Volume 51, Number 5

Inside This Issue

Picture of Joseph Chen, MD

Joseph Chen, MD

CANS President

CANS Influence on our National Organizations

President's Message

I’m pleased to announce that the next California Association of Neurological Surgeons meeting will return to the Mark Hopkins Intercontinental Hotel on San Francisco’s Nob Hill, January 12-14, 2024. An exciting program is being planned with leaders from our national neurosurgical organizations and local political leaders. The topics covered will be broad ranging from socioeconomic issues relevant to the practice of neurosurgery in California as well as presentations by neurosurgeons who represent the pinnacle of education, research, and clinical care. Highlight topics will include the California legislative agenda, ethical aspects of neurosurgical care, organization of employed physicians, complex spine care and future directions in brain surgery, and the study of nervous system function.

The Leviathans

Recent news events and reflections regarding our role as neurosurgeons gave occasion for me to think about Thomas Hobbes (1588-1679). An enlightenment philosopher, Hobbes is best known for his political tract, Leviathan (1651). In it, Hobbes formulates the state as being a sort of “Artificial Man,” having both material presence and a soul. The well-known frontispiece of his original publication is a stunning graphical realization of the concept, depicting the towering leviathan of the state – the artificial man- being composed of myriad individual peoples who, in their cooperative effort, give action to the arms of the state.  Here the leviathan wields on one arm the sword of government and on the other the crozier of the church.

While Hobbes conceived of the state as an “Artificial Man,” the treatment of other entities as artificial people has long been a feature of English common law that predates the American Republic. In this framework, formally organized groups of people (corporations) are therefore subject to laws, may participate in torts, and play roles in the political process.  Our societal landscape is filled with “Artificial Persons” big and small. They embody the interests of commercial concerns, labor unions, political advocacy groups, religions, and professional societies such as the AANS and AMA.

Some of these artificial persons may be internally conflicted, with one arm fighting the other, as is seen with factions within organizations since artificial people are often composed of constituent artificial peoples.

Most important, however, is the struggle between such leviathans in the competition for wealth and power. As is the case with natural people,

alliances form between the leviathans to seek power. Such private leviathans may also hold an outsized influence on the leviathan of the State. 

In relation to current events, we have witnessed the ailing of one of these artificial persons, an entity known as Envision Healthcare, having been struck down by twin blows from the leviathans of government and the insurance industry. Envision is a successor to EmCare, a large company that originated in the 1980s in Dallas, whose initial mission was to staff hospital emergency rooms with a then-new specialty, emergency medicine. Eventually growing to cover over 500 hospital emergency rooms and expanding into 7 major specialties with 25,000 physicians and advanced practice providers, EmCare passed through a succession of acquisitions, becoming a constituent entity of larger artificial persons.  Ultimately, Envision was acquired by KKR, one of the world’s largest private equity organizations, with approximately 500 billion dollars under management.

How did Envision grow, and how did it become an attractive takeover target for successive owners? Three factors were involved: 1) applying goal-oriented productivity benchmarks for its physicians and APPs, 2) market consolidation driven by Envision’s aggressive contracting and recruitment power, and 3) out-of-network billing.  This third factor, combined with a 7.7 billion dollar debt obligation, ultimately resulted in its downfall.

In 2021, Envision was removed from United Healthcare’s network of providers due to disputes regarding in-network rates for various services, including emergency medicine and anesthesiology.  UHC alleged that Envision demanded payments two to three times the median rate of other groups.  On the other hand, Envision alleged that UHC routinely denied nearly 50% of commercial claims in the months leading to being out of network.  While Envision was able to successfully sue UHC with an arbitration award of approximately 91 million dollars to compensate for underpayments in 2017 and 2018, the Consolidated Appropriations Act of 2021 resulted in a federal ban on most out-of-network balance billing, bringing an era to a close.

Envision filed for Chapter 11 bankruptcy on May 15, 2023.  While this artificial person is very ill, it is far from dead and continues to operate while under reorganization.

The battle of these artificial persons raises the question of the role and fate of those “natural persons” who are “the constituent elements” of competing commercial enterprises or any other “artificial person.”  Indeed, the role of the individual in the land of Leviathans has been a source of tension from the dawn of civilization.

In relation to the leviathan of the state, Hobbes posited that the individuals who comprised the corpuscles of the state did so as part of a social contract.  People delegated powers to the state in return for physical safety and a degree of well-being; it was better than that which could be achieved in the rude anarchic condition of individual people.

Many, however, believe the promises of such social contracts have progressively diminished in this modern era.  The leviathans of the state, commercial enterprises, and advocacy groups take a life of their own as artificial people with their own goals and desires, which have frequently been at odds with the interests of natural persons. Consolidating these large entities gives natural persons fewer opportunities for choice and expression of their goals within the working environment. These conflicts may produce many of the pressures that I mentioned in last month’s essay.

From this small corner of neurosurgery, I have observed that a career in corporate service has been highly satisfactory for some and less so for others. The rise of corporate leviathans and their complex networks derived from the division of labor have made our lives safer and given us more than a modicum of prosperity.  For many of us, however, life restrictions in servitude result in constant chafing – not surprising given the typical psychological makeup of a neurosurgeon. 

As a small interest group (4000 actively practicing neurosurgeons, give or take), we are minuscule compared to Envision.  Additionally, we are a politically fragmented group with diverging opinions on various hot-button issues.  What we must do, therefore, is put aside those differences that are immaterial to the issues that are the looming threats to our future as a learned profession.  We must return to a formulation of a broad core agenda that we can, as a group, agree to and act upon.  As neurosurgeons, for better or worse, we are often looked to as leaders within the medical community.  We should therefore take up this mantle of responsibility for ourselves and all of our medical colleagues to ensure that the leviathans will not abrogate the sacred trust between patient and doctor. 

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Corner

Happy Fourth of July! We are getting ready to celebrate our Nation’s Independence Day. My editorial committee and I wish you a safe and wonderful celebration. As a naturalized citizen of the US, an amazingly welcoming country open to new ideas and people of all ethnic origins, I always look forward to this patriotic celebration. Parades, Fireworks, and yes, BBQs with family and friends, old and new, bring us together as a Nation. Please see “Tidbits” in this newsletter, where two related events were featured: Flag Day on June 14 and Juneteenth Day on June 19, when I became a citizen in 1981. Please note that we are featuring two young female individuals in this issue. The first is not a neurosurgeon, but I am confident she will excel in her chosen fields, OBGYN and Global Surgery. She was the graduation speaker for the Harvard Medical Class of 2023. Leen Al Kassab was born in Syria, my county of birth; she adds to the rich fabric of this country, as all immigrants do.

The second is our own Adela Wu, one of our CANS Residents Board Consultants. Adela is a frequent contributor to this newsletter. I turn to her whenever I need to publish a certain column or essay. She comes through without exception. She is, obviously, very busy. Starting her PGY 6 year with her daughter Audrey, a one-year-old, and her husband. She reminds me of something Benjamin Franklin said: “If you need something done, ask a busy person!” Adela is that kind of person. Audrey

In her essay, she discusses “TRUST.” Learning to trust co-residents, colleagues, mentors, and patients. We also learn to trust our mentees, whether students, residents, or young neurosurgeons.  Adela notes how our patients trust residents in training, relying on the fact that a dedicated faculty of seasoned and senior surgeons of various levels of expertise closely supervise them. Indeed, Neurosurgery and our profession are built on trust. Yes, we generally trust the “System and the Process,” even though there are many examples where they let us down because of various competing interests and the dreaded unintended consequences. Please see the thoughtful essays of President Joseph Chen, our Private Practice Corner contributor Brian Gantwerker, and our Academic Practice contributor Anthony DiGiorgio. 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 or call me at 805-701-7007 if you prefer to discuss any issue directly with me. I hope you will enjoy this issue.
Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Changing Times

Recently the “fashion police” was scandalized that Hakeem Jeffries, the Minority Leader in the House of Representatives, showed up at a very high-level meeting with President Biden at the Oval Office wearing dress sneakers. The meeting aimed to raise the debt ceiling and prevent the US from defaulting on its obligations with potential worldwide catastrophic results.

This prompted the Editor to republish this essay, published almost 11 years ago. If any, the writer feels more strongly about the subject, given the tendency to dress down for work.

CANS Volume 39 Number 8 August 2012

What Should I Wear?

My wife always asks me this question, even though she is really not looking for my opinion; it is often a ploy to make me concentrate on something else besides the clock when she is running late. Let me make it clear: my wife dresses tastefully and looks great for any and all occasions.  Today is no exception as we get ready to celebrate our 39th wedding anniversary. August 2023 will mark 50 years! The decision is easy for me: either my “dress uniform” or a tux. I never have to wonder what to wear. I won’t discuss my tux, which is obvious, but I would like to discuss my uniform. It consists of a buttoned-down shirt, crisp slacks, a blue blazer, black closed-toed shoes, and … my bow tie. Oh, I have a choice to make regarding bow ties, of which I have several hundred. Yes, sometimes I feel out of place when I stop on my way to work at Starbucks for a cup of coffee wearing my bow tie since our society has become more and more casual. Still, generally, I feel very comfortable and in my element when I see patients or interact with colleagues while wearing “my uniform.” Usually, when I get to the office, I forgo my blazer for a crisply ironed white coat. I honor my late mother’s advice: better be over-dressed than under-dressed. Unfortunately, today, the new generation of physicians feels that wearing a tie, or God forbid, anything besides a pair of flip-flops, impairs their freedom. I remember the days when patients dressed up to go to the doctor’s office—no more. And our young brethren are competing to look like the patients. Should they pay more attention to their appearance? I, for one, think so! There is a dress for every occasion; an East Coast lawyer friend of mine told me that lawyers have to dress appropriately when they appear in court before a judge. He gave the example that it is probably desirable to wear cowboy boots if you practiced in Texas. However, if you plan to appear before a judge in the Commonwealth of Massachusetts, you must wear shoes with laces. So, dressing casually, in jogging suits, shorts, flip-flops, etc., is not appropriate when we plan to meet with patients and their families. It is not appropriate when we expect them to take us seriously. A whole field in psychology called enclothed cognition- the effects of clothing on cognitive processes, exists. People tend to associate a doctor’s white coat with a person who is careful, rigorous, trustworthy, and good at paying attention. People react to uniforms predictably. And studies have shown that even the reverse is true: wearing a doctor’s uniform makes one more attentive. I am certain that patients do not feel the same about a youngster dressed so casually that he looks like he should be playing in a sandbox with their own kids. And while we are talking about appearances, how about shaving? I know that George Clooney looks good with a day or two of old stubbles, but I venture to say that most of us look unkempt and downright dirty when we don’t shave. And while we talk dirty, how about wearing scrubs outside the operating room? No, I am not discussing uniforms that look colorful, scrubs-although I have my biases about them. I am talking about the fact that we see surgeons wearing scrubs all day long, in and out of the OR, even at the supermarket, yes, the supermarket. No, scrubs don’t belong outside the OR. There are many reasons I can think of, but two important ones come to mind. First, cleanliness-I certainly hope that my surgeon will be wearing fresh scrubs when he or she operates on me and that he didn’t wear the same scrubs when he stopped at Starbucks to get his daily fix. And second, the fact that there is a time and place for everything and there is a dress for every occasion. So please, take it from someone who just received his Medicare card: when you want to play doctor, dress for the part when you assume this important role! You will feel better, and your patients will appreciate it.
Picture of Adela Wu, MD

Adela Wu, MD

Residents’ Corner

Towering redwoods. Dense foliage with rope bridges and zip lines crisscrossing the sky. This was very different from the ground floor neurosurgery inpatient ward I had spent the better part of my intern year. For my first excursion as part of our program-wide resident wellness day, we were somewhere in the Santa Cruz Mountains in Felton, California. Instead of managing patients and operating, our agenda today was to navigate this massive ropes course together.

We were outfitted with safety harnesses and clambered up the steps and ladders to platforms among the trees, high enough to inspire some consternation even among the most adventurous of our group. I gripped heavy ropes that swayed with every breeze, picked my way across a rope net, and yelled as I ziplined through the leaves. With every step, I was aware of the height from which I dangled, but I had to trust the integrity of the ropes and my harness to complete the course.

I remember one particularly daunting aspect. I was paired with my co-resident, Ryan, and we faced an expanse across which a series of intersecting wooden beams were set. Each plank’s width was just one foot or so, requiring a person to walk across tandem to avoid stepping into thin air. It seemed relatively straightforward, except for one thing. We were in pairs because the person who chose to walk across had to keep their eyes shut, listening to and trusting their partner shouting directions from the platform.


When writing this essay for this month’s Resident’s Corner column, I had just started my PGY6 year, which, in my program, occurred after two years of research and professional development time. I anticipated the shift to my clinical years as a senior resident would involve a steep learning curve. And I admit that I was nervous at the start of the new year, knowing I still had so much to learn. In my very first week of PGY6 year, I completed several complex cases as the lead resident, including a retro sigmoid craniotomy to remove an acoustic neuroma and a craniotomy for resection of Grade 4 arteriovenous malformation.

I was thankful that the cases went smoothly and that the patients were doing well so far. I realized that I was also in a privileged position. Not only did our attendings trust us in our training, allowing us to gain more independence with time and experience, but our patients also trusted us as their surgeons.

And, just as co-residents had to trust each other eighty feet in the air during the ropes course, just as our attendings and patients trusted us, I had to trust myself and the process. While transitions can be nerve-wracking, they are also valuable opportunities for growth. 

Photo of the month

Blue Footed Boobie

Photo taken at 8:45 AM on May 19, 2023, on Santiago Island, the Galápagos Archipelago, Ecuador, by Moustapha AbouSamra, MD – iPhone 13 Pro.





Red Footed Boobie

Photo taken at 10:45 AM, on May 20, 2023, on Genovesa Island, the Galápagos Archipelago, Ecuador, by Moustapha AbouSamra, MD – iPhone 13 Pro



Annual Call for CMA Award Applications and Nominations

The California Medical Association (CMA) is seeking nominations for its annual awards. These awards are presented in conjunction with the annual meeting of the House of Delegates in October. Each award recognizes special contributions to an aspect of CMA membership and/or the practice of medicine. The deadline for all submissions is Friday, June 30, 2023.

This award best illustrates the association’s commitment to community and charity care.

Nomination eligibility: Active physicians or physician organizations who have demonstrated a history of providing charity or donated care to communities within the state of California. The selection process will focus heavily on services donated by physicians, or organizations, to the indigent or services rendered to charitable groups. Awardee receives $1,000 stipend and recognition plaque.

This award demonstrates a special or unique effort toward membership recruitment resulting in membership growth in their area during the past year. Awardee receives $1,000 stipend and recognition plaque.

This award honors significant contributions toward improving physician health and wellness. The CMA Physicians’ and Dentists’ Confidential Line Committee acts as the nominating committee to the House of Delegates. Awardee receives recognition plaque.

This award best exemplifies the practice and ethics of a rural practitioner.

Nomination eligibility: Physicians currently in active practice or recently retired, i.e., retired from active practice for a period of no longer than three years. The selection process shall take into consideration services donated by the physician to the indigent or services rendered to charitable groups. Awardee receives $1,000 stipend and commemorative silver bowl.

Requirements and Instructions
All nominations must reflect active CMA membership from a physician residing and practicing in California. See award description for any additional requirements.

Please email all nominations to by Friday, June 30, 2023.
Navdeep Dhaliwal 
Director, Governance
(916) 551-2073

2023 Annual Awards Descriptions & Criteria

UnitedHealthcare pauses controversial GI prior auth policy
Facing sharp pushback from organized medicine, UnitedHealthcare (UHC) announced it would be pausing a controversial policy requiring prior authorization for certain gastroenterology endoscopy services for commercial plan members that was set to take effect June 1, 2023. In place of the prior authorization policy, UHC will instead implement an optional advance notification process where physicians voluntarily submit patient data for clinical review, prior to performing certain gastroenterology endoscopy services.

Health Net files second protest on award of TRICARE West contract to TriWest Healthcare Alliance
Health Net Federal Services, the current contractor for the TRICARE West region, has filed a second protest over the federal government’s decision to award the new TRICARE West region managed care support contract to TriWest Health Alliance. This move may further delay the transition, currently planned for August 2024. The U.S. Defense Health Agency initially awarded the new contract in December 2022, but HNFS filed an initial protest with the Government Accountability Office.

Medi-Cal redetermination: Verify your patients’ eligibility
On April 1, 2023, California began the process of redetermining eligibility for about 15 million Medi-Cal enrollees following the official end of the COVID-19 public health emergency. As a result of the redetermination process, two to three million beneficiaries may no longer be eligible for Medi-Cal. The redeterminations are based on the beneficiaries’ next annual renewal date (done on a rolling basis and not all at once).

Cigna says it will delay problematic modifier 25 policy, work to optimize the provider experience
Cigna has announced it will be re-evaluating the policy that would require the submission of medical records for all Evaluation and Management claims billed with CPT 99212-99215 and modifier 25 when a minor procedure is billed. The California Medical Association (CMA) and others in organized medicine have been urging the payor to rescind the policy since it was first announced last year, as it effectively penalizes physicians for providing efficient, unscheduled care.

Superior Court upholds CMA legislation mandating reimbursement for COVID-19 testing and vaccination
In a ruling issued in May, the Los Angeles Superior Court upheld the constitutionality of a state law requiring health plans to fairly reimburse health care providers for the costs of COVID-19 testing during the COVID-19 state of emergency. Senate Bill 510, sponsored by CMA, mandates that health plans and health insurers reimburse health care providers, regardless of network status, for COVID-19 testing and vaccination services.

Medi-Cal Rx phases out 46 more grandfathered historical prior auths
The California Department of Health Care Services (DHCS) recently initiated Phase III, Lift 4 of the Medi-Cal Rx transition, which includes a series of Medi-Cal Rx transition policy lifts for beneficiaries 22 years of age and older. The original Medi-Cal Rx Transition Policy included “grandfathering” previously approved prior-authorizations and a 180-day period where DHCS would not require prior authorizations for existing prescriptions

U.S. Supreme Court preserves right to sue to enforce state compliance with Medicaid requirements
In a monumental case that represented an existential threat to America’s social safety net, the United States Supreme Court issued a 7-2 ruling that preserved the ability of people to sue government agencies and other state defendants to vindicate individual protections and rights secured under federal laws, including watershed civil rights and social welfare laws.

CMA president issues statement in response to Gov. Newsom’s proposal to address gun violence crisis
In response to Governor Gavin Newsom’s proposal for a 28th Amendment to the U.S. Constitution to address the country’s gun violence crisis, Donaldo Hernandez, M.D., President of the California Medical Association (CMA) issued the following statement: “On behalf of its almost 50,000 members, the California Medical Association supports Governor Newsom’s efforts to address our nation’s gun violence epidemic while respecting responsible gun ownership.”

Appeals court stays ruling that overturned ACA preventive care requirements
A U.S. circuit court of appeals issued a stay of a Texas district court decision that could jeopardize access to free preventive care for hundreds of millions of Americans. A Fifth Circuit Court of Appeals panel issued the stay while the court considers the federal government’s appeal of the lower court’s ruling that invalidated the Affordable Care Act (ACA) requirement that insurers cover, without cost-sharing, more than 100 preventive health services recommended by the U.S Preventive Services Task Force.

CMA and more than 90 physician groups warn of dangers in federal scope bill
CMA, the American Medical Association and more than 90 other medical and specialty societies recently sent a joint letter to Congress expressing strong opposition to a federal bill that could compromise care quality for millions of

Medicare and Medicaid patients. The Improving Care and Access to Nurses Act (HR 2713) would expand the scope of practice of non-physician practitioners (NPPs).

$47 million grant program launched to support health data exchange in California
With a January 31, 2024, deadline approaching for many entities to begin securely exchanging health information under the Data Exchange Framework (DxF), the California Health and Human Services Agency’s Center for Data Insights and Innovation is now accepting applications for the first of at least three rounds of Data Sharing Agreement Signatory Grants.

Lawmakers urge FDA to address adverse effects of drug shortages on cancer patients
Faced with a national shortage of more than a dozen cancer medications, California Congressman Ami Bera, M.D., led a bipartisan group of 66 Members of Congress in writing a letter to U.S. Department of Health and Human Services Secretary Xavier Becerra and U.S. Food and Drug Administration Commissioner Robert Califf expressing concern with the detrimental impact of drug shortages on individuals battling cancer.

Historic legislation will renew MCO Tax and expand Medi-Cal patient access to care
Largest Medi-Cal rate increase in California history begins next year
A budget trailer bill has been introduced that will renew the state’s Managed Care Organization (MCO) Tax to provide the largest Medi-Cal rate increase in California history, ensuring that millions of Californians will have greater access to life-saving health care. The proposal represents a generational opportunity to fulfill the promise of Medi-Cal and provide meaningful access to health care for millions of Californians.

Specifically, the legislation would increase provider rates to at least 87.5% of Medicare for certain primary care, maternity care and non-specialty mental health services in 2024 and provide $75 million annually for graduate medical education. Starting in 2025, the bill provides for an annual appropriation of $1.38 billion in primary care rate increases, $1.15 billion in specialty care rate increases, over $500 million for family planning and reproductive health care, and $600 million for behavioral health facilities including increasing inpatient psychiatric beds.

Once the legislation passes, the work to implement these monumental changes will continue over the next few months and into next year. Throughout the process, the California Medical Association (CMA) will continue to advocate on behalf of physicians to ensure the funding flows efficiently to providers.

Click here to view our MCO Fact Sheet and FAQ.

This is truly a historic moment, and CMA appreciates the Governor and the legislature for their work to achieve justice and equity in access to care for Medi-Cal patients. We are urging swift passage of the budget trailer bill and look forward to working with policymakers on implementing this important investment that will provide millions of California patients with increased access to life-saving health care. 

Picture of Brian Gantwerker, MD

Brian Gantwerker, MD

Private Practice Column

The Science of the Art

“Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained sufficient knowledge, but vouchsafe to me the strength, the leisure, and the ambition ever to extend my knowledge. For art is great, but man’s mind is ever expanding.”

Prayer of Maimonides, approx. 12th Century

Recently, the issue of scope creep has been increasingly a topic of conversation within the medical sphere.  As a private practice neurosurgeon, many of us may feel this is not a pressing issue and summarily refer it to the back of the mental Rolodex (think a rotating file – I realize I am dating myself).

The issue of scope creep is not new. For many years, there have been attempts to create a false equivalence between physicians and nonphysicians regarding skill sets and responsibilities. There’s never been a more serious time when there is a very obvious tendency now to not only called non-physicians doctors at the patient’s bedside but also to substitute them for a fully trained physician.

If you are on the Twittersphere, as much as I am, this topic is very sensitive. Some of the accounts are, as expected, anonymous due to fear of repercussions or doxing, as it is called when other users decide to post your personal information, including your cellular number, your home address, and your office address, in the hopes of embarrassing or pressuring another user into silence.

The spokesperson for the ANP organization, sounding much like a talking head out of 1984, insisted that nurses can do anything a doctor can.  It even sounded like a Sondheim musical.  There were even moments when some Twitter users tried to label physicians who disagreed with various inflammatory labels –misogynists, charlatans, etc.  It got quite ugly, and the ugliest comments came from anonymous accounts.  This was quite the newsflash considering not all doctors are men and not all nurses are women.

Thankfully, some of our female colleagues called out this and reaffirmed the importance of physician care.  It was a very surreal moment, especially for those in our community who are quite the opposite and support nurses in crises such as the recent pandemic and when they strike, asking for reasonable things such as better compensation and safe nurse-patient ratios.

The issue of scope creep is salient enough that even the Switzerland-like AMA has finally decided to weigh in on behalf of physicians.  The main issue with scope creep, as it is called when non-physicians are beginning to have the ability to make clinical decisions on par with those of actual physicians, has become prescient, as online programs are giving doctorates to both nursing students and physician assistants who are now referring to themselves as “Doctor.”  Salient to this are the repercussions of those decisions and how they affect our patients and potentially even our jobs.  Most neurosurgeons may not care about nonphysicians being the primary gatekeeper for patients.  What they fail to understand is that without the stubborn, independent streak so prevalent among physicians and more of a clock-in, clock-out mentality and for questioning that the mothership dictates – patients will have to spend more time in the ER having more unnecessary or missing important tests and not having timely referrals, or worse yet, ignoring critical problems that result in avoidable death and disability.  Some studies have suggested that patients have worse outcomes and cost more with nonphysicians in charge.

The truth is, this is no one’s fault but our own.  For many years, we have allowed our skills and interactions with patients to be commoditized. We have gone faster as dictated by the treadmill of reimbursements, and work value units have demanded of us.  This intern has been driven by “value-based care,” which is really “code” for costing the insurance companies and Medicare less money to do the same amount of work. Unfortunately, many program directors and medical officers have embraced this fully. They see it as a messianic return to patients getting what they paid for when it’s about saving insurance and CMS money.  We, unfortunately, fell for it. And we let ourselves be called “providers,” – but that is another diatribe.

To that end, seeing as Congress has not yet passed a large-scale bill that expands the number of residency slots, and due to the recent Cuts and Medicare, we are having a severe physician shortage where people with low-income and rural areas are in serious need of medical care. Corporatized medicine and private equity, seeking their almighty profit, have answered the call by helping foster the nursing lobby and other lobbies to allow them to be called “doctors” and have hospitals grant the same privileges therein.  They hope to improve their quarterly balance sheets while lobbying Congress to give them more money regarding their RVUs and work value units.  They asked us to jump – and we responded, “How high?”

One of the main goals of the ANP lobby is to convince Congress they are equivalent to doctors by using phrases like: “practicing the top of our license.”  This is essentially Info speak to say the training of nurses is the same as that of doctors.  On its face, it sounds ludicrous, and it is.  There is an order of magnitude difference in patient contact hours before doctors can treat patients independently.  Our specialty is not a 7-year residency because we greatly enjoy each other’s company.  The repeated exposure to clinical scenarios, sometimes dire, prompt, quick action, recognition, and mitigation of danger to the patient, and simultaneously forming a plan, and lastly – triaging your obstacle to get the patient taken care of (and maybe, just maybe, to get a little shuteye).

I enjoyed my time as a medical student and intern because I learned an incredible amount from our floor nurses.  My time at Cook County was invaluable:  the old building, a huge shadowy hulk with open-air parlors for the TB patients to “get fresh air.”  I learned how to place IVs from nurses, the right way to tape an arterial line, and how to dress triple-lumens so I don’t make it harder for them to draw off them. I loved the feedback from the ICU nurses when I was a resident.  Especially if I was being a bit of a schmuck – they taught me how to be a mensch and team player – even if it was 3 AM and I still hadn’t got all my orders in for the last subarachnoid hemorrhage that came in an hour ago whilst the Peds ER paged me with another shunt malfunction.  Nurses taught me how to be a good doctor in the extremes of residency.

Beyond my gratitude comes a sense of outrage.  Complex patients, our veterans, and our rural residents who live far away and have the utmost trust in medicine should not be shunted away from a trained physician.  My mother, a very medically complex person, was nearly sent into frank renal failure by a nurse practitioner who never bothered to taper her Bumex.  She had a nearly half-million-dollar medical bill because she ran out of Medicare days.  One of my patients was being seen by a person when I walked in the room who referred to himself as “doctor.”  He wore a natty white long coat that was carefully embroidered.  I look at the pocket where his title says “DNP.”  He quickly excused himself after my patient, who was a nurse, could not understand whether this person was a physician.  Again, the DNP just said: “call me doctor _____.” 

Suffice it to say I was livid at the charade and the attempt to gaslight my patient in front of me.  The supervising physician was advised never to have that person see one of my patients again, and further, I brought up this issue with our credentials committee.  And now, only physicians – an MD or DO – can call themselves “doctors” at the bedside.  Regarding professional circles, academia, and papers, I think it is fine to be called a “doctor.”  At the bedside of a sick patient, there is no room for chicanery.

Besides the title, there is the concept of nurses performing surgery.  At the NHS in England, there are nurses performing surgery:  In the name of patient throughput, nurses can do a two-year course and train to do hernia surgery, skin cancer, and “benign lesions.”  Those of our politicians and policy wonks who hold the NHS as the gold standard for socialized medicine should be queried if they would like a nurse or a 5-year trained surgeon to take out their appendix or fix their hernia.  Recently, a hospital in England tweeted that it allowed a nurse, not an NP or a PA, to do a TAVR.  Replace one of the four critical heart valves using a catheter.  They tweeted out gleefully, calling it “a proud day.”  What about the patient?  Did they know?  Would you let your mom or dad have a TAVR, cholecystectomy, or VP shunt put in by a nurse? A PA?  That should be the gold standard is what you would have for your family member, not whatever is expedient or “value-based.”

The hospital quickly took the tweet down with the standard “humina, humina, humina” à la Ralph Kramden (Jackie Gleason’s character from “The Honeymooners.”  It is important to note that, in all likelihood, HHS and CMS are looking at NHS closely.  While the insurers create new ways of delaying care and payments, hospitals get increased handouts from the government, and doctors are willingly taking the blame for high costs and bad outcomes – this will be our fate as well.  Increasingly, doctors are becoming technicians.  I spoke with a friend in NorCal who works for one of the large

entities doing Locums work and says their general surgeons have their preop visit with their patients in the holding area.  They never see them in the clinic, and not after either for postoperative care.  Remember that these surgeons are NOT Locums; the entity employs them.  Surgeons having been relegated to the role of proceduralists seems to be the desired final common pathway for surgeons and surgical specialists.  In the future, bad outcomes will be buried in various statistical sleights of hand to support the policy.  I can almost hear certain of my colleagues shrug and accept it – looking at it as an opportunity to be freed up to do other things.  That will certainly be a sad day.

We must resist that tide.  Without knowing our patients, we cannot honestly know our outcomes and report.  Without knowing our patients, we cannot perfect our art.  And without knowing our patients, we will have failed in our moral obligations as healers.  



Please help the CSNS by participating in these important surveys

Exploring Resident/Attending Knowledge of OR Costs and Waste Generation

Survey link:

The authors would like to survey both attendings/practicing neurosurgeons and residents about their knowledge and perception of costs in the OR and waste in the OR. This will hopefully allow patterns to be demonstrated and opportunities for improvement to become apparent. This survey should take five minutes to complete.

“Exploring the Impact of Serious Adverse Events on Neurosurgeons” 

link –

We invite you to participate in a research study being conducted by investigators in the Department of Neurosurgery at Penn State University, the purpose of which is to collect and analyze information about neurosurgeons’ emotional/psychological responses to serious adverse events (SAEs) that have occurred during their careers. The survey will take approximately 10 minutes to complete and your participation is confidential.

If you have any questions about the research study itself, please contact:

Mark Dias, MD, at

Mark Iantosca, MD, at

Case Minimum and Credentialing
Link –

The authors would like to survey all practicing neurosurgeons regarding their individual experiences with obtaining hospital and departmental credentials. The study specifically will seek to obtain information about the presence / absence of case minimums required to be credentialed in a variety of neurosurgical procedures. The survey should take 5-10 minutes to complete.

Malpractice and Medical Liability
Survey link –

The Council of State Neurological Surgeons Medicolegal Committee would like to present this survey aimed to uncover the perceptions and experiences by neurosurgeons on medical malpractice and liability. We appreciate you taking the time to complete the survey. It should take less than five minutes to complete. 

Leen Al Kassab

Physicians Ambassadors
Wearing your Identity as a Physician

Women in Neurosurgery – Medicine

Editor’s note: This month’s column is not about a woman neurosurgeon but about an impressive young woman physician. She happened to have been born in the city and country where I was born, Damascus, Syria. She and her family suffered many hardships, but she overcame all and was selected to be the speaker of the graduating Harvard Medical School Class of 2023. See the U-Tube below.

The title of her remarks was “Physicians Ambassadors.” She eloquently described her journey and her multi-layered identity: she is an American physician and a Syrian Arab Muslim Woman who wears a head scarf, and how she can “openly and unapologetically” be herself. She invited her newly minted-physician classmates to celebrate their multi-layered identities.

Bravo, Leen! Welcome to our noble profession!

2023 Class Day Student Address: Leen Al Kassab

In Memoriam

David F. Jimenez
February 10, 1954 — May 25, 2023

Dr. Jimenez was a pediatric neurosurgeon, the former  Professor and chairman of the Department of Neurosurgery at the University of Texas Health Science Center in San Antonio, and the CSNS Chair from 2001-2003. He was serving actively as the chair of Pediatric Neurosurgery at El Paso Children’s Hospital when he died suddenly and unexpectedly.

He played an instrumental role in establishing the CSNS Resident Fellowship program, which helped develop numerous AANS and CNS leaders.

He was a mentor and friend to many of us.

David was a guest speaker at the 2014 CANS annual meeting; his topic was “Fair Market Value – Determination and Significance.”

He will be missed dearly. May he Rest in Peace.

Historical Vignette

Editor’s Note: I had the honor, privilege, and pleasure of meeting and getting to know Dr. Eugene Stern when I moved to Ventura, California, in 1981. He immediately took an interest in me and my career, made me feel welcome at UCLA, and whenever I attended one of the lectures there, he acknowledged me and asked one of his residents to ensure that my needs were met. And whenever I ran into him at national meetings, he would greet me and enquire about my family, practice, and associates, particularly Mel Cheatham.

I hope you enjoy reading about one of the “giants” of Neurosurgery, particularly in California. Below we re-publish two essays. Eben Alexander Jr. wrote the first, originally published in SURGICAL NEUROLOGY 1982;17:393-4. And the second by Don Becker, who succeeded Dr. Stern as the chairman of Neurosurgery at the Division of Neurosurgery at UCLA; it was published in the Journal of Neurosurgery

Eben Alexander, Jr.
                                                                    Walter Eugene Stern, Jr.

Chance favors only the mind that is prepared
       Rene Vallei-y Radot

Gene Stern was prepared to study medicine. He was prepared to become a neurosurgeon. He was prepared to become the president of both the Society of Neurological Surgeons and the American Association of Neurological Surgeons.

Gene Stern seems to have prepared almost since his birth on January 1, 1920, for the multiple leadership roles he has assumed as an adult.

Eleven months after his birth in Oregon, his mother died in an automobile accident, and Gene was sent to live with his maternal grandparents in Red Bluff, California. When he was four years old, his father remarried, and the family was brought together in Los Angeles. However, until Gene entered college, he returned every summer to Red Bluff, where after his grand­ mother’s death, he shared the housekeeping chores with his grandfather and read – according to family ·legend – the entire Encyclopaedia Britannica in addition to most of the books in the Red Bluff public library. His grand­parents’ home provided a refined and intellectually stimulating atmosphere for this bright young boy, and his grandfather’s influence was said to have been one of the greatest in his life.

During the winter months, Gene attended school and, in his spare time, gathered rocks from the deserts and canyons, with which he and his father built a house; he also delivered The Saturday Evening Post and other magazines to homes in the hills north of Los Angeles, doing so with such diligence and thoroughness that he won a summer cruise to Alaska.  He graduated from Glendale High School with sufficient distinction to win a scholarship to the University of California at Berkeley. He worked part-time while in college but managed to graduate cum laude and become a member of Phi Beta Kappa. His distinguished collegiate record assured his admission to the University of California Medical School in San Francisco, from which he graduated in 1943, a member of Alpha Omega Alpha and a co-recipient of the Gold-headed Cane, an award given for scholastic excellence.

Lest it appears that he was interested only in his, studies, it must be mentioned that he did find time to notice Libby Naffziger, a nursing student at the University of California, and found enough time to meet her regularly at the local ice cream shop. Three years of meeting there prepared them for their marriage in 1946. During the 36 years since then, it has been a happy marriage. They have been a loving, supportive couple and have produced and delighted in their four children.

Gene Stern was not prepared to be just a neurosurgeon during his seven years of medical training; he spent a year studying neurophysiology at Johns Hopkins University and a year as a clinical clerk at the National Hospital for the Paralyzed and Epileptic at Queen Square in London.

Although he had planned to pursue a medical career at the University of California in San Francisco, chance came along in 1952 in the form of an offer from William Longmire, Professor and Chairman of the Department of Surgery at the newly established medical school of the University of California at Los Angeles. Gene staked his claim there, and the diggings have been rewarding: Assistant Professor, Associate Professor, Professor of Surgery (Neurological Surgery), Vice-Chairman of the Department of Surgery, Head of the Division of Neurological Surgery.

He has attracted a coterie of true geniuses and near­ geniuses to the department. Despite their varied eccentricities, he has skillfully managed to keep his staff members in check and working cohesively. He has developed one of the world’s most outstanding and most genuinely humanized neurosurgery training programs. This program is known for teaching excellent surgical skills and new techniques, stimulating research and advancing scientific knowledge, and attracting outstanding young people to its residency training programs. The products of the program exemplify its strength.

This account of Gene Stern’s life and accomplishments has not yet done justice to the humane, mature, disciplined person of immaculate integrity that he is. But merely to say that, has not yet done credit to the cultured, educated, sensitive, articulate person that he is. He is also a person whose interests embrace his family, church, university, community, and professional life. One needs to recognize the many facets of his personality to appreciate its depth and variety.

Who else would be sufficiently disturbed by the new language of the Revised Episcopal Prayer Book to write a letter to the Episcopal Review decrying the loss of fine language? Who else would return from a sabbatical year (1961-1962) at the University Laboratory of Physiology at Oxford filled with such a delight in the great choirs of England that he now fills his home with the sound of their recordings? Who else would feel a stirring in his medieval soul at the sight of castles and cathedrals and yet find in the Sierras the same magnificence? Who else would spend hours in his Santa Monica garden with its Tillotson roses and fluted Doric column, purchased during a trip to the Mediterranean, but would also enjoy wild Rowers, camping, and fly fishing? Who else would have performed as Master of Ceremonies at the 25th Anniversary of the Pacific Coast Surgical Association, complete with top hat and cane, in a style reminiscent of Fred Astaire’s, dancing the night away with elegance and one-liners? And who else would remember accurately not only what he has read but also what his wife tells him about what she has read?

It is small wonder that he has served as president of the oldest neurological society, the Society of Neurological Surgeons, and that his presidential address was entitled “Society Deserves No Less: An Address on the Struggle to Preserve Excellence,” given on May 31,  1977; that he served as secretary to the American College of Surgeons and has been on its Board of Regents since 1974; that he was the first chairman of the Harvey Cushi ng Society Long-Range Planning  Committee and became president of that Society in  1979, entitling his presidential address “A Nobleness of Purpose” J. Neurosurg 53: 137-43,  1980).

He has been an officer in the American College of Surgeons and the American Surgical Association, a member of the Board of Trustees at the American Board of Neurological Surgery, an honorary member of the Society of British Neurological Surgeons. He is currently the chairman of the Journal of Neurosurgery editorial board.

He became chairman of the Department of Surgery at the University of California, Los Angeles, but retained the direction of the residency program in neurological surgery at that institution.

Nobleness, tenacity, professional and personal excellence, a good memory, preparedness, and a capacity to enjoy many things-all are characteristics of Eugene Stern that, combined with chance, made him the influential and beloved man that he is.

Don Becker

Dr. Stern’s Greatest Love and Passion

Throughout his career, Gene’s greatest love and passion was reserved for his residency program and the residents, whom he treated like extended family. His teaching was superb. It was a marvel to participate in Saturdays, which began with a 1.5-hour teaching conference led by Gene, followed by a meeting of faculty and residents in his office, where the residents presented in depth the operative cases coming up that week; then lunch followed by teaching rounds, where Gene saw every hospital inpatient with

the residents and did a general and neurological examination on them, demonstrating the principles of those examinations and developing a doctor-patient bond. It is no wonder that the residency at UCLA was ranked as one of the best in the country.

The best way to learn of his high moral integrity, magnificence as a role model, and unique philosophy of developing and maintaining a teaching/training program is to watch the almost 1.5-hour interview conducted by Ulrich Batzdorf, a former resident and faculty member of his, that was filmed in the early 1990s at an AANS annual meeting; it can be seen via Google or Facebook.

From the US Department of Justice -Drug Enforcement Administration Diversion Control Division

Final Rule – June 2023

Federal Register Notice

The Final Rule, Reporting Theft or Significant Loss of Controlled Substances(DEA574), published on June 22, 2023, in the Federal Register under citation 88 FR 40707.  This rule amends DEA regulations regarding DEA Form 106, used by DEA registrants to report thefts or significant losses of controlled substances, to require the DEA Form 106 be submitted electronically, and clarifies the timeframe registrants have to complete the necessary documentation.

Effective July 24, 2023, registrants will be required to submit all DEA Forms 106 electronically (online) through DEA’s Diversion Control Division secure network application.  After July 24, 2023, DEA will no longer accept paper submissions of the DEA Form 106.  Thus, eliminating all paper submissions of the DEA Form 106 after July 24, 2023.

This Final Rule also requires a timeframe on the submission of the DEA Form 106.  Registrants will have 45 days, after discovery of the theft or loss, to complete and submit an accurate DEA Form 106 through the DEA Diversion Control Division secure network application. 

This final rule does not change the requirement that registrants preliminarily notify the DEA Field Division Office in their area, in writing, of the theft or significant loss of any controlled substances within one business day of discovering such theft or loss. 

For further information, please contact

Scott A Brinks, Regulatory Drafting and Policy Support Section, Diversion Control Division, Drug Enforcement Administration; Telephone: (571) 776-3882; Email:

Innovators in Neurosurgery

The Rainey Brothers

Editor’s Note:

In this issue, we start publishing articles about Innovators in our field whose contributions led to their names being used daily. These articles are published with permission from Elsevier, the publisher of World Neurosurgery, in a chapter titled “Eponyms of Cranial Neurosurgical Instruments: An International Collaboration to Optimize the Field of Neurosurgery,” by Lukasz Strulak 1Ferda Gronki 2Kaveh Shariat 1Daniel Schöni 1Alex Alfieri 1 3

World Neurosurgery

Volume 153, September 2021, Pages 26-35

The closing and opening of a craniotomy have always been time-consuming tasks. Improving mechanical hemostasis and the time required to achieve it reduces not only blood loss but also shortens operating time—a technique facilitated through the development of Raney clips (Figure 6B).33,34

Frazier first described hemostasis through manual pressure in a report from 1906.34 In 1927, Anatole Kolodny introduced the angular hemostatic forceps, and Henry Souttar described small steel clips that could be applied with forceps to the incision margins.34,35 As various solutions for clips were being proposed on an international platform, the Raney brothers introduced their hemostatic spring scalp clips in 1936, and since then have become one of the most popular solutions for hemostasis of the scalp.34 They decided against filing a patent for the public benefit.33

The Raney brothers (Figure 6A) were born in Loogootee, Indiana. Rupert was born on October 16, 1900, and Aidan was born 11 years later.33,36,37

The brothers graduated from Creighton University School of Medicine in Omaha, continued their education both as residents at the LA County General Hospital and later had a practice together in Los Angeles, working most of their lives in California.33,36,37 Both brothers were distinguished neurosurgeons and known as the “Raney Boys.”33,36 Aidan served from 1942 to 1946 with distinction as a surgeon with the Third Auxiliary Surgical Group of the United States Army and later became a clinical professor of neurosurgery at the University of Southern California School of Medicine.36 Rupert was elected president of the Academy of Neurological Surgery in 1954 and, together with his brother, published multiple medical articles.37 Aidan Raney died at the age of 91, on May 13, 2002, and Rupert Brandon Raney at the age of 58, on November 28, 1959, in Los Angeles, California, USA.33,36  

Quote of the Month

Picture of Anthony DiGiorgio, DO

Anthony DiGiorgio, DO

Single-Payer System in California | Unintended Consequences

Academic Corner

California is at it again.

California State Senator Scott Wiener is investigating a single-payer system in California.  Senate Bill 770 would be another step on the way toward achieving this goal.  All California neurosurgeons should look at this bill and make their own judgments.  There are some parts of the bill worth highlighting. 

Section “d” of the bill seeks to eliminate all distinctions between Medicare, Medicaid, and private insurance.  This would essentially make any insurance outside of that provided by the state of California illegal.  While I’m sure a few tears would be shed for Anthem, Aetna, Cigna, and Humana, many patients and doctors would be in for a rude awakening when they go to use their new universal California coverage.  The bill states that Medicare will be the starting point for rate-setting physician and hospital payments. 

These rates will be nowhere near private insurance rates and likely below that of Medicare.  The average American has approximately $13K in annual health expenses.  Covering all of California with no out-of-pocket costs would total half a trillion annually.  This is greater than the total budget for California right now. 

Medi-Cal covers approximately 15 million Californians now.  Another bill currently in the California legislature would raise Medi-Cal rates to 87.5% of Medicare.  There’s no way to give nearly 40 million people coverage that pays private insurance rates when the current state-run system can only pay 87.5% of Medicare rates on 15 million people. 

The unintended consequences of this would be problematic.  Many private practices would likely have to close if California rates were set below Medicare’s.  I ask my colleagues in CANS if their practice could survive on 87.5% Medicare. 

Administrative price controls always cause shortages.  That’s an economic fact.  One only needs to look at our Canadian counterparts to see what happens to wait times.  Over 50,000 Canadians travel to the US annually for medical care due to excessive wait times.  The Canadian Supreme Court even said private insurance should be allowed as the public infrastructure isn’t meeting its promise of timely care.  39% of Canadians must wait over two months to see a specialist, while only 6% of Americans wait that long. 

Patients in California would be unlikely to accept long wait times, also.  If private insurance is illegal, the only other option is cash-pay.  This would create a two-tiered system.  Those that could afford it would move to cash-pay services, such as direct primary care models that charge monthly subscriptions.  The resulting two-tiered system would be more inequitable than our current system.  If cash-pay is banned, that would be even more inequitable, as patients with means could easily travel across state lines for needed medical care, leaving behind all the people who can’t afford such a luxury.  Cash-pay clinics and surgery centers would pop up all over Nevada and Arizona for patients who don’t want to suffer through California’s wait times. 

There is also a real risk in trusting the federal waiver system.  The federal taxes Californians pay now partially go to the national Medicare pool, which is then re-distributed to the country as a whole.  California would need a federal waiver to ensure those dollars stay in the state to help fund the single-payer system.   A subsequent administration could take that waiver away if the federal government grants a waiver.  For California to go through the work of creating a single-payer system only to have a subsequent administration rescind the needed waiver would be catastrophic. 

This is not to say the current system is worthy of any praise.  Universal coverage is a worthy goal.  This can be achieved without moving to a single-payer system.  Countries like Germany, Switzerland, and Singapore have excellent systems that cover the entire population through a highly competitive insurance marketplace.  A system like this gives patients ultimate control over their coverage, their choice of providers, and their own health care.  We should strive for a system like this, universal coverage without a single-payer system.


June is Alzheimer’s and Brain Awareness Month

June 1 – A study by an international scientific group, “Earth Commission,” published in the journal Nature looked at climate, air pollution, phosphorus and nitrogen contamination of water from fertilizer overuse, groundwater supplies, fresh surface water, the unbuilt natural environment, and the overall natural and human-built environment. The study found that Earth has pushed past seven out of eight scientifically established safety limits and into “the danger zone,” not just for an overheating planet that is losing its natural areas but also for the well-being of people living on it. Only air pollution wasn’t quite at the danger point globally.

The study found “hotspots” of problem areas throughout Eastern Europe, South Asia, the Middle East, Southeast Asia, parts of Africa, and much of Brazil, Mexico, China, and some of the U.S. West — much of it from climate change.

Earth Commission co-chair Joyeeta Gupta, a professor of environment at the University of Amsterdam, said at a press conference: “If planet Earth just got an annual checkup, similar to a person’s physical,” … “our doctor would say that the Earth is really quite sick right now and it is sick in terms of many different areas or systems, and this sickness is also affecting the people living on Earth.”

June 2 – State Farm, the largest property insurance provider in the State of California, announced that it would stop writing new homeowner’s insurance policies in the state because of “rapidly growing catastrophe exposure,” such as climate change and its implications, including wildfires and floods.

June 4 – Allstate, California’s fourth largest property and casualty insurance provider, announced that it would stop selling new homes, condominiums, or commercial insurance policies in the state. According to the company, this was prompted by worsening climate and higher building costs, making it harder to do business in the nation’s most populous state.

June 5 – 98% of the 65,000 actors and members of the Hollywood Union SAG-AFTRA voted to authorize a strike if they don’t agree on a new contract with major studios, streamers, and production companies by June 30. Meanwhile, the writers continue to be on strike.

June 7 – Another unmistakable sign of Climate Change: the wildfires from Canada have resulted in thick smoke that is now seeping South and Southeast, affecting the Northern US states, And the Eastern Seaboard. NYC and Washington DC were particularly affected; even NY Yankees postponed two games.

Data from NOAA on Wednesday, June 7, 2023

Wildfire smoke casts a haze over the National Mall on Wednesday in Washington, D.C., Chip Somodevilla/Getty Images

The Statue of Liberty, covered in a haze-filled sky, is photographed from the Staten Island Ferry Wednesday, June 7, 2023, in New York. (AP Photo/Yuki Iwamura)

June 8 – World Oceans Day

June 9 – A 200 lbs. black bear, affectionately called Franklin, roamed the streets of Brookland, a densely populated neighborhood in Northeast DC, ending up perched on a tree on Franklin Street for hours, causing significant slowdown traffic; he seemed oblivious to the commotion. Is this a manifestation of climate change? I was at this exact spot on June 2nd, driving my grandchildren to school.

June 10 – Mont Saint Michelle Abbey celebrates 1000 years since the start of construction. It is one of the first sites on the UNESCO World Heritage List. I consider myself fortunate to have visited this world’s marvel in 2018.

June 13 – World Day Against Child Labor. Representatives Raul Grijalva (D-AZ) and Raul Ruiz (D-CA) introduced the Children’s Act for Responsible Employment and Farm Safety, or CARE Act. It seeks to raise the minimum age for farm work from 12 to 14, repairing a carveout from the era of the Jim Crow 1930s that permitted children to work on farms at two years younger than in other sectors. Congressman Ruiz stated that this bill has exemptions for family farms. It is intended not to stop the passing of farming knowledge from parents to kids.

June 13 – A Texas patient safety bill, HB 1998, was signed by Texas Governor Greg Abbott; it is aimed at closing a “Dr. Death” loophole. It’s now a class A misdemeanor to lie on a medical license application. Physicians convicted of a  felony or misdemeanor related to moral turpitude won’t be allowed to practice in the state, and those who had their license restricted or revoked in another state won’t be allowed to practice in Texas. The Texas Medical Board will have to update profiles on its website within 10 days of notification of any disciplinary action against a physician. Monthly monitoring of physicians will also be required with the National Practitioner Data Bank. The bill comes five years after Christopher Duntsch, MD, Ph.D., a neurosurgeon, nicknamed “Dr. Death,” was sentenced for killing or injuring multiple patients.

June 14 – Commemorates the adoption of the flag of the United States in 1777 by resolution of the Second Continental Congress.  Here is the text of the Flag Resolution: “Resolved, That the flag of the thirteen United States be thirteen stripes, alternate red and white; that the union be thirteen stars, white in a blue field, representing a new constellation.” In 1916, President Woodrow Wilson issued a proclamation officially establishing June 14 as Flag Day; on August 3, 1949, National Flag Day was established by an Act of Congress – Old Glory; Stars and Stripes; The Star Spangled Banner – Beautiful names for Our Proud Symbol: Oh Long May it Wave O’er the Land of the Free and the Home of the Brave!

Poster commemorating the 140th Flag Day on June 14, 1917

June 14 – According to a federal indictment filed in US District Court for the Middle District of Pennsylvania, a former morgue manager at Harvard Medical School faces federal charges for allegedly stealing, selling, and shipping human body parts. Cedric Lodge, 55, who worked at the medical school’s morgue in Boston, “stole dissected portions of donated cadavers, including…heads, brains, skin, bones, and other human remains, without the knowledge or permission of (the school) and removed those remains from the morgue in Massachusetts and transported them to his residence in New Hampshire,” the federal indictment. “We are appalled to learn that something so disturbing could happen on our campus,” a spokesman for the Medical School said.

Brian Snyder/Reuters

June 14 – Adriana, a roughly 80- to 100-foot fishing boat that set sail last week from eastern Libya hoping to reach Italy with people from Syria, Egypt, and Pakistan Adriana, capsized. At least 81 people are dead. Greek authorities said there were hundreds more people aboard, including women and children below deck, when it sank in one of the deepest parts of the Mediterranean in the dark early hours of Wednesday. They blamed smugglers for a disaster that may have been one of the worst of its kind.

A picture released by the Greek Coast Guard shows Adriana’s decks packed with migrants before it sank. The ship is unlikely to be retrieved from the sea floor. Credit…Greek Coast Guard, via Agence France-Presse — Getty Images

June 15 – A new survey published by KFF, formerly known as the Kaiser Family Foundation, a nonprofit health research group, found that a majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills, and a dearth of doctors in their plans. Those who were most likely to need medical care reported more trouble, and three-fourths of those receiving mental health treatment experienced problems.

June 15 – Mount Pinatubo in the Philippines exploded on this day in 1991 in one of the biggest volcanic eruptions of the 20th century, killing about 800 people. This week, the Philippines’ Mayon volcano began a gentle eruption. And overnight, a deep 6.2 magnitude earthquake shook part of the Philippines.

Mayon Volcano – AP News

June 16 – Cyclone Biparjoy, which means disaster in Bengali, made landfall in the western part of India near the town of Naliya in the western state of Gujarat, near the border with Pakistan. Tens of thousands of people in both India and Pakistan have been evacuated from vulnerable areas: 100,000 people In India; 73,000 people in Pakistan.

June 18 – Father’s Day
June 19 – Freedom Day – Emancipation Day – on this day in 1865, Gen. Gordon Granger of the Union Army ordered the freedom of more than 250,000 enslaved Black people in the state of Texas. It was the last stop on a long march for Union troops across the Confederate South, freeing the enslaved as they went. The first documented Juneteenth celebration took place in Galveston the following year. On this day in 1980, I became a Naturalized Citizen of this Amazing Country.

June 20 – World Refugee Day. The United Nations designated this day as an international day to honor people who have been forced to flee their home country to escape conflict or persecution.

June 21 – Summer Solstice.

A group of druids, pagans, hippies, residents, and tourists gathered around a prehistoric stone circle on a plain in southern England on June 21 to express their devotion to the sun. AP Photo/Kin Cheung.

June 21 – According to test scores released from the National Assessment of Educational Progress NAEP, the math and reading performance of 13-year-olds in the United States hit the lowest level in decades. The last time math performance was this low for 13-year-olds was in 1990, and in reading, it was 2004. Performance fell significantly since the 2019-2020 school year when the coronavirus pandemic wrought havoc on the nation’s education system. But the downward trends reported today began years before the health crisis. That is very disappointing information. Perhaps we need to rethink our approach to educating our children.

June 22 – the Census Bureau released data indicating that the median age in the United States reached a record high of 38.9 in 2022. This is a rapid rise. In 2000, the median age was 35; in 1980, the median was 30. However, we remain younger than Europeans; Europe’s median age is 44.

June 23 – 51st anniversary of Title IX, the part of the Education Amendments Act of 1972 that prohibited any school or education program that receives federal funding from discriminating based on sex. This measure updated the Civil Rights Act of 1964, and while people today tend to associate Title IX with sports, it actually covers all discrimination.

June 27 – National Orange Blossom Day.

June 28 – A heat dome in the South is creating dangerous conditions, with Arizona, New Mexico, and Texas seeing temperatures in the 100s today.


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


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

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 ( or fax (916-457-8202).

The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.

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CANS Board of Directors

CANS Board of Directors