college admission and residency training? Shouldn’t IMGs be at least given a chance for a face-to-face interview?
I think so.
The “Largest Hibiscus”
The photo was taken by Moustapha AbouSamra, MD, at Solimar Beach, Ventura, CA, at 1:40 PM. June 30, 2023, iPhone 13 Pro.
Editor’s note: We previously published concerns Alex Tenorio raised about the
border wall’s increased height. Alex has since lobbied Congress and met with White House policy advisers to brief them on the issue. He also testified as an expert witness before the Homeland Security Committee on July 19, 2023.
https://www.youtube.com/live/lOGeX0LdFXM?feature=share&t=9121
Below is a reprint of an Op-Ed recently published in “The Hill.”
“First published in The Hill”
https://thehill.com/opinion/immigration/4082480-a-new-crisis-at-the-border-traumatic-injuries-caused-by-falls-from-trumps-30-foot-wall/
A New Crisis at the Border: Traumatic Injuries caused by Falls from Trump’s 30-foot Wall
It was 5 a.m. on a Saturday morning. I was a 13-year-old kid, growing up in South Los Angeles. I packed my bags and headed downtown, where I set up a cardboard box with pens and a rack for shirts on the sidewalk, selling them to passersby. Migrants set up next to me and did the same.
This was my childhood. They all came with nothing, but they cared for me as if I were one of their own. I vowed to fight for them.
As a neurological surgery resident in San Diego, I recently joined human rights leaders to brief members of Congress and President Biden’s domestic policy advisors on the public health crisis occurring at the U.S.-Mexico border. I was the physician representative of the group, explaining to our elected officials the unnecessary injury and economic burden that new 30-foot barriers are causing.
We urged them to halt construction at Friendship Park, which has been a historic space for binational families at the San Diego-Tijuana border. I fear that these 30-foot barriers will turn this into a place of horrific injuries.
Since the Mexico border wall was raised up to 30 feet, there have been a record number of traumatic injuries from “border falls.” Our hospital costs and hospital stays have also seen a significant rise. Hospital admissions from border falls have increased almost seven times since 2019, and spinal injuries after border falls have cost an additional $26 million.
With the expiration of Title 42, I fear that this trend will only get worse. As a physician, it is my duty to reveal this unnecessary harm and strain on hospital resources. As the son of Mexican immigrants, it is my duty to continue to fight for this vulnerable population.
After my recent visit to Washington, D.C., it was clear that border infrastructure policy is one of the most divisive topics discussed by our elected officials. To be sure, this topic fosters very strong sentiments that can be endlessly debated. However, you cannot disregard objective evidence. For this reason, it is more important than ever for physicians to become ardent advocates and provide a balanced view of the harm from raised border walls.
Our visit did provide a ray of hope. Members of Congress penned a congressional letter urging President Biden to halt further construction of 30-foot barriers at Friendship Park after our briefings. The president’s senior policy advisors also assured us they would brief him on the issue.
This will be a long fight. I am reminded of a border fall patient who had suffered a severe brain injury. His wife and young daughter came to his bedside every day. He had been in a coma for several days when his wife asked me in Spanish, “When will he wake up?” I’ll never forget the horror in their eyes when I responded, “It is very likely that he will never wake up.
These are the people coming here for a better life. These are the people who cared for me as a child. These are the people worth fighting for as a physician.
Physician René Leriche once said, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray — a place of bitterness and regret, where he must look for an explanation for his failures.”
Now, it is inevitable that I will carry my own small cemetery. But I ask my physician colleagues to join me in this fight, and hope we don’t look back at this filled with regret.
Alexander Tenorio is a neurological surgery resident at the University of California, San Diego. He is considered a leading expert on traumatic neurological injuries at the U.S.-Mexico border and has worked with human rights groups to advocate for halting height extensions of these barriers. Follow him on Twitter at @AlexTenorioMD.
Are the Wrong Questions being asked at Interviews for Residency Spots?
My wife, Cathy, told me last month that I might want to consider making my column a little funnier. I have spent more than a bit of time pondering this proposal. What is funny about what we do? I kind of drew a blank. Sad.
Cathy practiced as a lawyer for over 30 years. She has tons of funny stories. A lot of them involve gallows humor. The law, like medicine, is a serious business. Why can’t we see the humor in the humanity that presents before us?
For confidentiality reasons, Cathy does not want me to go into specifics. Let us just say that she has seen multiple paternity issue cases and that they uniformly involve decreased inhibitions and fuzzy recall, because of alcohol and drug use. There was one particularly appalling/amusing one that involved double dating, love making in a car, and shared use of prophylactics. She calls the story front seat/back seat.
Reminds me of a residency interview question that one of my colleagues once proposed. Two men, two women, two condoms … how can each person have sexual intercourse with each of the two opposite-sex individuals and avoid both pregnancy and STD transmission? Clearly the front-seat/back-seat crowd would not be able to figure this one out … but perhaps I am not being fair. They had only one condom.
It is a tricky question. There is a solution, but it takes more than a little creativity and brainpower to figure out. An informal poll, at rounds, has suggested to me that only about 25% of practicing neurosurgeons are able to get the answer … at least quickly and on the spot. Hmmm. You might ask, what does this say about those neurosurgeons? Clearly, some of us are better at solving puzzles and being able to think outside the box. But do you really want the individual who is able to figure this out on your team? And what about the rest of us block-heads who are not able to figure it out right away?
I am starting to wonder if my musings have anything to do with the practice of neurosurgery. We spend over a decade, after undergraduate study, in medical school and then residency … some of us even more. It is very serious stuff. And when we are finally released from that purgatory, we end up having to commit large portions of our time to deal with patients and their families … often wrought, understandably, with fear and anxiety over ailments that threaten life and limb. What is funny about that? We also must deal with other doctors and ancillary/support staff. And then there is the burden of documentation and the ever-present specter of misadventure leading to legal trouble. What have I left out? The OR.
Ah, the operating room, the one place left in the world where surgeons can still behave like children. Of course, we cannot throw tantrums or instruments anymore, nor squeeze fannies or make sexually explicit jokes. Toddler and adolescent behavior have become verboten. But it is still the place where, like children, we get to explore our creativity, sometimes experience novel situations … to sometimes boldly go where we, and perhaps our colleagues, have never gone before. And while limits have been placed on what we can say and do, the patient is asleep, everyone is on the same team and we can be more ourselves than anywhere else. It is our Las Vegas … what happens there, for the most part, stays there.
Television, and movies, have generally not been able to capture the irreverence and fun that imbues some of what we do. The most realistic “doctor show” that I ever saw was the original “All Creatures Great and Small.” Based on the novels of James Herriot, it explored the practice of veterinary medicine in the first half of the twentieth century in rural England. Cathy and I watched several episodes of the original series on Netflix recently. The stories are just too real … you cannot make that stuff up. Eccentric practitioners, perplexing patients (both farm and domestic animals), their all too human owners; strained finances, unsuccessful business and romantic ventures. It is all there, in funny yet sensitive portrayals.
James Wolfe, the British general who defeated the French on the Plains of Abraham in Quebec, securing the conquest of Canada, famously recited Gray’s Elegy in a Country Churchyard the night before his great victory. He stated, “Gentlemen, I would rather have written that poem than take Quebec tomorrow.” I sort of feel the same way about Herriot’s book and the TV show. Why can’t I come up with something like that?
But on a more serious note, should residency interview questions be loosened up a bit? Maybe we would end up with a few more creative individuals? Or at least a few more Randy Smiths.
Leveling the Playing Field
I have a love-hate relationship with football. On any given Saturday in the fall, you may find me glued to the television screen watching ESPN’s Game Day’s Kirk Herbstreit predicting the future. Then if it’s my alma mater, Baylor, playing, or my son’s University of Michigan (can you believe he’s graduated already?), I am not missing a play. But as a neurosurgeon, it goes along with boxing (my neurosurgeon colleague in Texas boxed) in my mind as a taboo for the brain. Hence the love-hate relationship.
One of the best CANS Annual Meeting panel discussions I have ever attended was Langston Holly’s one on should kids play football. As parents, both my ex and I were against our son playing football. Luckily, he showed no interest, preferring the piano instead. But at the end of the panel discussion, I could see the advantages of letting testosterone ladened teenagers have a constructive, team-oriented outlet. One of the presenters was from Harvard-Westlake, a private, college-prep high school in Los Angeles. According to the school’s website: “Harvard-Westlake Athletics provides best in class coaching, first-rate athletic facilities and top of the range programming in Sports Science & Medicine, Sports Performance, Sports Nutrition, and Sports Psychology.” The school has the proper equipment, the athletic trainers, and the means to limit injury to children playing sports. I asked the panel, what about the public schools in poorer districts? The panel admitted that this was a problem without a clear solution.
This brings us to Bronny James. For those of you who purposely live in a sports vacuum, Bronny James is the son of Lamar James (that basketball player for the LA Lakers). On July 24, Bronny suffered a cardiac arrest during a practice meet at USC, where he was recruited. The USC staff has experience treating sudden cardiac arrest as a player (Vince Iwuchukwu) had a similar event last year. The trainers know CPR. The AED is close by in a hallway off the main court (source: LA Times,7/26/23). Bronny was treated, transferred (to Cedars-Sinai, interestingly), and is out of the ICU.
A secondary article in the LA Times brings up my initial point-“A Class Divide in Student-athletes’ Emergency Care.” According to the article, California is the only state that does not regulate athletic trainers. (On the side, I found out that only 18 states regulate surgical techs. California is not one of them. Hospitals may impose training requirements prior to employment, but it is not a law to do so. In other words, the person who cuts my hair must have proof of training, but the person who hands me a surgical knife does not). LAUSD has eight athletic trainers for 150 high schools. Most high schools do not have a trainer on the field during the game or in practice. And what about the difference in equipment, playing fields, sports nutrition, and sports psychology? I suspect the latter two are nonexistent in most schools.
My son’s public high school was able to hire an athletic trainer several years ago. I was asked to review the job description and make comments. I don’t know how good the equipment is at his alma mater, and I doubt the school has a sports psychologist, but it is a start. There are ways to aid our less fortunate schools. Help them build foundations. Encourage sports figures to do what Labron James did for Akron, Ohio (ipromise.school). Consider corporate advertising and personal naming rights of buildings and fields. Have the rich schools make it a community service project to help the less fortunate. There will always be the haves and the have-nots. But leveling the playing field is good for the game and the student-athletes.
CANS Resident Consultant 2023-2024
Franz Weitlaner
Editor’s Note: Franz Weitlaner was not a neurosurgeon, but his eponymous retractor is used daily in neurosurgical procedures.
Despite pioneering advancements in minimally invasive approaches, operative exposure remains a critical component of neurosurgical procedures. Early soft-tissue “self-retaining” retractors like the Broz Wound Dilator (pictured to the right) relied on a screw-mediated mechanism to secure them opened or closed. However, once seated into the operative field, the retractor itself would dislodge rather easily, partly due to the small and freely rotating hooks on each end. Furthermore, holding open tissues of interest would cause the screw to disappear out of view, leaving the surgeon unable to adjust it once efficiently dislodged.
Dr. Franz Weitlaner created his own solution in 1905 while working in a remote Austrian village. Born within the empire of Austria-Hungary, he initially pursued schooling to join the Catholic priesthood but shortly thereafter changed his mind and enrolled in medical school at the Innsbruck Medical University. After completing his studies and residency training, he traveled around Asia as a ship physician, studying and writing about syphilis, the plague, and sea sickness. He returned from his voyages to establish a practice as a general physician in Ottenthal, a small town with scarce resources, let alone surgical assistants. Having to tackle any surgery, big or small, without help adjusting the operative exposure, Dr. Weitlaner solved his own problem, establishing his legacy.
He did not financially benefit from this game-changing contribution to the field of surgery; however, he chose the right to name his invention over pursuing a patent. The irony, of course, is that many still refer to the Weitlaner (pronounced “VIGHT-lahn-er”) as “Wheatlander” or, worse yet, “Wheaty.”
Palliative Care in Neurosurgery/ The Long and Short of It
One night during the second year of my residency, I admitted a patient with a ruptured aneurysm, a young man who worked as a contractor. Surgery to clip and secure the aneurysm was successful. A few days later, however, Mr. Marzon was found struggling to breathe normally, and a team of doctors and nurses rushed him to the CT scanner, where we discovered that he had developed a large infarct in the left hemisphere of his brain. He was intubated and taken to the operating room again for a hemicraniectomy for malignant edema. Then, where his scalp used to be soft and pliable over the spot where the skull was missing, his head gradually stiffened again over the next three days, an ominous sign. Mr. Marzon’s brain was so damaged that even surgery to release the mounting pressure from the stroke’s aftermath was insufficient.
As one of Mr. Marzon’s doctors, I had to tell his family that we, the surgical team, recommended stopping further treatments in preparation for taking Mr. Marzon off life support. When his wife incredulously asked, “Why?” I tried to explain brain death and medical futility over our phone conference. Two medical interpreters, one fluent in Spanish and the other in an indigenous dialect, also spoke with the family.
Mr. Marzon’s wife’s sobs cut through the phone, and additional voices joined in the wailing. The interpreters relayed that the family wished to see him in the hospital. I had to tell them, “No.” Not to mention the paperwork normally needed to get even one member of the extended Marzon family to Palo Alto, California, from Ecuador, the entire hospital, like others across the nation, closed its doors to any visitors during the early months of the pandemic.
That patient encounter left a particularly deep impression on me, especially as a junior resident. The family meetings I led had shaken me to my core, magnified by the difficulties of conducting serious illness conversations virtually during the pandemic. I thought about Mr. Marzon and his family for a while, eventually considering the value of palliative care principles in the neurosurgical field, including the neurosurgeon’s role in shared decision-making, goals of care discussions, and advanced care planning.
At the same time that I was going through residency and taking care of acutely ill patients like Mr. Marzon, my father continued to decline from his longtime diagnosis of atypical meningioma slowly. Since 2017, he has undergone craniotomies almost yearly for recurrent tumor resection. On top of recovering from multiple surgeries, he cycled through different chemotherapies, some experimental, and all requiring numerous clinic visits for symptom monitoring in a valiant effort to keep his metastasizing tumor at bay. I often wonder whether my parents could have benefited greatly from palliative care approaches during my dad’s illness.
Palliative care is defined as a person- and family-centered approach to serious illness that aims to reduce suffering and preserve and improve quality of life. A landmark trial published in NEJM by Temel et al. found that patients with metastatic non-small cell lung cancer who were randomized to receive palliative care referral and support early in their disease course had longer survival and significant improvements in quality of life and mood.
Even so, it may beg the question: why should surgeons care about palliative care for our patients? I believe that surgeons have significant parts to play in advocating for patients’ and families’ overall well-being, even when surgical intervention is not a viable option to pursue. The American College of Surgeons Palliative Care Workgroup, established in 2003, identified seven focus areas, including different aspects of decision-making, communication, symptom management, care delivery, and care processes. For instance, one priority area was to define and measure quality outcomes that matter to patients and families, including symptom burden and postoperative needs.
In this column, I tried to tell only two stories as examples. One described events unfolding over the course of two weeks. The other spanned a little over seventeen years. The long and short of it all is that, though the surgery itself may be one moment in a patient’s overall trajectory, there are many opportunities to further impact the lives of our patients as neurosurgeons by also considering palliative care principles.
*Patient names and details have been changed for privacy reasons.
For additional reading:
Kluger BM, Hudson P, Hanson LC, Bužgovà R, Creutzfeldt CJ, Gursahani R, Sumrall M, White C, Oliver DJ, Pantilat SZ, Miyasaki J. Palliative care to support the needs of adults with neurological disease. Lancet Neurol. 2023 Jul;22(7):619-631. doi: 10.1016/S1474-4422(23)00129-1. PMID: 37353280.
Lilley EJ, Cooper Z, Schwarze ML, Mosenthal AC. Palliative Care in Surgery: Defining the Research Priorities. Ann Surg. 2018 Jan;267(1):66-72. doi: 10.1097/SLA.0000000000002253. PMID: 28471764; PMCID: PMC6088241.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. doi: 10.1056/NEJMoa1000678. PMID: 20818875.
July 2 – Dr. Susan Love, a surgeon, author, researcher, and activist who was for decades one of the world’s most visible public faces in the war on breast cancer, died on Sunday at her home in Los Angeles. She was 75. Dr. Love helped reshape both the doctor’s role and that of the patient in breast cancer treatment. Breast Cancer kills more than 43,000 women in the United States annually.
Dr. Susan Love in 2013. Credit…Michal Czerwonka for The New York Times
July 2 – On this day in 1776, the Second Continental Congress passed a “Resolution for Independence” declaring “That these United Colonies are, and of right ought to be, free and independent States, that they are absolved from all allegiance to the British Crown, and that all political connection between them and the State of Great Britain is, and ought to be, totally dissolved.” Also known as the “Lee Resolution,” after Virginia delegate Richard Henry Lee proposed it, the resolution was the final break between the king and the thirteen colonies on the North American continent that would later become the United States of America.
July 3 – John Adams, Massachusetts delegate, wrote to his wife, Abigail, “The Second Day of July 1776, will be the most memorable Epocha, in the History of America.”
July 4 – Independence Day!
The Second Continental Congress adopted the Declaration of Independence “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty and the Pursuit of Happiness.”
“The Betsy Ross Flag” is believed to have been originally designed and sewn by Elizabeth Griscom, known as Betsy Ross.
On June 14, 1777, the Second Continental Congress passed the first Flag Resolution. This resolution officially adopted the “Stars and Stripes” as the national flag and stated: “Resolved That the Flag of the united states be 13 stripes alternate red and white, that the Union be 13 stars white in a blue field representing a new constellation.”
Our Banner in the Sky by Fredric Edwin Church – 1861.
National Air and Space Museum
Flag of the United States of America, Apollo 11
The current flag with 50 stars was adopted on July 4, 1960, after Hawaii joined the Union – on August 21, 1959.
July 5 – The “Climate Reanalyzer” at the University of Maine indicated that the Earth’s average temperature spiked at 17.18 degrees Celsius or 62.9 degrees Fahrenheit, nearly a full degree Celsius (1.8 degrees Fahrenheit) warmer than the 1979-2000 average, which is itself warmer than the 20th and 19th-century averages. Antarctica’s average was a whopping 4.5 degrees Celsius (8.1 degrees Fahrenheit) warmer than the 1979-2000 average. Climate scientist Stefan Rahmstorf at the Potsdam Institute for Climate Research in Germany said, “The increasing heating of our planet caused by fossil fuel use is not unexpected; it was predicted already in the 19th century, after all.” “But it is dangerous for humans and the ecosystems we depend on. We need to stop it fast.”
July 6 – The FDA approved the Alzheimer’s drug Leqembi, and Medicare said it would cover much of its high cost. The F.D.A.’s decision marks the first time in two decades that a drug for Alzheimer’s has received full approval, meaning that the agency concluded there is solid evidence of potential benefit. But the agency also added a black-box warning, stating that in rare cases, the drug can cause “serious and life-threatening events” and that there have been cases of brain bleeding, “some of which have been fatal.” Leqembi cannot repair cognitive damage, reverse the course of the disease, or stop it from worsening. But data from a large clinical trial suggests that the drug may slow
decline by about five months over 18 months for people with mild symptoms. Still, some patients may not afford the 20 percent Medicare does not cover, possibly about $6,600 a year. The treatment could cost about $90,000 a year.
July 6 – Thousands packed the town hall square in the northern Spanish city of Pamplona to celebrate the traditional “chupinazo” fireworks that start the “Running of the Bull Festival” of San Fermín.
AP photo – Alvaro Barientos
July 8 – On this day in 1868, the XIVth Amendment to the U.S. Constitution was passed.
July 11 – On this day in 1804, Vice President Aaron Burr mortally wounded former Treasury Secretary Alexander Hamilton during a pistol duel in Weehawken, New Jersey. Hamilton died the next day.
Image of the original flintlock pistols used in the duel (AP Photo/Manuel Balce Cenea).
July 13 – The FDA approved an over-the-counter birth control pill for the first time in the United States. The medication, called Opill, manufactured by Perrigo Company, based in Dublin, will most likely become available in the United States in early 2024. This could significantly expand access to contraception.
July 13 – One hundred years ago today, to promote a subdivision in the Hollywood Hills, a 50-foot-tall letters “HOLLYWOODLAND” sign was dedicated. “LAND” was removed in 1949.
July 13 – The Hollywood Union SAG-AFTRA leaders, representing 160,000 television and movie actors, voted to strike on Thursday. Screenwriters have been picketing for over 70 days, the first industrywide shutdown in 63 years.
According to the Hollywood Chamber of Commerce, the Hollywood sign draws some 50 million visitors a year. The New York Times
July 13 – The World Health Organization declared that the widely used artificial sweetener aspartame could possibly cause cancer. But also indicated that the “results do not indicate that occasional consumption should pose a risk to most.” The F.D.A. and the beverage industry protested the new findings.
July 14 – Bastille Day.
July 16 – The temperature at Furnace Creek in Death Valley reached 128 degrees – down to 116 at night, the hottest place on Earth. The hottest temperature ever recorded on Earth was also in Furnace Creek. It was 134 degrees in July of 1913.
The temperatures as expected on July 15.
July 19 – Phoenix experiences 20 consecutive days of temperatures above 110 degrees, breaking a 49-year-old record. And in the Persian Gulf region, the heat index reached 152 degrees, nearing — or surpassing — levels thought to be the most intense the human body can withstand. The heat index, also known as the apparent temperature, is what the temperature feels like to the human body when relative humidity is combined with the air temperature.
The heat index is designed to max out at about 136 degrees, but on Sunday, it surpassed 150 degrees in the Persian Gulf.
July 19 – A tornado touched down near Rocky Mount, North Carolina. It ripped up the roof of a Pfizer factory that makes nearly 25% of sterile injectable medicines used in U.S. hospitals. This could put even more pressure on already-strained drug supplies at U.S. hospitals.
July 20 – On this day in 1969, Astronauts Neil Armstrong and Edwin “Buzz” Aldrin became the first men to walk on the moon after reaching the surface in the Apollo 11 lunar module.
This image, taken by Armstrong, shows reflections of Armstrong, the U.S. flag, the lunar module, and a television camera. (Neil Armstrong/NASA via AP)
July 21 – A three or four-year-old, 210-pound black bear named BB-12 was struck and killed on Highway 101 near Newbury Park in Ventura County, three months after National Park Service scientists started tracking his movements in the Santa Monica Mountains. Scientists with the Santa Monica Mountains National Recreation Area said the bear appeared to be the only one of his kind in the Santa Monica Mountains.
July 24 – Yale University history professor Hiram Bingham III found the “Lost City of the Incas,” Machu Picchu, in Peru, On this day in 1911.
This image is a view of the Inca citadel of Machu Picchu. (AP Photo/Martin Mejia)
July 24 – In 1847, Brigham Young and his followers arrived in the Great Salt Lake Valley in present-day Utah.
July 25 – President Biden established the Emmett Till and Mamie Till-Mobley National Monument on what would have been Emmett Till’s eighty-second birthday. On this occasion, Biden said: “We can’t just choose to learn what we want to know … We have to learn what we should know. We should know about our country. We should know everything: the good, the bad, the truth of who we are as a nation. That’s what great nations do, and we are a great nation.”
July 25 – Body Painting Day in New York City.
Many of the event’s models showed off their painted bodies at a photo shoot in Washington Square Park. Credit…Amir Hamja/The New York Times
CSNS Fall Meeting, Washington, DC September 8-9
CNS Annual Meeting, Washington DC September 9-13
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 – Intercontinental Mark Hopkins
San Francisco, CA
CSNS Spring Meeting, Chicago May 2-3, 2024
AANS Annual Meeting, Chicago May 3-6, 2024
NSA Annual Meeting Penha Longa Resort, Portugal June 16-019, 2024
Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter. Submit your text to the CANS office by E-mail (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.
or to the CANS office emily@cans1.org.
