Newsletter

Volume 50, Number 8

Inside This Issue

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

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

CANS President

President's Message - Our Future is Bright!

Another class of neurosurgery chief residents graduated in June 2022, filling their faculty, family, and well-wishers with pride. I cannot overestimate the sense of accomplishment felt by me on my own six graduates, three from the Riverside University Health System Medical Center program (Moreno Valley) and three from the Desert Regional Medical Center Program (Palm Springs).

I’m sure that all California neurosurgery residency program faculty and program directors share this feeling. While we can think of the annual graduation as ‘routine’, in looking back at the latest graduation, I cannot help but feel the immense landmark in our profession’s history that comes with each graduation, when newly minted neurosurgeons are ready to expand our profession’s outreach, to commit to lifelong learning, and to carry the torch to greater heights. There is no better way to contribute to neurosurgery than to help mold the next generation of neurosurgeons.

Over the seven years that the latest class spent in residency, we all got seven years closer to retirement, and the new class reassured us that there will be other committed individuals to fill our shoes. Over those same seven years, my own kids progressed from primary school to high school; my family faced many ups and down; we all experienced a pandemic, among various global catastrophes.

Most importantly though, California neurosurgery residency programs added a handful of neurosurgeons to continue to fight the world’s fight, both in our state, and across the nation. Class of 2022 neurosurgery graduates, thanks for inspiring us with your hard work and commitment, for your dedication to overcoming numerous obstacles, and for reminding us of what true grit looks like. You are the future of our profession, so we are clearly in good hands.

Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Corner

This issue deals with Beauty. Beauty in neurosurgery and the beauty of our Country. It also deals with some ethical issues and some heartbreaking personal experiences.

Enjoying the graduations of neurosurgery residents across our state is a reminder that our future is bright and beautiful. President Siddiqi expressed that eloquently in his President’s Message.

A novel way to get medical students more involved in a sub-internship is described by CANS Board Member Omid Hariri in the Large Groups Corner. A medical student perspective is included. Also included is an essay by Shivum Desai, now MS IV describing his learning experience in working up a patient with a large frontal meningioma, as well as his unforgettable exposure in the OR when he assisted in surgery.

In my Changing Times essay I celebrated our Independence Day, as well as the beauty of our amazing Country. As a naturalized citizen, I am always learning about our history since I missed some of the details when I grew up being taught in a French educational system; I’ve always felt that learning from our past will help us set the stage for a more beautiful future and a more perfect union.

My photo of the month essay elaborated on one aspect of the beauty of America.

In her Women in Neurosurgery Column, CANS Board Member Nicole Moayeri discussed how opportunity, mentorship and sponsorship helped her excel in neurosurgery.

In her brain waves essay about morality and legality, Deborah Henry raised several ethical issues with which our country is dealing at the moment.

In his private practice corner, Brian Gantwerker discussed how much he enjoys independence, but also the fact that independence means different things to different people.

In his academic surgeons’ corner, Anthony DiGiorgio discussed the necessity to be involved in advocacy in order to improve access to care for our patients. He also remarked on the fact that neurosurgeons have an outsized representation in various state and national organizations.

Our new Resident Board Consultant, Angela Wu, who is not new to this newsletter wrote a moving tribute to a friend. She drew a parallel between dealing frequently with tragic situations affecting patients and families, as neurosurgeons, and a dealing with a tragedy as it affects a personal friend.

All other regular columns are included and contain important information that you would want to have.

I hope you will enjoy reading this issue, and as always, if you have questions, comments, or concerns please do not hesitate to call me 805-701-7007, or e-mail me at mabousamra@aol.com

Nicole Moayeri, MD.

Nicole Moayeri, MD.

Contributing Editor

Women in Neurosurgery

Initially, when I was asked to write about my experience as a woman in neurosurgery I bristled because I think of myself as a neurosurgeon and not as a female neurosurgeon. Certainly, there have been challenges as a woman in neurosurgery but rather than focus on these challenges I would rather focus on building my practice and surgical skills.  Then recently one of my male colleagues said to me “Why do we need to celebrate the first black president or first woman president? Aren’t we past that point?” and I thought “This is coming from my friend, really?!” The realization that a young neurosurgery colleague does not recognize that adversity still persists for women and people of color surprised me. When we don’t acknowledge our biases or challenge inequity it gets to flourish or at least remain part of the fabric of our experience.

Over my career I have unfortunately experienced some neurosurgeons who seemed comfortable with their bias against female neurosurgeons. These views interfered with appreciation of us as valuable team members and kept female members of the department from experiencing the same support as our celebrated male colleagues. Also, I witnessed women being held to a higher standard than male neurosurgeons both in regard to behavior and performance. Fortunately, in the formative period of my career there were more neurosurgeons who rejected such biases and served as excellent mentors. So, the big lesson I have learned as a female neurosurgeon is that inevitably biases exist and that we have to consciously overcome our biases. Overcoming bias is how we can provide an equitable distribution of opportunity, mentorship and sponsorship which is paramount when building a diverse and healthy neurosurgical community.

After college and medical school at Stanford, I matched to neurosurgery at the Massachusetts General Hospital in Boston. For internship I wanted to spend time with the wonderful surgeons and mentors I met at USC – Drs. Weiss, Giannotta and Apuzzo. My mentors during my MGH residency – Drs. Steichen, Crowell, Ogilvy, Cosgrove, Chapman and Ojemann – helped me to develop my neurosurgical skills. At MGH I was immersed in the traditions of excellence in surgical care performing over 300 cases during my six-month chief residency which helped me to launch my academic vascular neurosurgery practice at Brigham and Women’s Hospital and Children’s Hospital, Harvard Medical School, Boston. Drs. Black, Stieg and Scott were mentors who supported my interest in teaching, research and patient care providing a warm welcome. Even in such a supportive environment I remember a conversation with Dr. Black when I noted the discrepancy between the newly hired male chief resident and my own junior attending salary and he told me “Do not be afraid to ask for what you deserve” then promptly corrected the pay inequity.

Departing academic neurosurgery in Boston I moved to a large group practice at Redwood City, Kaiser Permanente and recently I have started private practice in Santa Barbara at Cottage Hospital. Each of these settings has enhanced my experience and allowed me to develop my surgical expertise in treating complex neurosurgical problems. Initially my focus was treating cerebrovascular diseases such as aneurysms, AVMs, cavernous malformations and Moyamoya disease. This focus required me to develop bypass skills through seeking hands-on courses, believing in my abilities, and taking on cases that were previously sent out of the Kaiser system. As endovascular neurosurgery replaced open vascular, I expanded my practice in pituitary and skull base surgery and awake mapping for intrinsic tumors. In my new setting at Cottage, I am developing neurosurgical oncology and surgical epilepsy programs, in conjunction with the USC Epilepsy Consortium, to serve Santa Barbara and surrounding communities. Mastering microneurosurgery skills and embracing new technology has allowed me to take on challenging tumors, including recently a rare third ventricular meningioma. I enjoy performing challenging neurosurgical cases and being part of a tradition of neurosurgeons pushing the envelope in neurosurgical care.

Opportunity, mentorship, and sponsorship are what have enabled me to excel in neurosurgery and for the individuals who have been those mentors and sponsors I am eternally grateful. Let us hope that those who seek to support and promote diversity in our field have a greater presence and voice than those who deny that bias still exists.

Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

Editor

Changing Times - The Beauty of America

I decided to become a surgeon when I was thirteen years old. I also decided to do my training in the United States. It was an ambitious goal for a teenager living in Damascus, Syria, and receiving his education in French. I should also mention that my command of the English language, which I learned from a French teacher, was very limited.

I needed to learn everything about America. Fortunately, I had access to the American Cultural Center in Damascus. It was located a walking distance from my home. It was there where I first learned about William Faulkner, Ernest Hemingway, Mark Twain, Robert Frost, F. Scott Fitzgerald, Harper Lee, and many more American writers. It was also there where I learned about the abundance in this incredibly affluent Country. And it was there where I learned about the natural beauty of this amazing Country. I couldn’t get enough books about the National Parks and about what, to me growing up under a strict dictatorship, was a description of an absolute personal Freedom, an alien concept.

In this essay, I will concentrate on the beauty of my adopted home.

Well, to start, it is even more beautiful than I remember from the various books I read in Damascus …

I recall vividly my first trip to Yosemite National Park, which remains my absolute favorite National Park. I was awe struck. This was in the early 1980s. I was still writing letters, longhand, to my father who was still living in Damascus, to share with him my experiences in America. I was stumped, as I couldn’t find a way to describe the breathtaking beauty of this place … but finally I referred him to “Genesis” and the Bible, where God created the whole universe and its inhabitants in six days and rested on the seventh. In my own version, God, in any of the six days, was partial to one creation amongst his many, so he kept it for himself. On the seventh day and before he rested, he decided to put all six of his most favorite creations in a magical place we call Yosemite: Half Dome, El Capitan, Amazing Waterfalls, Giant Sequoia Groves, Tuolumne Meadows …

And, since that magical visit, everywhere I go, I discover more Beauty …

I will never forget sitting on the steps of the US Capitol on July 4, 1974, with my bride and parents who were visiting us from Syria, listening to the President’s – then Gerald Ford – Own Marine Band playing patriotic music and eventually watching the fireworks – I had never seen fireworks in Syria.

Fireworks burst on the National Mall

I’ve been fortunate to live in Ventura since 1981, where I can walk on the beach of the amazing Pacific Ocean with its changing colors and moods, almost every day; it is better than therapy. And where the hills that are usually green in the late winter and spring, turn mustard color and eventually display a golden hue as summer progresses; some say that our state is called the Golden State because of the golden color of its hills, not because of the discovery of gold in 1849.

I love the explosion of purple and green that our many Jacaranda trees display for most of the spring; I have always admired Kate Sessions who introduced these beautiful trees to Southern California. Please see Photo of the month.

Kate Sessions Statue in Balboa Park

And I look forward to seeing the graceful and expressive Matilija poppies when they bloom; I think of them as “typical Ventura.”

I am not eloquent or capable enough to include many of America’s “beauties” in one essay, but we are fortunate to have had a poet who was able to do just that: Katharine Lee Bates. Her iconic poem initially titled “Twin Peaks” is now “America the Beautiful!”

Below is an adaptation from Wikipedia that tell the story of this most patriotic song, as well as its lyrics.

The lyrics of this patriotic and very popular song were written by Katharine Lee Bates and its music was composed by church organist and choirmaster Samuel A. Ward at Grace Episcopal Church in Newark, New Jersey.

Bates wrote the words as a poem originally entitled “Pikes Peak”. It was first published in the Fourth of July 1895 edition of the church periodical, The Congregationalist. It was at that time that the poem was first entitled “America”.

Ward had initially composed the song’s melody in 1882 to accompany lyrics to “Materna”, basis of the hymn, “O Mother dear, Jerusalem“, though the hymn was not first published until 1892. The combination of Ward’s melody and Bates’s poem was first entitled “America the Beautiful” in 1910. The song is one of the most popular of the many U.S. patriotic songs.

In 1893, at the age of 33, Bates, an English professor at Wellesley College, had taken a train trip to Colorado Springs, Colorado, to teach at Colorado College. Several of the sights on her trip inspired her, and they found their way into her poem, including the World’s Columbian Exposition in Chicago, the “White City” with its promise of the future contained within its gleaming white buildings; the wheat fields of America’s heartland Kansas, through which her train was riding on July 16; and the majestic view of the Great Plains from high atop Pikes Peak.

On the pinnacle of that mountain, the words of the poem started to come to her, and she wrote them down upon returning to her hotel room at the original Antlers Hotel. The poem was initially published two years later in The Congregationalist to commemorate the Fourth of July. It quickly caught the public’s fancy.

hymn tune composed in 1882 by Samuel A. Ward, the organist and choir director at Grace Church, Newark, was generally considered the best music as early as 1910 and is still the popular tune today. Just as Bates had been inspired to write her poem, Ward, too, was inspired. The tune came to him while he was on a ferryboat trip from Coney Island back to his home in New York City after a leisurely summer day and he immediately wrote it down. He composed the tune for the old hymn “O Mother Dear, Jerusalem”, retitling the work “Materna”.

Ward’s music combined with Bates’s poem were first published together in 1910 and titled “America the Beautiful”.

O beautiful for spacious skies,
For amber waves of grain,
For purple mountain majesties
Above the fruited plain!
America! America!
God shed His grace on thee
And crown thy good with brotherhood
From sea to shining sea!

O beautiful for pilgrim feet,
Whose stern, impassioned stress
A thoroughfare for freedom beat
Across the wilderness!
America! America!
God mend thine every flaw,
Confirm thy soul in self-control,
Thy liberty in law!

O beautiful for heroes proved
In liberating strife,
Who more than self their country loved
And mercy more than life!
America! America!
May God thy gold refine,
Till all success be nobleness,
And every gain divine!

O beautiful for patriot dream
That sees beyond the years
Thine alabaster cities gleam
Undimmed by human tears!
America! America!
God shed His grace on thee
And crown thy good with brotherhood
From sea to shining sea!

Yes, the beauty of America is endless. I am so fortunate to live here!

Photo of the Month

Photo of the Month

Jacaranda Mimosifolia- Blue Jacaranda Photo Taken by Moustapha AbouSamra, i-Phone X Ventura, CA, May 4, 2022, 3:01PM

Native to subtropical Argentina and Brazil, Jacaranda Mimosifolia is one of about 49 species of Jacaranda trees. It was introduced to San Diego and eventually Southern California by Kate Sessions, the horticulturist and creator of Balboa Park.

Kate Session, a native of the San Francisco Bay Area was amongst the first women to graduate From UC Berkley with a degree in Natural Science; she also went to business school. She is credited with introducing many exotic plants/seeds to Southern California that have now become typical of the charming and beautiful landscape of our area. Some say 183 species including: jacaranda, bougainvillea, birds of paradise, yellow oleander, and star jasmine.

Jacarandas are one of my favorite trees and they are abundant in Ventura. They bloom in May and again in the Fall. Their blooms last a long time, but they are beautifully messy.

Deborah C. Henry, M.D.

Deborah C. Henry, M.D.

Morality & Legality

Brain Waves

Sometimes on those rare no traffic days when I am waiting for the green left turn arrow to appear at the entrance to my housing complex, I contemplate the difference between morality and legality. Morally, what is wrong with me turning on red when the nearest car is nowhere in sight? Legally, it’s just illegal. So I wait, idling, adding to the carbon waste in the atmosphere. One could even rationalize that it is my moral obligation to help prevent climate change by driving a minute less by turning on red. But still I wait.

I see abortion rights in Roe vs. Wade and now the Dobbs vs. Jackson case as a moral issue, not a legal one. What my moral concerns are regarding abortion are not necessarily another’s. Abortion will always happen whether it is legal or not because morally we feel different about it and that’s okay. However, it is an equity issue. Those with money can find a place to have a safe abortion. Those without the means may not and then death or infertility could result. This inequity is true of all medical care.

Having a Supreme Court that makes decisions based on their morality and not precedent legality also has unforeseen consequences. According to the LA Times, July 18, the number of women opting for sterilization procedures especially in Arizona, Texas, Florida, and North Carolina has increased. Many of these women are in their twenties. Here the morality and legality issues fall on our Ob-Gyn colleagues. Though it is currently legal to offer sterilization and even forced sterilization (in 31 states), is this the moral way to go for many doctors? Current sterilization procedures for women involve removal of both fallopian tubes, leaving no chance for reversal. And because of the Supreme Court’s moral decision, is now this the alternative to selective abortion-to decide it is better to never be able to have a child?

Universities are also feeling the pain of this decision. The following day, the LA TImes reported on how academic researchers and university faculty (especially women) are no longer looking for jobs in states where abortion is illegal. One woman reported she takes methotrexate for her rheumatoid arthritis. She did not want to be in a state where she encountered difficulty obtaining a drug that is also used to treat ectopic pregnancies. Women applying to colleges are also trimming from their lists schools that are in antiabortion states. Many women implied that they would not want to raise their children in states that promote the exclusion of others.

Neurosurgery is not immune to moral versus legal decisions. Anencephaly, meningomyelocele, persistent vegetative state, recurrent glioblastoma-as neurosurgeons, we are constantly weighing our own morality with the rules of society. Often, we need to remind ourselves that it is the patient that we are treating and not the disease or ourselves. Where one of us may feel morally obligated to evacuate a huge intracerebral hematoma on the slight chance of survival, another of us may feel obligated not to do the surgery as any slight chance of survival will not result in any quality of life. We make these beginning of life and end of life decisions based on our morality, our experiences, and the desires of the family. Sometimes we make these decisions because there is no family, and we do what is most legally acceptable.

Our moral compass is a part of who we are as a physician. Like how individuals view abortion, one physician’s moral views are not the same as the physician next door. As doctors, we must have the ability to say yes or no to what we feel is morally acceptable treatment. With this Supreme Court decision to make abortion a legal and not moral issue, who is to say the next step is the Supreme Court preventing morphine drips in terminal care? After all, Clarence Thomas commented that banning contraception was next on his to-do list. Who would ever think we’d come to debating contraception in this country? Medical moral decisions should be left to the patient and their healthcare provider. Keep the legal decisions to the fact that I cannot turn left on red, even if there are no cars.

CMA

CMA

Assembly Health Committee Advances CMA Sponsored Prior Authorization Bill

A California Medical Association (CMA) bill to reduce prior authorization red tape has passed out of the Assembly Health Committee. This bill—SB 250 authored by Senator Richard Pan, M.D.—will allow physicians to spend less time on paperwork and billing and will allow patients to get the care they need without unnecessary delays.
SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan’s criteria 80% of the time. All other physicians will have the right under the bill for a prior authorization appeal to be conducted by a physician in the same or similar specialty.

“Insurance company prior authorization red tape creates serious and dangerous delays in care for many California patients,” says CMA President Robert E. Wailes, M.D. “We thank the Assembly Health Committee for passing SB 250 and bringing us one step closer to streamlining prior authorization requirements and minimizing delays or disruptions so that patients get the care they need when they need it.”

The bill now heads to the Assembly Appropriations Committee.

Share Your Prior Authorization Stories
CMA is asking you to share your unique experience as a patient, physician or health care professional so that we can demonstrate to lawmakers how prior authorization policies are harming patients.

If you have waited days or months for an insurance company to approve a medicine prescribed by your doctor, we want to hear from you. If you are a physician frustrated with the administrative headaches and their impact on your patient, we want to know your story.

CMA asks CIGNA to rescind burdensome modifier 25 policy

The California Medical Association (CMA) is urging Cigna to rescind its recently announced policy that would require the submission of medical records with all Evaluation and Management (E/M) claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. This change effectively penalizes physicians for providing efficient, unscheduled care to Cigna enrollees.
Cigna’s policy change would result in significant, unnecessary administrative burden and compliance cost to physician practices, would disincentivize physicians from providing unscheduled services and would create duplicate requests thus wasting health care dollars. The policy also lacks clarity on product types impacted, is inconsistent with industry standards and CMS guidance, and appears to violate California law.

CMA recently sent a letter outlining these concerns in detail and has asked the payor to rescind the policy before the August 13, 2022, effective date.

The new Cigna policy is overly broad, requiring all physicians billing for office visit codes 99212-99215 with modifier -25 and a minor procedure code to submit medical records as a precondition for payment. This creates yet another unnecessary administrative burden on physicians that are using the modifier appropriately.

CMA believes a more collaborative approach to identify alternative methodologies for cost containment—including provider education on proper coding practices that do not bluntly penalize physicians using the modifier appropriately—will prove more effective and less costly in the long term.

Practices with questions regarding this policy update can contact Cigna Customer Service at (800) 88Cigna

(882-4462).

Cigna to reevaluate burdensome modifier 25 policy
CMA has learned that Cigna will delay implementation of its recently announced policy to require the submission of medical records with all Evaluation and Management claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. CMA had serious concerns with Cigna’s policy change as it would result in significant, unnecessary administrative burden.

CMA had serious concerns with Cigna’s policy change as it would result in significant, unnecessary administrative burden and compliance cost to physician practices, would disincentivize physicians from providing unscheduled services and would create duplicate requests thus wasting health care dollars. The policy also lacks clarity on product types impacted, is inconsistent with industry standards and CMS guidance, and appears to violate California law.

CMA and the American Medical Association reached out to Cigna regarding these serious concerns and urged the payor to rescind the policy. Due to this advocacy, Cigna has delayed implementation and the policy is under additional review. The reimbursement policy update therefore will not go into effect on August 13, 2022, as originally scheduled.

CMA believes a more collaborative approach to identify alternative methodologies for cost containment—including provider education on proper coding practices that do not bluntly penalize physicians using the modifier appropriately—will prove more effective and less costly in the long term. We will continue to work with Cigna to address our concerns and will provide updates as more information becomes available.

CMA urges CA Supreme Court to review ruling that could destabilize the health care marketplace
CMA recently submitted an amicus curiae letter with the California Supreme Court in support of a petition for review of an appellate court decision that if allowed to stand would create a significant gap in managed care regulation that ultimately could destabilize the health care marketplace.
In this case, County of Santa Clara v. Doctors Medical Center of Modesto, et al., an appeals court ruled that Santa Clara County—through Valley Health Plan its county-based Knox-Keene licensed health plan—is immune from common law reimbursement claims under public entity immunity in the Government Code.
While Santa Clara County is required to reimburse emergency services at the “usual, customary and reasonable” (UCR) amount under the California Health & Safety Code, the appeals court determined Santa Clara County is vested with discretion to determine the UCR amount.
The appellate court’s opinion insulates Valley Health Plan from civil liability for violating the Knox-Keene Act’s requirement for reasonable reimbursement for emergency care.
The ruling unjustifiably eliminates any accountability or responsibility of county health plans to fairly reimburse providers of emergency care. The disruption and uncertainty that will result if this ruling is allowed to stand could also impair patients’ access to care as more providers abandon the managed care market.
This ruling would disproportionately affect the neediest patients, as 95% of county-based health plan enrollment is Medi-Cal beneficiaries participating in Medi-Cal managed care. This is an underserved population that cannot afford to pay out-of-pocket for medically necessary services.
“There is no material distinction between Knox-Keene plans offered by a county, like Valley Health Plan, and those offered by commercial corporations. All licensed, full-service health plans must be subject to the same requirements under the Knox-Keene Act,” the CMA letter said. “To allow otherwise would create a patchwork of provider networks and service levels. That sort of uncertainty would threaten the financial viability of the managed care system, to the detriment of patients.”

CMA board chair issues statement in support of Prop. 1 to enshrine the right to reproductive freedom in CA
Shannon Udovic-Constant, M.D., Chair of the CMA Board of Trustees, issued a statement in support of California’s Proposition 1.
“The California Medical Association (CMA), representing the physicians of California, is proud to support Proposition 1, which will place a constitutional amendment on the November ballot to enshrine an individual’s right to reproductive freedom.
California has a long history of protecting and defending reproductive health care rights, and by reaffirming our basic and fundamental principle that women should be able to get the health care they need, our state is once again leading the way.
CMA strongly believes that medical decisions – including those around abortion and contraception – should be made by patients in consultation with their health care providers.
Passage of Proposition 1 will send the strongest possible message that reproductive freedom is a fundamental human right that will be protected in California with the fullest force of the law.”

Letter from CMA President
Dear CMA member,
On June 24, the U.S. Supreme Court overturned nearly a half century of precedent protecting patients’ rights to critical reproductive health care. While we had expected the decision, it did not lessen the blow.
The decision in Dobbs v. Jackson Women’s Health Organization is a direct assault on the practice of medicine and the patient-physician relationship and represents a dangerous intrusion of government into the medical examination room.
In response to the decision, California leaders worked quickly by placing Proposition 1 on the November 2022 ballot to explicitly enshrine the right to abortion and contraception in the state constitution through a vote of the people.
The California Medical Association (CMA) Board of Trustees voted to support Proposition 1 and we are a leading proponent of the initiative.
While abortion remains legal in California, one of the many difficult impacts of the Dobbs decision is the uncertainty and confusion it has created, even here in our state. California remains a sanctuary for people seeking abortion care and we are already seeing an influx of patients from states with abortion bans seeking care here. Additionally, there are now many states where medical residents cannot receive training in abortion care. CMA intends to be at the table to help answer questions around training out-of-state residents and how California physicians can help care for patients from states with abortion bans if those patients travel to California.
Fortunately, California has already begun to expand its abortion network to ensure equitable access to abortion services and protect reproductive health care providers. California started preparing for this possibility before the Dobbs decision was issued. CMA was proud to participate in the Future of Abortion Council and to support measures that came out of that work, including:

• AB 1242 (Bauer-Kahan, Bonta and Garcia) to create a comprehensive framework of civil and criminal protections to protect abortion providers and patients seeking abortion care
• AB 2626 (Calderon) to ensure abortion providers can obtain professional liability coverage
• AB 1918 (Petrie-Norris) to create a California Reproductive Service Corps in the Department of Health Care Access and Information, meant to recruit, train and retain more reproductive health providers


Additionally, CMA supported a $200 million investment into reproductive health, access and justice in the 2022-23 state budget, including:


• Over $40 million to increase the reproductive health care workforce, including scholarships and loan repayments for health care providers that commit to providing reproductive health care services
• $40 million to reimburse health care providers for uncompensated care provided to low- and moderate-income individuals who do not have health care coverage for abortion services
• $20 million for targeted recruitment and retention resources and training programs for health care providers who serve patients at a facility that provides reproductive health care


As California’s physicians, our voice is very important in this fight. And we have heard from many CMA members who stand committed to protecting the fundamental human right to access reproductive health services and ending this governmental interference in the practice of medicine.
CMA has long advocated for unencumbered access to reproductive health services and strongly believes that all personal medical decisions—including those around abortion—should be made by patients in consultation with their health care providers. In addition to continuing this advocacy, we are also working to develop resources that will help physicians understand and navigate the aftermath of the Dobbs decision.
Stay tuned in the coming weeks for more information, including what you can do to support your physician colleagues across the country who are grappling with the realities of the Dobbs decision. In the meantime, if you have questions, please feel free to reach out to our CMA member service center at (800) 786-4262 or email memberservice@cmadocs.org.
Best wishes for a healthy future,
Robert E. Wailes, M.D.
President, California Medical Association

Urgent Survey: CMA needs your help to advocate for better Medicare payments

Since 2001, inflation has increased by 40%, yet physician Medicare payments have only increased by 7%. Today’s Medicare payments on average lag 40% behind the cost of providing care. While hospital and nursing home payments are indexed to inflation (and as a result have increased by 60% since 2001), the broken physician payment system has burdened physicians with an uphill fight just to stop statutory and budget neutrality payment cuts year after year.

The California Medical Association (CMA) and the American Medical Association (AMA) are launching a major advocacy campaign in Congress to reform the Medicare physician payment system by implementing an annual inflation adjustment. You can help us be more effective in our advocacy efforts by taking this brief 3-minute survey about the status of your practice and access to care in your community. Click here to take the survey by August 2.

James E Boggan, MD

James E Boggan, MD

History of Neurological Surgery at the University of California, Davis

Kia Shahlaie, MD, PhD

Kia Shahlaie, MD, PhD

Historical Vignette

In 1966, C. John Tupper M.D., the founding Dean at the University of California, Davis School of Medicine, recruited Julian R. Youmans, M.D., Ph.D. from the Medical University of South Carolina (MUSC), as his eighth faculty member. At the time, Julian was the youngest Chairperson in Neurological Surgery and newly funded by the National Institutes of Health (NIH) to pursue a cerebrovascular research project. Dr. Youmans was promised a role in the design of the university hospital, state of the art research facilities, and support to build a strong referral-based clinical program. When Dr. Youmans arrived, he found that the department did not have assigned research space and federal budgetary constraints would not allow transfer of his new NIH grant to Davis. Unperturbed, Dr. Youmans decided he would write a comprehensive text on neurological surgery. When Youmans’ Neurological Surgery was released in 1973, it immediately became the definitive reference for neurosurgery training and practice.

Glen W. Kindt, MD, who like Julian completed neurosurgery training at the University of Michigan and had also moved from MUSC, rounded out the initial academic faculty. They provided neurosurgical care at the county hospital, covering emergencies with local volunteer faculty and general surgery residents. The Department began hiring “fellows in neurosurgery” to assist the faculty until a residency program was established in 1970. Since January of 2020, UCD has been ACGME approved for two residents per year and offers fellowships in endovascular, spine, skull base, and functional neurosurgery, and a UCNS-approved fellowship in neurocritical care. An NIH sponsored R25 training program provides support for residents interested in academic careers.

The School of Medicine started its clinical program at the County Hospital, Sacramento Medical Center in 1966, purchasing the hospital for $1 in 1973. It gradually expanded to establish a state-of-the-art medical center that had the first clinical CT brain scanner (1975) in the University of California system. The University of California, Davis Medical Center is a now a sprawling 142-acre campus comprised of 29 buildings on 142 acres. The main hospital is a 625-bed tertiary academic medical center that serves a catchment area of 6 million people in 33 counties. UCDMC is recognized by the American College of Surgeons as a Level 1Trauma Center for both adult and pediatric patients. It has intra-operative and ICU MRI and CT scanners and a dedicated 10-bed neurosurgical intensive care unit.

At present, the Department is composed of 15 clinician-scientists, 4 research scientists, and 6 joint appointees. In the clinical arena, all subspecialties are well covered, from intra-uterine fetal surgery to those addressing geriatric functional disorders. All basic scientists are extramurally funded, as are most of the clinical faculty and two of the professor emeriti who maintain active research projects. The Department has been honored with two endowed chairs. There have been five Chairpersons of the Department: Julian R. Youmans, M.D., Ph.D., Franklin C. Wagner, M.D., J. Paul Muizelaar, M.D., Ph.D., James E. Boggan, M.D., and Griffith R. Harsh IV, M.D., M.B.A.

 

CMS Publishes Program Year 2021 Open Payments Data

CMS

Applicable manufacturers and Group Purchasing Organizations (GPOs) collectively reported $10.90 billion publishable payments and ownership and investment interests to covered recipients in Program Year 2021. Program Year 2021 includes payments or transfers of value made between January 1, 2021 and December 31, 2021, and is the inaugural year for the Open Payments program expansion mandated by the SUPPORT Act.

Today, the Centers for Medicare & Medicaid Services (CMS) published Open Payments Program Year 2021 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 physicians, physician assistants, advanced practice nurses, and teaching hospitals available to the public. Through this program, the public has access to a transparent and accountable healthcare system.

Program Year 2021 Highlights
Program Year 2021 is the inaugural year for the Open Payments program expansion, put into place under the SUPPORT Act of 2018. Beginning with Program Year 2021 the Open Payments definition of a “covered recipient” is expanded to include: physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, anesthesiologist assistants and certified nurse midwives.

For Program Year 2021, CMS published $10.90 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 12.10 million total records attributable to 533,056 physicians, 233,471 non-physician practitioners and 1,237 teaching hospitals.

Payments are reported across three categories: general payments, research payments, and ownership or investment interests. The dollar value in each of the three major reporting categories for Program Year 2021 are:
• $2.55 billion in general (i.e., non-research related) payments
• $7.09 billion in research payments
• $1.26 billion of ownership or investment interests held by physicians or their immediate family members

The Program Year 2021 data publication is the first Open Payments data publication that includes data about physician assistants and advanced practice nurses. Due to the program expansion and inclusion of these provider types as covered recipients the amount of data increased noticeably when compared to prior program years. However, the ratio of payment trends remains the same with the highest dollar value of the data being in research payments, and the largest number of records being in the general payment category.

Also, if the newly added covered recipients are removed from the Program Year 2021 data, the dollar value of the data as well as the number of records remains on par with previous program years, therefore we can attribute the noticeable increases in the data to the addition of the physician assistants and advanced practice nurses. Open Payments also considers the impact of the COVID-19 pandemic as reasoning to the decrease in amount of data for Program Year 2020. While there are lingering results from the global pandemic, the Program Year 2021 data may indicate a return to normal data trends for purposes of the Open Payments program.

The Open Payments data will be refreshed in early 2023 to reflect any updates made to the data since this publication.

For more information and resources, please visit: https://www.cms.gov/openPayments

Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSGov.

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Brian R. Gantwerker, MD, FAANS, FACS

Brian R. Gantwerker, MD, FAANS, FACS

The Price of Independence

“Life without liberty is like a body without a spirit.” ~Khalil Gibran

Private Practice Corner

With the majority of neurosurgeons in the country now employed, the feasibility of remaining in independent practice has been questioned. Currently, a high percentage of neurosurgeons in the major cities of California are employed. When I go to meetings in other parts of the country, I get looks ranging from confusion to out and out disbelief when I mention that I am in independent practice.

When I decided to leave my first job, as about 50% of us do, I had to take stock of my skill set. I had never owned a business, no MBA, zero contacts when it came to an accountant, a bookkeeper, or a business banker. My wife assented to start it with me, as she had experience running an oral surgery practice when she was younger, but had not done so in almost ten years. It was daunting, perhaps foolish – certainly against the prevailing currents.

I did not anticipate the wave that was to come: practices selling themselves to large corporations and in some cases to insurance companies. The ensuing tsunami has been a giant shudder and has shaken loose the very foundation of what came before.

During my residency, we had several surgeons who in the 1990s had closed their private practice and joined larger academic departments. Two of them in particular, Drs. Benedict Colombi (of blessed memory) and Matt Likavec became my mentors. Teachers in not only how to do surgery in the operating room, but how to function as an ethical physician. During longer surgeries, they would regale me with stories of when giants walked the earth, of when remuneration was good and reverence for doctors was at an all-time high.

I guess it was there that I got the bug. I dreamed of not working for anyone else, of choosing what I did instead of being “voluntold” of what I would do. Or maybe it was years before, my grandfather (also of blessed memory) had broken away from Mutual of Omaha, despite being named to the President’s Club and having Marlon Perkins of the nature show “Wild Kingdom” (the show was largely supported by the insurance company) leave my grandparents’ answering machine greeting message.

My independence became more and more precious to me as training progressed and I saw what could be, of how well patient care could be done. Churning through clinic at the speed of light nagged at me. Inevitably, patient questions went unaddressed, sometimes something very subtle got missed in everyone’s clinic that could later transmogrify into a rip-roaring infection or some other major issues.

To me, the independence meant taking time with the patients, really assessing if something I did worked, and what it really looked like as patients went through their very unique recovery periods. Some of my colleagues would brag about seeing forty or more patients per day. They got paid really well. The price tag of their being sent to various outlying clinics and told what operations they need to do, even outside their comfort level, was too dear.

Independence in medicine might look differently to each of us. For some, it is the funding and support to do research projects or the ability to innovate and sell designs to companies unmolested by your parent

institutions. For me, it was to practice the way I wanted to. To say “no” to certain cases, and to spend extra time with patients who needed it.

It does cost. Financial stability at times is iffy. Mastering a revenue cycle’s ups and downs is akin to riding a methamphetamine charged bull. Stress (the bad kind) is also plentiful; physical activity becomes paramount to stress management. Business opportunities may come up, in which you just don’t have the capital to get involved. Consulting opportunities may also pass you by, in favor of the academics in your community. The kind of notoriety that may come from the “rockstar” surgeons may be out of reach, due to lack of a large brand name institution footing the marketing bill.

Independence in neurosurgery is changing. It may be that the halcyon days of when the apex neurosurgical predators roamed the earth are gone. And in many cases, maybe that is for the best. Instead, it has evolved. So, it may look and sound different, but at its core, there is nothing more fulfilling than hanging your own shingle and truly practicing the way you want to and delivering the best care only you can.

News from the Washington Committee-AANS/CNS

Washington Committee

Neurosurgeons Announce Principles for Reforming the Medicare Physician Payment System

On May 25, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) endorsed principles for reforming the Medicare physician payment system. In collaboration with the American Medical Association, the 120 state and national medical societies developed “Characteristics of a Rational Medicare Payment System,” which outlines a unified set of shared goals for improving the current system.

Subsequently, the AANS and the CNS issued a press release announcing support for the unified goals. “The current Medicare physician payment system is on life support and needs an overhaul. We are grateful that Congress has stepped in to mitigate steep cuts over the past few years, but comprehensive reform to reflect practice costs and inflation is needed,” stated John K. Ratliff, MD, FAANS, chair of the AANS/CNS Washington Committee. The AANS and the CNS also lead several coalition efforts, including the Surgical Care Coalition, to prevent steep Medicare payment cuts and preserve patient access to care.

Prior Authorization Legislation Introduced in the House
On June 9, Reps. Michael Burgess, MD, (R-Texas) and Vicente Gonzalez (D-Texas) introduced the Getting Over Lengthy Delays in Care As Required by Doctors Act (GOLD CARD) Act ( H.R. 7995), a bipartisan bill that the AANS and the CNS helped draft. This bill would exempt certain physicians from prior authorization in the Medicare Advantage (MA) program. Specifically, the legislation would exempt providers from prior authorization requirements for one year if the provider had at least 90% of prior authorization requests approved the preceding year.

In announcing the introduction of the legislation, Reps. Burgess and Gonzalez issued a press release featuring John K. Ratliff, MD, FAANS, who stated:

Since most medical services are ultimately approved, the GOLD CARD Act is a commonsense approach to addressing the unnecessary burdens caused by the widespread use of prior authorization. Neurosurgical patients suffer from painful and life-threatening neurologic conditions such as brain tumors, debilitating degenerative spine disorders, stroke and Parkinson’s Disease, and without timely care, they often face permanent neurologic damage and sometimes death. If adopted, Rep. Burgess’ and Gonzalez’s legislation would be a significant step in making sure our seniors get the care they need when they need it, and America’s neurosurgeons are proud to endorse this bill.

Adela Wu, MD.

Adela Wu, MD.

A Tribute

Residents’ Corner

Neurosurgery is a field that exposes us to the breadth of life. I’m sure that any of us, from the intern to the senior attending, can tell somber stories of tragedies – devastating traumatic injuries, children diagnosed with brain cancer, strokes without meaningful recovery beyond the “last known normal”, and more. I’ve often wondered how our patients and their families can deal with their injuries and illnesses. Neurosurgical diseases can literally change people’s lives. Where did they find their courage when these terrible things happened?

Nothing prepared me to hear bad news about my good friend Steve. A few months ago, he passed away from a rare cancer. When he was diagnosed, the disease had already spread throughout his body. He had a nagging shoulder pain that didn’t improve with medications or physical therapy, prompting imaging that revealed the terrible truth, an ugly bone-eating tumor. I was close with his family – his sister-in-law is one of my best friends from medical school, and she told me that he also had another tumor encasing his vertebral artery and another growing within his femur. He was swiftly booked for hip surgery to prophylactically stabilize the weakened bone. It was his first step out of many in a short and challenging journey.

When I first heard about what happened, my brain switched on its sympathetic system mode. Even though I encountered disease and disability nearly every day while at work, this was personal and unexpected. Before the diagnosis, the last time I saw Steve was when he attended my and my best friend’s medical school graduation. He was excited about his new job teaching computer science at that time. He and his wife also just celebrated their wedding anniversary that weekend, and my mom gifted them a pair of lovely crystal swans. Then, even though I was moving across the country to start residency, I cheerfully bid them goodbye, thinking for sure that I would see them again soon for another afternoon of board games or banter around a homecooked meal seasoned with peppers from their own container garden.

In the classic Illness as Metaphor, Susan Sontag writes, “Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and the kingdom of the sick.” I didn’t realize that humid June afternoon four years ago was my last recollection of Steve’s “last known normal” before he received his cancer diagnosis and entered the realm of serious illness. For the most part, his wife Bonnie kept us updated about Steve’s journey through these kingdoms by email. Before he embarked on an experimental treatment that involved radioactive medication and required him to stay in a leaded hospital room, I visited them in Maryland last summer. He was much thinner and preferred sitting rather than his usual energetic pace setting up the latest tabletop game or jigsaw puzzle for everyone to play. The coffee table was stacked with pill bottles and Bonnie’s carefully annotated calendar agendas about Steve’s medication regimen and doctors’ appointments. I could see exhaustion etched on Steve’s face and Bonnie’s anxiety and anticipatory grief shadowing hers. Those were just the most basic of glimpses I had into the night-side of life. His illness had constructed a glass sheet I was initially afraid of stepping around. From some of the difficult conversations I held in the hospital, I knew that patients and people didn’t like hearing apologies laced with pity (empty “I’m sorry’s”) or some other weak expressions of sympathy and sorrow. So, we talked about good memories and their small but mighty hopes for the future.

The cadence of Bonnie’s email updates varied. Sometimes, she sent multiple messages per week. Other times, it would be one or two months in between updates. I particularly enjoyed the ones where they included photos of Steve wearing a Spiderman costume after he completed the radioactive medication. But, when his disease took a turn for the worse, I started dreading seeing the emails arrive in my inbox. I wasn’t sure what news they could contain. I suppose my sympathetic system never truly got accustomed to what was happening to my friends. One of the last messages we received from his family was forebodingly entitled “Steve is in the hospital and wanted us to share this with everyone.” He wrote about new, concerning symptoms that landed him in the emergency department, where two doctors gave him additional information about the spreading cancer and that “[his] questions about time were responded to in hours, not the years and months [he] thought in [his] head.” 

 

In a follow-up message just a few days later, Steve and Bonnie left everyone with a quote that Steve first shared with one of his computer science students: “Courage is not a switch that you just turn on, it’s not something that you decide to be one day. It’s like a muscle you test and work out and build up. There is a test of faith where you choose to take on a challenge that you don’t know how to solve. That jump is a moment of courage that you must force yourself to take.” I will try my best to exercise and practice courage, as should we all aim to, no matter if it is within the scope of our work as doctors taking care of others or, throughout life, for ourselves. 

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Anthony DiGiorgio, D.O.

Anthony DiGiorgio, D.O.

Our needed advocacy

Academic Surgeons’ Corner

We neurosurgeons love to complain. Come in to my OR and you will hear me complain about the instruments and how I work too much. However, what really gets me up in arms, really stokes my ire, is when patients lack access to care.

That is what neurosurgeons really complain about. And that is why we need to be involved in administration and advocacy.

The issues that matter to organized neurosurgery, such as prior authorization reform, stopping Medicare pay cuts, fixing surprise billing or broadening telehealth are about access to care. Neurosurgeons cannot care for patients if they are stuck behind a computer or can’t pay overhead costs. They cannot care for patients if they are over-regulated and under paid. They can’t care for patients if telehealth rules won’t allow care across state lines.

The Neurosurgery DC office recently tweeted the importance of advocacy and neurosurgeon Sarah Woodrow wrote about it on the neurosurgery blog. I wanted to use this space to emphasize that message.
As healthcare providers, neurosurgeons have an outsized voice in policy. Legislators and think tanks listen to us. Our op-eds are well received and reach readers who matter. We tend to write often and write well.
Most of all, we know what policies impede our patients’ access to care. We recognize that administrative burdens are leading to burnout and not enhancing the efficiency of care. We see neurosurgeons retire or reduce their publicly funded patients rather than operate at a financial loss.

Neurosurgeons are needed in advocacy and administration to ensure policies facilitate access to care. Among the many things I learned in residency, I learned that complaining to the ether accomplished little. We must show up to meetings, support our advocacy groups and generally make noise.

One need not write policy, join a think tank, or run for congress. Simply joining CANS, CMA and AMA helps. California’s delegates to the Council of State Neurosurgery Societies are determined by our CANS membership. The California Medical Association has strong representation by neurosurgeons, with members on various councils and on the Board of Trustees. The neurosurgery delegation to the AMA is determined by our AMA membership. The more delegates, the bigger the voice. Donating to the Neurosurgery PAC is encouraged, as well.

Health services research is important as well. For residents and medical students, these can be some highly impactful papers. Policies should be investigated with the same rigor that accompany a new surgical technique or medication. Even though Mark Twain would put those statistics in with the “damn lies,” they do make a compelling case in discussions of administration.
Rightfully or not, we have an outsized voice in policy matters. Neurosurgeons need to stop complaining and start advocating.

Omid R. Hariri, D.O. and Shivum Desai, MS IV

Omid R. Hariri, D.O. and Shivum Desai, MS IV

Sub-Internship. A different Kind of Neurosurgery?

Large Group

Medical Student Director perspective:


A sub-internship at Kaiser Anaheim Medical Center can provide medical students with a special opportunity to push the limits of their education and practice supervised medicine with a degree of autonomy that is typically only experienced by first year residents. Such an opportunity is available only to students who go through a rigorous selection process, which includes evaluation of their grade point average, board scores, letters of recommendation, and a formal phone interview. Such stringent
evaluation is undertaken to ensure only those students who are ready for the rigors of a neurosurgery sub-internship are accepted. Yet, the goal of such high acceptance standards is not meant to exclude students who may not be as academically inclined as others, rather it is to establish a standard so residency programs can use a student’s rotation at Kaiser Anaheim as a method of evaluation.

For those students who are selected to participate in a sub-internship, the opportunity is often foundational to their education. With 7 attending neurosurgeons, 4 advanced practice providers, and 1 chief neurosurgery resident on staff, medical students have the opportunity to learn neurosurgical practice from various perspectives and levels of education. This is a different approach of teaching compared to the more traditional method from junior residents. For attending neurosurgeons, this opportunity allows us to influence medical education at its earliest stages. Often, the foundations of neurosurgery are not laid until early in residency, but the opportunity to train third and fourth medical students not only helps provide attending surgeons with a sense of contribution to those in their earliest stages of medical education, but also helps to refresh more senior neurosurgeons on unique information that may have been long forgotten, providing an opportunity for full circle education.

Supervised autonomy is key to the educational environment at Kaiser Anaheim. To become an efficient and capable surgeon, confidence is of utmost importance. Thus, we focus on providing an environment where students can round on their own patients, write independent supervised notes, and develop diagnosis with plans, which they then present to the chief resident on a daily basis. As a result, the independence that PGY-1 residents quickly feel upon their first day of residency, is readily understood by students much earlier in their career. The objective of providing such autonomy is multifold and includes providing students the ability to critically think on their own, develop their physical exam skills, and understand the weight which comes with practicing medicine independently in a time-efficient manner.

Lastly, the case volume and operating experience greatly prepares students for future upcoming rotations and residency. Unlike most neurosurgical rotations in residency-based programs, at Kaiser Anaheim students have the opportunity to scrub into any and all surgeries, which take place daily. At most programs, due to the number of junior residents present, students are often unable to participate in surgeries or not able to scrub in at all. Fortunately, due to the presence of only one chief resident in our department, participation by students is greatly encouraged and they often finish their rotation not only knowing the steps to many common surgeries, but with the technical skills and knowledge commonly held by junior residents. The goal is to reward hard floor work, by providing maximal operating room education.

Overall, the goal of a sub-internship rotation at Kaiser Anaheim is to fully prepare students for their fourth-year audition rotations and residency. To become an efficient and capable surgeon, confidence is of utmost

importance. Thus, we focus on providing an environment where students can develop their medical and surgical knowledge, physical exam skills, and medical decision-making abilities. As a result, the benefits of this rotation are multifold and aim to provide a superior educational experience to those students dedicated to pursuing a career in neurosurgery.

Medical Student Perspective:

From the perspective of a medical student, the neurosurgical education at Kaiser Anaheim can be described as nothin

g less than exemplary. There are many different components that contribute to such an incredible learning experience, but at that top of the list is the unique lack of a traditional residency hierarchy. At Kaiser Anaheim, medical students can learn directly from a single senior/chief resident, experienced physician assistants, and attending physicians, which is an environment unlike most others. The lack of a traditional residency hierarchy allows students to take over responsibilities which are typically held by junior residents. As a result, students participate greatly in patient care, with a level of supervised autonomy that is rarely seen at hospitals with traditional residency structure. Students have the ability to perform morning rounds and present treatment plans with complete independence on a daily basis. Though this is a deviation from the typical hierarchical structure and course of medical education, this environment helps to place greater responsibility on the shoulders of students. This ultimately helps to facilitate more rapid learning and growth for medical students. Fortunately, for students that are up to the challenge, this experience only helps to accelerate the development of new skills and knowledge. For students who are at a different level in their training, the highly experienced and helpful physician assistants and attendings are always there to teach and help fill in any gaps in knowledge. In the end, this model helps to further medical student’s knowledge through practice and repetition.

Likewise, the surgical experience at Kaiser Anaheim is truly spectacular. Having spent time rotating in neurosurgery at other hospitals, I can easily say that the case load and diversity at Kaiser Anaheim is one of a kind. Students have the opportunity to witness a multitude of cranial and spinal tumor resections, spine oncology, open aneurysm clippings, and treatment of arterio-venous malformations, in addition to more typical neurosurgical cases. Such exposure to a diverse case load not only helps to educate students on the breadth of neurosurgery, but also the many sub-specialties that form the field of neurological surgery and their specific nuances. If the case diversity was not enough, medical students are also provided the opportunity to perform surgical tasks which are frequently reserved for junior residents at more traditional residency-based programs. As a result, students gain surgical skills and knowledge that are years beyond their current level, which only furthers prepares them for future neurosurgical rotations, sub-internship rotations, and residency.

For the medical student rotating in neurosurgery at Kaiser Anaheim Medical Center, the experience is second to none. Though the expectations may be high, the non-traditional structure of this department helps to provide all the pros of learning within a residency format, without any of the cons. Students will be able to function with as much or as little independence as they choose. They are given increasing responsibilities by the chief resident and attending’s as their skills progress, participate heavily in surgery, and learn continuously through both hands-on experiences and weekly didactics provided by the chief resident’s respective residency program. Though it may be atypical, the educational structure at Kaiser Anaheim provides a phenomenal learning experience to any student and fully prepares them to pursue a career in neurosurgery.

Shivum Desai, MS 4

AZCOM, Midwestern University
Misperceptions

Medical Student Essay

I believe I can speak for the general public when I say that the phrase “brain tumor” is almost never regarded with any thoughts other than ominous ones. In fact, throughout most of my life I believed that if a person developed a brain tumor, it meant death was imminent. Thankfully, my knowledge of the subject has grown, and I am now much better informed. However, it was not until I helped care for my first patient with a meningioma that I was able to realize how well these patients are capable of doing after their treatments. Fortunately, I was able to care for a gentleman with such an illness and it was an experience I will remember for many years to come.

It was the third day of my neurosurgery rotation, and my attending asked me to obtain a thorough history and physical from a patient but instructed me to not look at the patient’s imaging, before I spoke to him. I found this odd, but nonetheless proceeded. Throughout my questioning of the patient and his wife, I learned that over the last year their relationship had become very tumultuous. The patient’s wife described that with every passing week, her husband would speak to her less and less, avoid his household responsibilities more and more, and even ignore their young child. Overtime, the patient’s behavior took its toll, and his wife became worried. She asked him to see a psychiatrist, thinking his behavior was due to depression. Yet again, the patient avoided this suggestion and continued on with his progressive personality changes. Eventually, his wife decided that divorce was the only option left and initiated proceedings. Due to the severity of his sister-in-law’s decision, the patient’s brother took him to the doctor where a thorough work up finally revealed his final diagnosis: a right frontal lobe meningioma. However, this patient’s tumor was far from typical. After measurements were taken, his lesion measured nearly 10 cm X 8 cm in size. I was in awe. I simply could not comprehend how such a large mass could exist inside of a person’s head and his only symptoms be personality changes. Fortunately, we took the patient to the operating room soon after his admission and successfully removed his tumor without complications. But the patient was not out of the woods yet, and his long road to recovery was just beginning.

When I rounded on the patient several hours after his operation, I was immediately concerned. His personality changes had worsened, and he was no longer speaking or following commands. I immediately alerted the chief resident who put my mind at ease and informed me that abulia was an expected potential outcome and that he would likely improve with time. Over the next week I checked in on this patient morning and night, constantly concerned that he would never return to his old self. But thankfully, I was wrong.

It was 4:30 am on a Monday morning and I had I just returned to the hospital after having a day off. I walked into the patient’s room and greeted him pleasantly as I always did and to my complete surprise he responded with “Hi.” The moment caught me off guard. I was smiling from ear to ear. He had just spoken his first word in nearly one week and I was fortunate enough to be the one to first hear it. It was an incredible experience to say the least. From that point onwards, I watched him improve daily. Eventually, by the end of his hospital course he was functioning on his own and even having full conservations with me. Caring for this patient was nothing short of a remarkable experience, and though I was happy to eventually see him leave the hospital, I was even happier to see his wife picking him up at the end of his hospital stay.

As someone who had never cared for a brain tumor survivor, nothing could have prepared me for the patient’s symptoms after surgery or during his miraculous recovery. Nonetheless, to have helped care for someone whose life was in shambles due to an unknown illness, to be there to help remove his tumor, and to care for him afterwards as his personality returned, was simply extraordinary. This experience was one I will cherish forever and is yet another reason why I dream of becoming a neurosurgeon.

Tidbits- July

Tidbits

July 4 – We celebrated the 246th anniversary of the adoption of the Declaration of Independence. For a Naturalized American Citizen, knowing the fact of our History is very important, so bear with me:
The Continental Congress adopted the Declaration of Independence while meeting in Philadelphia at the Pennsylvania Statehouse (now Independence Hall) on July 4, 19776. The Congress declared the American colonies free and independent states.

Benjamin Franklin, John Adams, Thomas Jefferson, Roger Sherman, and Robert R. Livingston comprised the committee that drafted the Declaration. Jefferson, regarded as the strongest and most eloquent writer, actually wrote most of the document. The committee and Congress as a whole made a total of 86 changes to Jefferson’s draft. John Hancock signed on July 4th. The rest signed on August 2, 1776.

First two paragraphs of the Declaration of Independence:
“When, in the course of human events, it becomes necessary for one people to dissolve the political bonds which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the laws of nature and of nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

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. That to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed. That whenever any form of government becomes destructive to these ends, it is the right of the people to alter or to abolish it, and to institute new government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.”
Such wise, true, and sweet words: “All men – and women – are created equal, that they are endowed by their Creator with certain unalienable rights …” In fact, I view them as an admonition to do better!

July 5 – Muslims from around the world return to Saudi Arabia this week to perform the annual Hajj pilgrimage after a two-year hiatus caused by Covid-19 restrictions. It’s an opportunity for Muslims to fulfill a once-in-a-lifetime religious obligation. Hajj is one of five pillars of Islam.

Muslim worshippers pray around the Kaaba at the Grand Mosque in Saudi Arabia’s holy city of Mecca on July 5. CNN

July 6 – The FDA added pharmacists to the list of health care professionals who are allowed to prescribe Pfizer’s pills, Paxlovid, for the treatment of Covid-19. There are more than 300,000 licensed pharmacists in the US.
Statement from AMA: “While the majority of COVID-19 positive patients will benefit from Paxlovid, it is not for everyone and prescribing it requires knowledge of a patient’s medical history, as well as clinical monitoring for side effects and follow-up care to determine whether a patient is improving — requirements far beyond a pharmacist’s scope and training,” AMA President Jack Resneck Jr., MD
In the past the expanded pharmacists’ authorizations only included vaccinations. Diagnosing Covid and prescribing Paxlovid may be an important new precedent for expanding primary care providers in the US. It would appear that this scope of practice issue has been creeping up on us for a while.

July 7 – Twitter said, during a briefing that aimed to shed more light on the company’s fake and bot accounts, that it removes 1 million spam accounts each day. Imagine how many accounts they have.

July 9- Eid al-Adha, one of the biggest holidays of the Islamic calendar is celebrated by millions of Muslims across the globe. Known as the “Feast of Sacrifice”, the observance coincides with the final rites of the annual Hajj in Saudi Arabia. The “Sacrifice” refers to the willingness of Abraham/Ibrahim’s to sacrifice his son as an act of obedience to God. Jews, Christians, and Muslims agree on this “tale.” However, Muslims assume that it is Ismail/Ishmael, Ibrahim’s first-born son from Hagar the slave, even though this is not specified in the Koran. By contrast the Bible states that it is Isaac/Is-hak who was born second to his wife Sarah. A simple misunderstanding within a family/stepfamily.

July 10 – The 1,591-acre Washburn Fire began on July 7 and doubled in size in a few days. It is threatening the famed Mariposa Grove of giant sequoia trees, including the 2000 year old Grizzly Giant, in Yosemite National Park, and smoke is traveling hundreds of miles north. My favorite National Park, so sad!

A helicopter drops water on the Washburn fire, which is burning in Yosemite National Park. Noah Berger/Associated Press

July 11 – World Population Day. According to the United Nations, the world’s population will hit 8 billion this year, up from 7 billion in 2021. Incredible growth. How can we feed all the humans?

July 11 – The first image from the $10 billion James Webb Space Telescope is the farthest humanity has ever seen in both time and distance, closer to the dawn of time and the edge of the universe. The “deep field” image released at during a brief White House event is filled with lots of stars, with massive galaxies in the foreground and faint and extremely distant galaxies peeking through here and there. Part of the image is light from not too long after the Big Bang, which was 13.8 billion years ago.

Galaxy Cluster SMACS 0723 – NASA/ESA/CSA/STScl via AP

July 12 – The Library of Congress announced that Ada Limón, a native of Sonoma, CA, will become the next poet laureate of the United States. Poetry, she said, can help the nation “become whole again.”

July – 13 – The FDA authorized a COVID-19 vaccine developed by Novavax, a biotechnology company in Maryland. The vaccine will be a new option for Americans as vaccination rates stagnate. Novavax’s vaccine, given in doses spread three weeks apart, works differently from mRNA vaccines. It provokes an immune response

with nanoparticles made up of proteins from the surface of the coronavirus that causes Covid-19. Similar protein-based vaccines have been widely used around the world for decades. About 22 percent of people in the United States have not received a single Covid vaccine dose.

July 14 – Bastille Day. Growing up in the French Education System in Damascus, Syria, I was taught that the USA could not have gained/claimed its Independence without France.

July 14 – National French Fries Day. No comment!

July 16 – The National Suicide Prevention Lifeline officially transitioned to a simple 3-digit number on July 16, 2022. Anybody can now call or text the 988 lifeline if they, or somebody they know, is having thoughts of suicide, or experiencing a behavioral health or substance use-related crisis. Users of the lifeline can also access help via live chat at 988lifeline.org.

July 17 – National Ice Cream Day. President Ronald Reagan signed a proclamation declaring July National Ice Cream Month and the third Sunday National Ice Cream Day. I wonder if there is a National Jellybeans Day.
July 20 – The anniversary of the first moon landing. Apollo 11 became the first manned spacecraft to land on the moon. Neil Armstrong (commander), Buzz Aldrin (lunar module pilot) and Michael Collins (command module pilot) were the crew. The Apollo 11 spacecraft consisted of the command module, Columbia, and the lunar module, Eagle.
At 4:18 p.m. EDT, Armstrong reported: “Houston, Tranquility Base here. The Eagle has landed,” At 10:56 p.m. EDT, Armstrong said: “That’s one small step for man, one giant leap for mankind,” as he became the first human to set foot on the moon. I will never forget that day in 1969. My entire family and I were listening to a transistor radio transmission of that event from a balcony in our home in Damascus, Syria.

July 21 – North America’s monarch butterfly has been classified as endangered by the International Union for Conservation of Nature, the world’s most comprehensive scientific authority on the status of species. The North American monarchs’ migration is considered one of the natural world’s wonders: tiny insects flying thousands of miles north over the course of a few generations and back in just one generation, with single butterflies flying perhaps more than 2,500 miles. Please plant milkweed native to your area.

July 22 – National Mango Day
July 23 – NY Times – For the second time in two years, the World Health Organization has taken the extraordinary step of declaring a global emergency. This time the cause is monkeypox, which has spread in just a few weeks to dozens of countries and infected tens of thousands of people. Dr. Tedros Adhanom Ghebreyesus, the W.H.O.’s director general, declared a “public health emergency of international concern,” a designation the W.H.O. currently uses to describe only two other diseases, Covid-19 and polio. Monkeypox has been a concern for years in some African countries, but in recent weeks the virus has spread worldwide. Some 75 countries have reported at least 16,000 cases so far.
July 24 – National Parents’ Day and also National Tequila Day. Sometimes , having a Margarita helps with parenting.
July 25-The Oak Fire that started 3 days ago in Mariposa County burned many homes located close to Yosemite and is threatening many more. It has burned 15000 acres and is so far zero percent contained. More wildfires are in store for California this season. But while the rest of the Country is experiencing record breaking heat, there remain many climate change deniers/skeptics.

July 26 – NY Times – Teva Pharmaceuticals, one of the country’s biggest manufacturers of generic opioids, announced a settlement in principle with some 2,500 local governments, states and tribes over the company’s role in the deadly, ongoing opioid epidemic. The deal is worth up to $4.25 billion. Though much lesser-known, Teva, an Israeli company, and its affiliates produced far more prescription opioids during the peak years of the crisis than marquee-name opioid manufacturers such as Johnson & Johnson did. Its production of both generic and branded painkillers dwarfed the output of Purdue Pharma, the maker of OxyContin, the medication most immediately associated with setting off an avalanche of overdoses and deaths. I never heard of this company-Incredible!

July 27 – Norman Lear, The Emmy Award winner who gave us “Archie Bunker” and “All in the Family” turns 100.

Special thank you to Surgical West for their Silver Sponsorship!

Surgical West, Inc. is Southern California’s leading distributor of high-quality surgical products from the industry’s most reputable manufacturers. Excellent customer service, knowledgeable sales representatives, and strong customer relationships are what Surgical West has based its reputation on for over 25 years. 
 
Mike Laliberte: mikel@surgicalwest.com 
Rob Spurlock: robs@surgicalwest.com 

Special gratitude to NuVasive for their platinum Sponsorship!

NuVasive, Inc. is the leader in spine technology innovation, focused on transforming spine surgery and beyond with minimally invasive, procedurally-integrated solutions designed to deliver reproducible and clinically-proven surgical outcomes.
 858-909-1937
www.nuvasive.com

Calendar

Calendar

Western Neurosurgical Society: Annual Meeting, September 9-12, 2022, Kona, Hawai’i, HI
CSNS Fall Meeting October 7-9, 2022 San Francisco, CA
CNS Annual Meeting October, 9-15, 2022 San Francisco
CANS, Annual Meeting, January 13-15, 2023 – Riverside, CA The Mission Inn

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.

• To place a newsletter ad, contact the executive office for complete price list and details.

• Comments can be sent to the editor, Moustapha AbouSamra, M.D., at mabousamra@aol.com
or to the CANS office emily@cans1.org.

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

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

 

 

CANS Board of Directors

CANS Board of Directors

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