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CANS President
CANS Influence on our National Organizations
As April arrives, it appears clear that California’s drought-fed thirst has finally been quenched. In fact, the heavy storms over the last three months have produced record snowpack levels. Here in Central California, the local rivers are full, and Tulare Lake has started to fill. As our La Nina conditions change to El Nino, some of our old problems have disappeared and been replaced by new ones.
April also brings us the 2023 AANS meeting in Los Angeles. Along with it comes the spring meeting of the Council of State Neurosurgical Societies. CSNS, along with the component state neurosurgical societies, is the primary grassroots mechanism to address the socioeconomic concerns of the working neurosurgeon. Your California Association of Neurological Surgeons is our nation’s largest such society and has been extremely well-represented nationally and has been very influential over the years. Our 2019 CANS president, Dr. John Ratliff, is the current CSNS chair. Congratulations are due to one of our CANS Directors, Nicole Moayeri, who will be the new head of the Medical Directors subsection, taking over from another CANS member, Sherry Taylor, who has served on this committee for many years.
One of the primary activities of the CSNS is the resolution process. Resolutions are statements brought to the floor of the CSNS by delegates for discussion, editing, and voting. The passed resolutions directly affect the CSNS, AANS, and CNS operations and agendas.
CANS members have been extremely active this year, authoring or co-authoring 12 of the 17 proposed resolutions presented at this spring meeting. If passed, these resolutions will influence much of the agenda for the AANS, CNS, and Washington Committee. The spectrum of topics being addressed is broad. It encompasses topics including medical staff proceedings, EMR burdens, medical treatment of migrants, hospital administrator accountability, the role of private equity in neurosurgical practices, and more.
I encourage your participation in this process. CANS is your conduit to be heard. Please reach out to any of the board members or me if you have particular issues that you would like to discuss or bring up. I hope to meet with as many of you as possible at the AANS meeting and discuss your aspirations and concerns.
Lastly, I would like to make some remarks on our Ablin Award winner, Fr. Gregory Boyle, founder of Homeboy Industries, the world’s largest gang rehabilitation and re-entry organization. He is a best-selling author of books including “Tattoos on the Heart” and “The Whole Language.” Due to inclement weather, Father Boyle could not attend our annual meeting in Riverside. On St. Patrick’s Day, 2022-23, CANS President Javed Siddiqi, 2008-9 CANS President Moustapha AbouSamra and myself made our way to Father Boyle’s office on the outskirts of Los Angeles Chinatown to sit down and chat with “G-dog.” Father Boyle struck me with his irrepressible good cheer, true brotherly love, and friendship toward the “homies.” His glass-walled office is front and center in the crowded lobby, a whirlwind of activity. Gestures of hugs seemed to be exchanged through the glass wall every few seconds between Father Boyle and the many homies walking by, some with their wives and children. A visionary, his most striking message to me was that Homeboy Industries was not a place where people were told what not to do but rather a place where everyone, no matter where they came from or what they may have done in the past, has a place to belong where healing may be found. I encourage you to learn more about and support the work of Homeboy Industries at www.homeboyindustries.org.
CANS Newsletter Editor
In this issue, we have a new feature, a profile of our president, who is hard at work planning the next annual meeting and running our association’s day-to-day operations. I admit that I am at fault for not having published a profile of our 2022 president, our immediate past president Javed Siddiqi. But, since it is better late than never, I plan to correct my error and publish his profile next month.
Linda Liau, chair of Neurosurgery at UCLA, wrote this month’s Women in Neurosurgery column. We are fortunate to have such an accomplished neurosurgeon, academician, clinician, leader, and teacher share the wisdom she imparted to her medical students. Her “three commandments,” though simple, are very relevant to each of us. Please see a write-up about her in FOCUS https://thejns.org/doi/abs/10.3171/2020.12.FOCUS20954
President Joseph Chen led a group of us to a visit with Father Gregory Boyle, who was awarded the Ablin Award during the January CANS Annual meeting, to present him with his plaque since he could not attend. Please see a summary of this visit and a profile of a humble man who deserves this award and more. And it should be no surprise that this newsletter mentions Father Boyle on three separate occasions.
Adela Wu wrote a pictorial essay about Wilder Penfield and his contributions to neurosurgery in this month’s Innovators in Neurosurgery Column. We are excited that This column will become a regular feature in our newsletter.
In his Academic Corner Column, Anthony DiGiorgio made strong arguments in favor of Private Practice and Private Ownership in Healthcare. Coming from an academician, the statements are all the more powerful.
Past President of CANS and Vice Chairman of the NeurosurgeryPAC, Ken Blumenfeld, wrote about the reasons we must support the PAC, our PAC. Please read and contribute if you can.
Both the Quote of the month and the Photo of the Month were expanded; there was more than one quote and more than one photo. The Editor took his prerogative to turn each into a mini-essay.
Also included in this issue are all the regular columns.
As always, my editorial committee and I welcome all suggestions and criticism. Please e-mail me at mabousamra@aol.com or call me at 805-701-7007 if you prefer to discuss any issue directly with me.
I hope you will enjoy this issue.
At CANS, we’ve had presidents from the worlds of Private Practice, Academic Practice, Large Groups Practice, and Alternative Practice, such as Locum Tenans. However, we never had a president with the experience of Joe Chen.
Joseph Cheng-Thai Chen was born on March 12, 1965, in Bangkok, Thailand, to a Chinese father and a Vietnamese mother. The Chen family immigrated to the US when Joe was two years old. He had a typical childhood in Southern California while his aerospace engineer father worked at Lockheed.
Dr. Chen received his BA in Biology from Johns Hopkins. This was followed by Medical Scientist Training at New York University Medical Center, Medical School at New York University, and Neurosurgical Training at Los Angeles County-University of Southern California Medical Center. Joe also had Functional Neurosurgery training in Grenoble and Lyon, France. He does have a particular interest in cranial base tumors and radiosurgery.
Joe is married to Lisa, an OR nurse. They have two children. Lisa Marie is a program analyst at the USDA in Alexandria, Virginia, dealing with food insecurity. She is completing an MPH at Johns Hopkins University in May. Malcolm is attending Pasadena City College while he explores his options.
Dr. Chen’s favorite authors are Gabriel Garcia Marquez and Milan Kundera. And to stay fit, he enjoys riding his bicycle. He also likes to travel.
Joe worked at Kaiser for fifteen years and now works as Chief of Neurosurgery Service, at Kern Medical Center, Bakersfield, California, and Medical Director, Neurosurgery, at Kaweah Delta Hospital, Visalia, California. He also held an academic appointment at UCSD early in his career and continues to hold academic appointments in the Department of Neurological Surgery, Keck School of Medicine, University of Southern California.
While Joe’s patients at Kaiser were mainly from the middle and working-upper class, his patients now are similar to those he served as a resident at the LA County General Hospital; they have far more complex health and social issues than those seen at Kaiser. So, Joe’s experience includes treating patients from all socioeconomic levels and various healthcare institutions. He is concerned about the state of healthcare and the social determinants in underprivileged communities. He also worries about risk mitigation to compensate for systemic inadequacies in the local healthcare environment.
Dr. Chen is uniquely qualified to serve as President of CANS in these changing and challenging times.
We were privileged to visit with Father Greg Boyle in his office at the headquarters of Homeboy Industries in Los Angeles on St. Patrick’s Day. President Joe Chen, Lisa Chen, Past president Javed Siddiqi, Seema Siddiqi, Joanie, and I enjoyed a warm and very touching exchange that lasted a bit over an hour. Mark Linskey, as chairman of the Awards Committee, deserves the credit for deciding not to give the Ablin Award to a politician as it had been the custom, rather to a better deserving individual. And the choice of Father Boyle was … inspired. Unfortunately, Mark could not attend this meeting, which was planned in order to deliver the CANS Plaque/Award to Father Boyle, since Father Boyle was not able to attend the annual meeting due to the fact that Southern California was experiencing what is now a common occurrence, one of its atmospheric rivers.
Father Greg, alternatively called Papa, G, and G Dog, was in his element in an office accessible to his “Homies,” whom he frequently refers to as his “Heroes.” In fact, during our visit, we were interrupted a few times by homies who wanted to introduce their families to their own Hero. And while he was talking to us, Father Greg would frequently signal to people outside the glass windows and doors of the office, with a hugging signal as he crosses his arms against his chest, or with a love signal, as he taps his right hand over his heart. Love and affection were abundant and flew both ways between the Homies and Father G.
Gregory Joseph Boyle grew up in a happy family in Los Angeles and decided to receive a Jesuit Education. He liked being with Jesuits, intelligent, inquisitive, and happy people. He joined them and eventually became a Priest in his early thirties. His first assignment took him to the Delores Mission Church, in a neighborhood with many gangs and gang members. He was the youngest priest in the Los Angeles Archdiocese. He also strongly felt that gang members were his parishioners and started reaching out to them. At first, they didn’t trust him, but he persisted.
Initially, he felt that he could make a difference by helping gang members find jobs, thus his famous saying: “Nothing stops a bullet like a job.”
Soon, he realized that young children/teenagers/adults joined gangs because of the abuse and trauma they suffered during childhood. So, he started providing counseling and an environment where they could heal. He also felt that “Gang violence is about a lethal absence of hope,” so he ensured that his homies were offered hope and jobs. Father Greg created a joyful place in the Homeboys Industries Headquarters where homies feel cherished. In fact, he is delighted that “the place itself is therapeutic … it has its own aroma … and the people sense it.”
While in Father Greg’s office, we felt in the presence of a wise, successful, but humble man who is compassionate and empathetic; He truly is a transformative figure. His office wall was adorned by many awards and photos of celebrities, including the Pope. However, more prominent were the photos of his “homies, his heroes.”
Father Boyle created a series of successful businesses to help give hope to his “homies.” He now has an emeritus role in his organization, which is run by professional staff. There are 100 senior staff members and 500 core members. He resisted the idea of franchising his idea but encouraged others to adopt the model while adjusting it to their local needs. There are about 300 programs modeled after the Homeboy Industries in the US and worldwide.
What Father Greg accomplished is nothing short of miraculous.
As we discussed his CANS award, I realized that G Dog does not need another recognition. But it also occurred to me that Sainthood is in his future.
NeurosurgeryPAC Vice Chair
AANS Southwest Regional Director
AANS Delegate to the AMA
Please Give to YOUR NeurosurgeryPAC
While a small percentage of California neurosurgeons reliably donate generously to the NeurosurgeryPAC, most contribute nothing. This needs to change.
There are lots of reasons why people decline to donate. A frequent comment is, “I can’t afford it.” While decreasing discretionary funds may be a reality, the truth is that we can’t afford not to contribute. There is no investment with a higher rate of return for neurosurgeons and our patients. Year after year, the NeurosurgeryPAC has outperformed. Take a minute to review the yearly “scorecards.” And if you are interested, click here to read the NeurosurgeryPAC 2022 report.
Another recurring concern is that the NeurosurgeryPAC doesn’t recognize the specific issues of importance to neurosurgeons. This is inherently untrue regardless of the practice mode (e.g., large group, solo, academic, or government based). Although many of us give to multiple political action committees (PACs) and candidates, the NeurosurgeryPAC should be the first stop on the way to neurosurgical advocacy. Simply put, the NeurosurgeryPAC is YOUR PAC, and no other PAC primarily represents neurosurgeons and the patients we serve.
Others have not contributed, stating, “I’m a Democrat or Republican.” Some object to giving campaign contributions to particular politicians. This represents a fundamental misunderstanding of how and what a PAC does. To dispel some myths, the NeurosurgeryPAC is strictly nonpartisan and supports those candidates who support neurosurgery’s advocacy agenda. In the 2022 election cycle, the PAC supported an equal number of Democrats and Republicans. The purpose is not to endorse candidates. Instead, the goal is to establish a connection with political candidates who are likely to gain office and understand or are at least willing to discuss our issues and concerns. The bottom line: access to our legislators is mission-critical to advancing neurosurgery’s advocacy priorities.
When it comes to political advocacy, we have far to go as a specialty. A culture of advocacy and giving must start in residency and continue throughout our careers. Other specialties do far better, and it’s frustrating to hear expectations, demands, and complaints from those who decline to be involved or invested.
Ironically, our NeurosurgeryPAC and Washington Committee have been tremendously effective — particularly given the small size of our specialty. We punch above our weight by forming alliances with the organizations like the American College of Surgeons, the American Medical Association, and the California Medical Association. Neurosurgery also has created and leads multiple Washington, DC-based coalitions — such as the Surgical Care Coalition, Alliance of Specialty Medicine, and Regulatory Relief Coalition — to help amplify our voice. NeurosurgeryPAC is also a leader in the Medical and Dental PAC group, allowing our PAC to leverage our contributions with others to gain more influence in the political space. In truth, we are the “tip of the spear” of medicine.
To maintain this level of advocacy, I humbly ask every member of CANS to contribute to our NeurosurgeryPAC. Give what you can. Feel good about your contribution. Ask your neurosurgical colleagues to give. It is money invested in our future that is critical to our success. Contributing is easy. Just click here to make your contribution today!
Ownership in Healthcare
Our current policy battlers (RVU reimbursement, prior authorization, tort reform, etc.) are essential. We also need to focus on the big picture. Physicians must regain ownership of healthcare, from private practice clinics to hospitals to large vertically integrated systems. By regaining control of the means of production, we can do what’s best for our patients. Physician ownership is the key to fixing American healthcare.
I greatly respect neurosurgeons who own their practices: the estimable Brian Gantwerker, my former chairman and still mentor Frank Culicchia. These doctors have ownership and skin in the game. They embody the American entrepreneurial spirit. Unfortunately, they are also a dying breed.
There’s no secret that physician ownership in healthcare is waning. Federal regulations are largely to blame, such as the cost of compliance, unfavorable payment policies (such as 340B), and the outright ban on physician owned hospitals. Instead of physicians, the decision-makers are from non-medical backgrounds, finance, business, and law.
Policies for physician ownership must focus on leveling the playing field between doctors and practitioners of corporate medicine. The regulatory burden on private practice must be reduced, including a scaling back of value-based metrics. These metrics favor hospital systems that can employ coders to game numbers in their favor. A small private practice stands no chance.
Government reimbursement must be equivalent across owners. A service should be reimbursed the same regardless of the site of service, and site-neutral payments would level the playing field. Handing out extra reimbursement to large systems just because the building is near a hospital puts physician-owned practices at another disadvantage. The Gantwerkers and Culicchias of the world should be reimbursed at least the same amount from government payors as the large hospital corporation down the street.
Of course, allowing physicians to own hospitals, and changing the portion of the Affordable Care Act law that prohibits it, is a significant hurdle. By banning physician-owned hospitals (POH), the healthcare industry ensured that physicians would never participate in the ownership of the most significant cost center: hospitals. Thanks to an effective ban (by prohibiting Medicare payments to POHs), physicians are barred from owning this meaning of production, instead relegated to work as corporate employees and middle management. With a lack of ownership, thus goes autonomy.
If physicians owned hospitals and if the private practice was competitive with corporate medicine, healthcare would have higher quality and lower costs. Competition would increase, hospital monopolies challenged, and patients would be given a greater choice and greater access to care. Hospitals and clinics would succeed by providing high-quality care at a lower price, not by extracting every tax-protected dollar from a myriad of legislative loopholes. Patient care would be prioritized, not coding queries.
Some of us would continue as employees. This is good as heterogeneity refines the market. My neurotrauma specialist and academician roles are tied to a large hospital system. However, a competitive market ensures that our employers provide at least an acceptable baseline level of job satisfaction and compensation. Exploitation cannot exist in a competitive market.
Our legislative priorities are important. Medicare cuts must be fought. RVUs pay the bills. However, these battles will be easier to fight and much less important if physicians have more ownership in healthcare. We must not lose sight of that.
Department of Justice – Drug Enforcement Administration
Federal Register Notice
Notice of Proposed Rulemaking – March 2023
On Friday February 24, 2023, DEA announced that it would be publishing two Notice of Proposed Rulemakings (“NPRM”) in the Federal Register which pertain to expanding patient access to prescriptions for controlled substances via telemedicine encounters. These two NPRMs, titled “Telemedicine prescribing of controlled substances when the practitioner and the patient have not had a prior in-person medical evaluation” DEA-407, RIN 1117-AB40 and “Expansion of induction of buprenorphine via telemedicine encounter” DEA-948, RIN 1117-AB78 published March 01, 2023, in the Federal Register.
These NPRMs may be found at www.regulations.gov. DEA encourages registrants to direct all comments and questions pertaining to these rulemakings directly on the proposed rules which may be found here, and here. For more information regarding DEA’s Diversion Control Division, please visit www.DEAdiversion.usdoj.gov.
FOR FURTHER INFORMATION CONTACT:
Scott A. Brinks, Diversion Control Division, Drug Enforcement Administration.
Mailing Address: 8701 Morrissette Drive, Springfield, Virginia 22152, Telephone: (571) 776–3882.
Also
To all DEA Registered-Practitioners
Dear Registrants: On December 29, 2022, the Consolidated Appropriations Act of 2023 enacted a new one-time, eight-hour training requirement for all Drug Enforcement Administration (DEA)-registered practitioners on the treatment and management of patients with opioid or other substance use disorders. Below is information on this new requirement.
Who is responsible for satisfying this new training requirement?
How will practitioners be asked to report satisfying this new training requirement?
How can practitioners satisfy this new training requirement?
There are multiple ways that practitioners can satisfy this new training requirement.
Group 2: All practitioners that graduated in good standing from a medical (allopathic or osteopathic), dental, physical assistant, or advanced practice nursing school within five years of June 27, 2023, and successfully completed a comprehensive curriculum that included at least eight hours of training on:
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What accredited groups may provide trainings that meet this new requirement?
Education (AACCME) or the Commission for Continuing Education Provider Recognition (CCEPR), whether directly or through an organization accredited by a State medical society that is recognized by the ACCME or CCEPR
Any other organization approved or accredited by the Assistant Secretary for Mental Health and Substance Use, the ACCME, or the CCEPR
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We hope this information is helpful. For information regarding the DEA Diversion Control Division, please visit www.DEAdiversion.usdoj.gov. If you have any additional questions on this issue, please contact the Diversion Control Division Policy Section at (571) 362-3260.
Sincerely,
Thomas W. Prevoznik
Acting Assistant Administrator Diversion Control Division
All Join Together with The Band
“In order to change the world, you have to get your head together first.”
Jimi Hendrix
The practice of neurosurgery, like all aspects of medicine, is regarded as an industry or service. We diagnose, treat, and hopefully cure diseases of the central and peripheral nervous systems. Training is long and vigorous, and we are notoriously critical of ourselves, our colleagues, and our trainees. We are taught to believe, quite early in medical school, that what we do is a noble profession. We are also, unfortunately, taught an implicit devaluation of our skillset.
It is rare that we see our mentors and peers openly fight for just treatment and just compensation. And, in practice, we are told by insurers how very little what we do is worth. This writing comes on the heels of over nine months of fighting with a state-run HMO, I have been forced to write off a very, very costly case.
The patient was very sick and had a pathological fracture due to osteomyelitis. I performed a lateral approach corpectomy and posterior fixation. He did relatively well. I monitored him with serial scans, inasmuch as I could get the HMO to approve, which took a slew of phone calls and paperwork to do. He missed a few doses of his antibiotic, and the hardware loosened as the infection came roaring back.
The cage was socked in and loose. I could not find a vascular surgeon willing to help me get back in, as I was concerned going back in, the ureters, vessels, and of course lumbar plexus itself would be very much at risk. I had done all I could. I felt uncomfortable doing anymore. Furthermore, I had no one to get me back there safely. I told the hospitalist and the case manager that he needed further treatment at an academic center.
The insurance plan delayed authorization for a week. Then the medical director called me, from the gym, and offered me a contract. I told him that they still had not paid me for the case I did four months ago, but more importantly, this patient needed treatment, at a higher level of care. The hospitalist and I documented day after day that this patient needed an academic level of involvement with a multidisciplinary surgical team, more than our community-level (albeit excellent) hospital could give them.
Ultimately, the insurance plan asked another surgeon to see the patient, and he was lost to follow-up.
We kept after the insurance plan, which kept declining the original claim. First, one office branch stated that another office branch was responsible. We would call that branch, and they would send us somewhere else. We trudged through the Byzantine system. Finally reaching the office we had initially contacted, we were able to submit it (six months later). The organization rejected our claim due to some “modifiers.” CCI edits were followed to the letter. We asked which modifiers. They wouldn’t say.
We finally wrote off the entire case, which was more than my father would make in a year. Did I want the whole bit? Of course – but I knew it was likely unreasonable to get or expect that. But in the end, the compensation was ZERO.
This is not the first nor last time it has happened to me. I am confident everyone reading this has gotten scammed into giving free care to these supposed charitable and state-mandated payers.
Ultimately, the patients get shuffled back and forth, shopped around like a commodity, and lose. This unfair system benefits only the administrators and medical directors of these plans. Many patients cannot see doctors for months and then end up in the Emergency Room with advanced or even terminal diagnoses.
Running a private practice, things cost money. Not needing to enumerate the various cost centers of just running a business. And when we add malpractice insurance, running this business becomes very costly. In fact, some practices’ overhead is at least a multiple of a teacher’s salary. I bring this up again because my father was a Chicago Public School teacher, and it is the only measuring stick I can keep returning to.
The continued cutting of reimbursements by CMS and the above story, which enumerates the hucksterism of many of the state-run insurance plans, threatens us all, not just in private practice but also in employed and academic positions. Any action we would take to preserve compensation will be spun as “greedy doctors” by the insurance lobby and ignored by the hospital associations.
What most working people might do in this situation is stage a strike. My father would, begrudgingly, on multiple occasions, attend. I went with him several times, held signs, and walked the line. He did not enjoy doing it. He also
really did not care for the president of the CTU and kept a cartoony picture of him as a duck (“Fearless Frank” – which he really did resemble) on the wall of his “office” in our basement, which doubled as our laundry room.
Now, as doctors, we never want to engage in this practice. Our patients might suffer, the ERs become packed, and then we play right into the hands of the narrators of the story we are fighting to change.
However, in 1975, doctors did just that. We got MICRA – the national model for tort reform (which we just blew up – but, this is a tale for another day). So, should we strike? How does that look?
Many house staff organizations across the country have unionized. The house staff at Cook County hospital, mostly experienced foreign medical grads practicing medical doctors and surgeons in places like Mexico, India, and Romania, have been unionized for almost 30 years. The house staff of the University of California hospitals have chosen to form a union. There are prohibitions to be sure for practicing physicians; the federal and state governments have made sure of that.
There are specific organizations based on blockchain technology that are trying to make a workaround. It is, in a way, a kind of guild. In a guild, the members have a shared trade and represent themselves. See here for a comparison: https://artisans.coop/blog/union-vs-guild-vs-cooperative-vs-collective-whats-the-difference/
The Directors Guild, Writers Guild, and SAG (Screen Actors Guild) are all examples of this type of entity. As we have seen, they exert significant influence on the largest industry in our state.
Now, imagine a Doctors Guild. We would have individual representation but not be subject to the restrictions on unionizing. Another option is a cooperative, where the organization negotiates as a group, but each member (or practice) still operates independently. The largest example in our nation is ACE Hardware. Growing up, my dad would take my brother and me to our local ACE almost every weekend.
Now that I know this, I will be frequenting them even more so.
With the recent Medicare cuts, many in our field consider opting out entirely. This would tremendously limit our seniors’ access. In the end, though, how many cuts can a business tolerate? This is in addition to the sequestration, the effect of inflation, and the fact that there has never been a Cost-of-Living Adjustment (COLA) to our payments. No other business would make less money every year and subsist.
Collective bargaining in some form, once many of our more starched colleagues get over the knee-jerk reaction of crying “Socialism!” might be our only option in the future. Our PACs are important tools, like a specialized adapter for interfacing with our elected officials. They need our help to keep the volume of our voices turned up. They can also be effective for individuals, but it is hard for them to be hyperlocal.
Our professional organizations are also important and excellent at getting us CMEs and networking. But they cannot deliver the kind of grassroots advocacy we need. Our state medical society has been, at times, a helper and a disappointment, though necessary to work with our state government.
Without some form of amalgamated voice, we will continue to be like Gregor Samsa (protagonist, The Metamorphosis by Franz Kafka), with our legs flailing in the air as our patients and our income get fleeced. We should consider some form of banding together because the current modus operandi has not worked, and without change, we will remain cannon fodder.
CMA files complaint about Anthem’s unlawful denial of claims for emergency services
The California Medical Association (CMA) has submitted a formal complaint with the California Department of Managed Health Care (DMHC) regarding Anthem Blue Cross’ ongoing pattern of denying payment for emergency department services in violation of California law. CMA is urging DMHC to formally investigate and take appropriate enforcement action to require Anthem to promptly reimburse physicians for denied emergency room services with
interest.
Physicians seeking federal public service loan forgiveness must have direct gov’t loan by May 1
The U.S. Department of Education has released the final rule on the national overhaul of the broken Public Service Loan Forgiveness Program (PSLF). Included in the rule is the specific fix sought by CMA, so that all eligible California and Texas physicians can participate in the program, despite our state prohibitions on physician employment by private non-profit hospitals. Physicians should be aware that to be eligible for the PSLF program, they must have a direct government loan or consolidate their loans into a direct loan by May 1, 2023.
What physicians need to know about the end of the COVID-19 state of emergency
California’s State of Emergency ended on Tuesday, February 28, 2023, while the federal public health emergency is scheduled to expire on Thursday, May 11, 2023. CMA has published a guide – End of the COVID-19 Emergency: What Physicians Need to Know – to help physicians navigate the end of the state’s emergency authority.
CMA sponsors bill to reform the broken prior authorization process
When insurance companies get between patients and physicians, patients get sicker and health care becomes more expensive. That is why CMA is sponsoring legislation to reform the prior authorization process, which will result in less time spent on administrative work, increased access to necessary care for patients and a restoration of the physician-patient relationship in medical decision-making.
Agenda now available for CMA’s first annual Health IT conference
Historic gains in health information exchange and the rise of consumerism are driving health technology’s evolving landscape. The future will be shaped by the evolution taking place today. CMA’s first annual Health IT Conference on May 22 – Health IT: Powering Value-Based Care – will help you and your organization get ahead of policy reforms and trends that will shape the future of medicine.
Lend your expertise and review loan repayment applications for CalHealthCares
With the most current CalHealthCares loan repayment grant application cycle closing soon, Physicians for a Healthy California (PHC) is looking forward to the next step in determining our Cohort 5 awardees – application review and scoring. To assist in this process, PHC is seeking volunteers from the medical and dental communities.
Cigna re-releases costly, burdensome modifier 25 policy
The California Medical Association (CMA) has learned that Cigna is re-releasing its policy to 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. The updated Cigna policy is scheduled to become effective nationwide on May 25, 2023.
MedPAC calls for inflationary Medicare physician payment update
Recognizing that physician pay has not kept up with the cost of practicing medicine, the Medicare Payment Advisory Commission (MedPAC) has called for a physician payment update tied to the Medicare Economic Index. CMA, the American Medical Association (AMA) and others in organized medicine have long championed this move and appreciate MedPAC’s acknowledgement that the current Medicare physician payment system is inadequate.
CMA opposes bill that would place unnecessary burdens on physicians treating pain
CMA is urging physicians to contact their legislators to ask for a no vote on a bill that would place misguided and unnecessary burdens on physicians trying to prescribe pain management. AB 1751—sponsored by the California Chiropractic Association—would require physicians to share information on and offer referrals to non-pharmacological treatments for pain and confirm with patient signature that this was done.
CMA announces 2023 priority bills
CMA recently announced its priority bill package for 2023, which includes legislation that would reform prior authorization, expand cultural and linguistic competency, streamline provider credentialing, protect physicians providing reproductive health care and more. Click the headline to read more about CMA’s seven priority bills.
Polyglots and Accents
I once read with interest an article in the New Yorker about polyglots.
https://www.newyorker.com/magazine/2018/09/03/the-mystery-of-people-who-speak-dozens-of-languages
The fMRI studies are very interesting. It seems that polyglots’ brains may be wired differently than the rest of us. Some of their abilities and personality traits are very interesting. But I noticed one factor was not mentioned: practice and frequency of use of any particular language related to fluency.
I speak four languages with varying levels of proficiency. So, I’m no polyglot since, by definition, the threshold is 11, and there is a move to make it 20. But I love languages, particularly because of the culture they portray and represent.
I learned French in grade school in Damascus, Syria; my school was Lycée Franco Arabe de Damas. We learned everything in French except for the Arabic Language and, eventually, Arabic Literature. We even studied the history and geography of Syria in French. I was fluent in French and Arabic throughout my schooling and certainly at the end when I received my “Baccalaureat.”
Starting in seventh grade, I learned English through French- not the best way. When I finished high school, I was not fluent in English. In retrospect, I think it is more logical to learn any additional language using one’s dominant language as the reference; in my case, it was Arabic. The need to survive in America led me to an immersion type of spoken American-English, with a New Jersey influence.
I learned conversational Spanish in San Antonio, Texas, while training in neurosurgery in my mid to late twenties. I could conduct a detailed neurological exam in Spanish and, with some help, would have a basic conversation with patients. Still, if I knew in advance that I needed to relay sensitive information to the patient or his/her family, I usually insisted on having a formal translator.
Here in America, we do not frequently speak other languages, and some say that English has become the “global bully language.” There is no doubt that it is the dominant world language. By contrast, people frequently speak two or three languages in Europe and other parts of the world.
About five years after moving to the US, English became my dominant language. One day I woke up and suddenly realized I was dreaming in English. Since, I’ve had a few Arabic dreams, mostly nightmares. I don’t dream in French or in Spanish.
Along the way, I forgot most of my French, a sad fact I faced disappointedly on a recent trip to France. The need to regain my ability to communicate better in French became obvious—more trips to France may be the solution.
What is worse is that my fluency in Arabic also suffered, and I prefer to communicate in English, even with my Arabic-speaking family members.
My Syrian-Damascene-Arabic accent is still unadulterated. As to French, I was interested to hear people I met in France complimenting me on my “good” French accent while feeling sorry for my poor French and my struggle to communicate. What about Spanish? I learned it mostly from communicating with Mexican and Mexican American patients in San Antonio, most of whom were immigrants. Some years later, I was surprised and flattered when a Mexican patient, a farm worker in Ventura, California, told me that my Spanish was “good” and that I spoke like a peasant; he meant it as a compliment.
And let me not forget English. I, personally, don’t think I have an accent. But I guess I do since, on occasion, I am asked: “where were you born?” When I became more fluent in my early days in New Jersey, I was frequently told that I spoke English with a French accent. Later on, after moving to Texas and on one of my trips to California, a store clerk exclaimed when she found out I lived in Texas: “gee, you don’t have a funny accent!”
In general, it is accepted that, for one to speak as a native and without an accent, one has to learn the language before puberty, an observation that was repeated in this article; afterward, the brain starts losing plasticity. I don’t know how to explain my Spanish Mexican accent, which I acquired in my late twenties. I am proud of it!
And it is also accepted that it is never too late to learn another language, or better yet, to improve one’s fluency in a language. I know, in my case, English, yes, English.
I plan to take advantage of my frequent flyer miles when I travel both here in America and abroad, maybe I’d improve my English and learn more languages.
Frances Perkins, the first woman to serve in a president’s Cabinet in 1933, said after her first Cabinet meeting: “I tried to have as much of a mask as possible,” … “I wanted to give the impression of being a quiet, orderly woman who didn’t
buzz-buzz all the time. … I just proceeded on the theory that this was a gentleman’s conversation on the porch of a golf club perhaps. You didn’t butt in with bright ideas.”
As Labor Secretary, she helped develop plenty of bright ideas, including Social Security. She argued that “Out of our first century of national life we evolved the ethical principle that it was not right or just that an honest and industrious man should live and die in misery. He was entitled to some degree of sympathy and security,” Perkins stood behind President Franklin D. Roosevelt when he signed the Social Security Act in 1935, the only woman in the now historic photos of the event.
W. Eugene Stern, Professor & Chair of the UCLA Department of Neurosurgery
David Geffen School of Medicine, University of California, Los Angeles
Inspiring Medical Students
In 2019, before the COVID pandemic, I had the honor of being the Keynote Speaker at the White Coat ceremony for the entering class at the David Geffen School of Medicine at UCLA:
https://www.youtube.com/watch?v=M-WB1Zzmdv4. This year, as we approach graduation for the M.D. Class of 2023, several of the women medical students that I helped to welcome four years ago have inspired me to reflect on what I told them on their first day of medical school:
“Congratulations to the Class of 2023! It is truly an honor to be able to speak here to all of you today.
Congratulations to all of you for reaching this exciting milestone in your life and your career. You all undoubtedly have worked hard to get to this point, and you and your families must be so very proud! You are about to embark on an amazing journey. I can think of no other profession that has so much purpose, honor, duty, respect, and compassion. Although it has been over 30 years since I started medical school, I still am in awe of what I get to do every day. I get to touch people’s lives in a way that nobody else other than a neurosurgeon or a neurosurgeon-scientist can do… I get to touch their brains (literally), to pique my curiosity in the research lab, and to talk to and teach young people like all of you. I think it is amazing that I actually get paid to do what I do. And this is what I wish for all of you – that you find a career and a profession that you truly love and will continue to be passionate about 30 years from now.
When preparing this talk, it was suggested to me that I tell you a little about my own journey. Well, my parents immigrated to the United States in the 1960’s to a small college called Wittenberg University in Springfield, Ohio. When I was a young child, I began to realize that nobody else around me looked like me. I think we were the only Asian-American family in Springfield, Ohio 50 years ago, so everyone stared at us when we were at the park or the local K-mart. I kind of felt like I was from another planet. But, I remember that whenever the other kids would make fun of my name, slant their eyes, or ask me if I knew kung-fu (which I don’t), my mom used to always tell me that I was “special” and that I was put in this strange new world to “make things better.” Because I believed everything my mom told me at the time, I really took that to heart. And to this day, even when I am in a room full of white male neurosurgeons, I think that I am 6’-feet tall (even though I’m only 5’2”), and I tell myself that I belong here to “make things better”. So, in case any of you ever feel that you are different from your peers or that you somehow don’t belong, please remember that each and every one
of you was chosen to be here in those seats because you have a special gift, and you are now being given the privilege to “make things better” as our future doctors to be.
When I entered the field of neurosurgery almost 30 years ago, there were only about 20 board-certified women neurosurgeons in the whole country; and to this day, it is still a very male-dominated field. So, I’ve often been asked if I have ever felt discriminated against. Ultimately, my answer to that question is “no”. It’s not that people haven’t done things to me that could be construed as being unfair or discriminatory; on the contrary, I’ve often gone home crying and can fill books with all the stories that I could tell. But, in the words of Eleanor Roosevelt, “No one can make you feel inferior without your consent.” You oftentimes cannot control what other people say or do (i.e., patients, colleagues, attendings), but what you can control is your response to what happens around you. And your response should always be to be the better person, and “do what’s right.” I think medicine has a higher calling – it is a profession that can give you enormous purpose beyond yourself. But, in order to gain that purpose and mastery of your field, it is important to be introspective and embrace the opportunities for life-long learning and improvement.
To give you a personal example, when I was a junior resident, one of my attendings told me that women should not do neurosurgery because we simply lacked the 3-D visual-spatial skills for such a highly technical field. After crying about this insensitive comment, I realized that I really could not change his views or opinions unless I could prove him wrong. However, the reality of the matter was that I really wasn’t as skilled surgically at that point in my training, especially when compared to one of my senior co-residents, who somehow was able to tie knots forward and backward with one hand and dissect out blood vessels in the brain with incredible ease and finesse. So, I asked him for help to teach me how he tied knots and held surgical micro-instruments. And I scrubbed in on every brain tumor and aneurysm case that I could, even when I was not on-call. By the end of my residency, after hundreds of hours of extra hard work and practice, I think I was able to get that attending to change his mind about women in neurosurgery, and I became the first woman faculty member in our department. And, as for that co-resident who helped me to develop the skills and confidence to be a better brain surgeon, he eventually became my husband and we’ve been happily married for the past 22 years.
Finally, the last anecdote that I wanted to share is just to remind you to “be kind.” Several years ago, I happened to be walking in the hallway in the operating room in my nondescript scrubs, and a visiting medical student that I had not met before spilled a pan of water on the floor. He then came up to me and demanded that I clean it up. I think he thought that I was one of the scrub nurses, but he was very rude and impolite. Nevertheless, it was true that the puddle needed to be cleaned up or else someone could slip and fall, so I went ahead and cleaned it up while the medical student walked away. Later on, I met that student again when he was interviewing for residency slots, and when he realized we had met before in a different context, he was so embarrassed that he couldn’t carry on the conversation. So, the moral of this story is that you should always be kind to everybody, regardless of who you think they may be.
So, my message to all of you today, as you may have noticed, follows the framework of the David Geffen School of Medicine’s Cultural North Star that Dean Kelsey Martin introduced to you earlier this week. So, as you embark on this phenomenal new journey into the house of medicine. Please be guided by these 3 pillars:
Congratulations again on this wonderful rite of passage as you get your white coats today! I hope that you all will do amazing things here at UCLA and beyond in the years to come, and I am confident that you can do exceptionally well if you always remember to do good! Thank you!”
National Women Physicians Day
Well, I missed it. Chances are you did too.
National Women Physicians Day was February 3, the birthday of Elizabeth Blackwell, the first woman to receive a medical degree in the U.S. at Geneva Medical College in 1849. This college eventually became the State University of New York at Syracuse, where I was the second woman to finish its neurosurgery residency program. My predecessor had a baby during her residency year of lab work, perhaps a first at that time. National Women Physicians Day was not established until 2016, thirty years after I finished medical school.
According to the Association of American Colleges (AAMC), women comprise 37% of practicing physicians. They are most represented in pediatrics (65%) and the least in orthopedic surgery (5.9%). For residency programs, women currently fill most of the obstetrics-gynecology slots (86%) and least the orthopedic surgery (sports medicine) positions (10.7%).
In 2021, there were 5,744 practicing neurological surgeons, with 551 identifying as female (9.6%). Of the 1393 neurosurgical residents in 2021, 309 were women (19.7%).
I have a friend who lives in China and whose husband is a neurosurgeon. I was curious to know the percent women surgeons in China. When I was in Beijing in 1997, I operated with a woman general surgeon, but I do not remember seeing any other women surgeons. According to the data from my friend, in 2020, 42% of doctors were female. In 1995, the China Medical Women’s Association was created, and currently, they have 35,000 members. At China’s first Women Neurosurgical Professional Committee conference in November 2022, the reported percentage of women neurosurgeons in China was 0.4%. The most common surgical subspecialties for women surgeons in China are thyroid, breast, gastrointestinal, and hepatobiliary/pancreatic.
March 8 was also International Women’s Day. My friend from China told me that they have a half day of rest in celebration. The date March 8 also roughly coincides with the calendar day of pay equity for women. According to the March issue of the AARP Bulletin, U.S. women earn 83 cents for every dollar that a man makes.
And March is Women’s History Month, established in 1987. Jimmy Carter started the idea with Women’s History Week in 1980.
As I near another birthday (April 8, also Harvey Cushing’s birthday), I’m reflecting on what I have seen too little of during my career:
And I’m reflecting on what I hope to see before I die:
Happy belated National Women Physicians Day!
Medical “Malpractice” Woes
I am sitting in pretty good seats, watching the Rose Bowl football game on January 2 (my neighbor scored some comp tickets at the last minute). I have been off all weekend. But it has not been a great holiday … I am worrying about a medical malpractice suit that might go to court later in the week.
Total bullshit. And I am looking at having to cancel a week and a half’s worth of office and surgery for something that I am pretty sure is going to go nowhere. But then again, when something goes to court, you never know. A text arrives from my lawyer. “Happy new year … Just got an offer for a free dismissal … No payments … I presume this meets with your approval.”
“Yes!!!“ I promptly reply.
It starts to drizzle. The game is OK. I am not 100% invested in it … Penn State v Utah. And we get soaked walking home afterwards. My hip hurts. But hey, I have had worse days.
Five years earlier, I had been called to do a “mechanical thrombectomy” on an elderly lady with multiple co-morbidities. It was about 8 in the morning. I was already in the hospital. We got her to the angio-suite pronto and I was able, with some difficulty, to get up and access the embolus in the brain. It was not a thrombus (and thus not technically not going to be a thrombectomy procedure), rather a small piece of calcium/plaque that had broken off somewhere upstream and lodged in a proximal MCA branch. These bits of plaque can be dicey to remove. They do not come out easily, and as a result, if you are too aggressive, or have bad luck, the vessel can perforate. Sort of a no-win situation. I was not able to get the piece of calcium out, though my manipulations did manage to move the piece a little further downstream, opening some more proximal branches. Sadly, but predictably, she did not do well. About a year later a statement of claim arrived looking for damages. They claimed that I had been negligent because I had not prescribed recombinant tissue plasminogen activator (rtPA).
I never prescribe iv rtPA. The stroke neurologist is the one who does that; and he made the decision not to do so in this case. He is also getting sued. My lawyer pleaded with the judge in a preliminary hearing to drop me from the case, pointing out the fact that prescribing iv rtPA falls outside the scope of my practice. But the judge refused to dismiss it … saying that juries are best to decide these things. What a wimp! Then the guy had the nerve to invite my lawyer and me into his chambers (office). He showed us a photo of his dad, who had been a well-known cardio-thoracic surgeon. The photo was from a Time magazine article from the 1960s. Surely, I said, he understood from growing up with his father that things do not always turn out when doctors deal with very ill patients in high stakes situations. He looked and me and my lawyer and said that he was not aware of his father ever having had any complications.
This guy was living On the Good Ship Lollypop. We clearly were not going to get anywhere with him.
Over the subsequent year, my lawyer kept pointing out to the plaintiff’s lawyer that we would prove that the Stroke Team was set up in a way that precluded me from ever prescribing rtPA and that, furthermore, it would not have worked even if it had been given. Clot busting drugs are for blood clots and this lady had a piece of calcium that was blocking the flow.
When we got closer to the court date, my lawyer said that it would probably get thrown out as the plaintiff’s lawyer had not even qualified any expert witnesses to testify against me (there had been no discovery/deposition of her “experts”). The whole thing was bogus and mismanaged by an incompetent lawyer. But the plaintiff-sympathetic judge had not recognized this. I was getting tense.
I called the lawyer who managed my case a few days after the dismissal, to thank him for getting me a good litigator. I asked him how much it had cost to defend me to that point. He got back to me a few days later, $65,000.00 for the experts and legal fees. One year’s premium.
I think that MICRA had to be updated. It is not 1975 anymore; $250,000.00 is not what it used to be. But the sad fact is that with Assembly Bill 35, it is certain that the number of frivolous lawsuits is going to go up, with more incompetent attorneys taking shots. I do believe that the overall tort system remains unchanged, and that we will still usually prevail when the facts are on our side. But it is going to cost more time and money to deal with these headaches … not a great thing in this era of decreasing re-imbursement.
ChatGPT
I first learned about ChatGPT a month ago when it was an answer to the LA Times crossword puzzle, which I complete religiously every morning in hopes that it will help prevent the Alzheimer’s disease that claimed my father’s life. Then I saw a series on ChatGPT running in the Dilbert cartoons, which I also enjoy because it’s like where I work. Next, ChatGPT showed up twice on the evening news-one episode, illustrating its ability to create detailed artwork with simple prompts and then being sold as original artwork, and then a second episode showing how it is being used/misused by students across the country (Stanford Daily).
So, what is ChatGPT, and why all the buzz? ChatGPT means “chat generated pre-trained transformer” and is a chatbot created by the San Francisco company OpenAI (AI stands for artificial intelligence). OpenAI released ChatGPT free to the public in November, and in five days, more than a million people signed up to test it. I checked today to see if I could try it out and received a ChatGPT message that they were at capacity. I tried again a few minutes later and received a differently worded message stating the same. The chatbot was at work.
Reading their website, I came across this example. The user part is what one would type into the chatbot. Next is the chatGPT’s answer:
User: what is Fermat’s little theorem
ChatGPT: Fermat’s Little Theorem states that if p is a prime number and a is an integer not divisible by p, then ap (a to the power p) is congruent to a modulo p. In other words, if we divide ap by p, the remainder is always a.
For example, if p=5 and a=2, then 25=32, and 32 divided by 5 has a remainder of 2. Therefore, 25 is congruent to 2 modulo 5, and Fermat’s Little Theorem holds for this case.
Fermat’s Little Theorem is often used in cryptography and other applications where it is necessary to perform modular arithmetic operations quickly and efficiently. It is also a useful tool for proving other theorems in number theory.
So how is ChatGPT doing this? My layman’s knowledge is that ChatGPT was trained using internet text databases, which it searched for all the information on Fermat’s Little Theorem. It then “intelligently” puts together an answer. If one typed “draw a blue puppy,” ChatGPT would search all types of artworks (apparently copyrighted or not) and generate its own image artwork of a blue puppy. None of the hundreds/thousands/millions of search sites are cited in the answer given.
Google (Alphabet, Inc) realizes that this will change search engines. Instead of getting a list of sites to research when one puts in the prompt, one will get the answer as illustrated above.
Why should we worry? For one, students can use ChatGPT to write essays, do artwork, solve math problems, etc. The Stanford Daily reported that in a recent survey that 17% of students said they used ChatGPT for their fall assignments and final exams and 5% of students said they submitted ChatGPT work as their own. This is like surveying doctors and asking if they made an operating error. It is likely to be an underestimation of the true numbers.
Not only will we have to find ways to use artificial intelligence like this in our education and develop new ways of assessment of everyone from an elementary school child to a medical student, but we have a new means for patients (and us) to find uncited information. I wish I had access to the system to see what it says about “how should I treat my glioblastoma?” Artificial intelligence is here. We need to find ways to stay ahead of the ethical and legal issues it will bring.
Wilder Penfield
Few in neurosurgery–and beyond–would not know his name.
Dr. Wilder Penfield (1891-1976) was an American Canadian neurosurgeon and innovator, a luminary who made several lasting contributions to neuroscience and healthcare. After attending Princeton University and Oxford University on a Rhodes scholarship, he pursued neurosurgery, training under Dr. Harvey Cushing. As a result of performing numerous delicate brain surgeries, he popularized a still widely used surgical instrument now known as the Penfield dissector. He eventually established his career at McGill University, becoming Montreal’s first neurosurgeon.
I recently had the opportunity to visit Montreal for a medical conference and decided to make a trip to see some of Dr. Penfield’s legacy at the Maude Abbott Medical Museum at McGill University (Figure1).
Dr. Penfield devoted most of his practice to treating patients suffering from epilepsy. While providing care for these patients, Penfield discovered that, by applying mild electrical current to the brain’s surface while the patients were under conscious sedation, he could reproduce their seizure auras and thereby pinpoint the epileptogenic sources that he could remove via surgery. This method – the “Montreal procedure”– allowed him to minimize neurological deficits from these operations. Figures 2A/2B show the 16-channel electrode device used for intraoperative electrocorticography by Dr. Penfield at the Montreal Neurological Institute.
Yet, his revelations did not end there. Penfield further created somatotopic sensory and motor cortices maps by electrically stimulating and probing the brain. The classic “homunculus” figure resulted from his work, published in the seminal “Epilepsy and the Functional Anatomy of the Human Brain.” He also applied his research to the parietal and temporal lobes, charting the areas that gave rise to hallucinations, dreams, and memories. Penfield’s studies from decades ago continue to inform our current understanding of the localization of certain neurologic functions.
Dr. Penfield’s legacy also includes the formation of the Montreal Neurological Institute and Hospital in 1934, fulfilling his dream of establishing a center for neurological illness where physicians and scientists could collaborate. Initially, the institute was created by the Department of Neurosurgery at the Royal Victoria Hospital. Figure 3 is the facade of the hospital today, which houses 85 hospital beds and also allows multidisciplinary research in neuroscience and neurology.
I walked around the McGill University campus and its surrounding neighborhood, including the impressive crest of Mount Royal Park with its view of the city skyline below. During my journey, I noted numerous things bearing Dr. Penfield’s name, an avenue, a medical school building, and a placard, all testaments to this day of his manifold, extraordinary innovations in science and patient care.
Natural Death and Advanced Directives
I was born, raised, and educated in Canada, and, by corollary, I have a soft spot for the monarchy. The upcoming coronation of Charles III reminded me of his mother and how she died. Dealing with family members of elderly patients with severe illness or injury can be frustrating. How the Queen died and legal decisions in my native land suggest that it does not have to be this way.
An elderly lady recently fell, hit her head, and landed in the Emergency Department (ED). I will call her Joan. A CT scan showed some bleeding in her brain. Joan was not in extremis. The usual conversation with her daughter ensued. I explained that this bleeding into a contusion might not stop right away. She could get a lot worse, even though the situation looked reasonably benign. Joan was sitting up in bed, a little addled but communicative.
Was there an advance directive? What did Joan want if she deteriorated to the point where she could not breathe properly? What did the daughter want? Did they ever talk about it?
Does this sound like a familiar situation? It is one that I deal with this several times a month. I am sure that most of us do. While many people have advanced directives, they and their families often have not really thought much or talked about what they mean. Sure, no one wants to end up with a feeding tube and/or tracheostomy, lying semi-comatose in bed, or sitting slumped over in a wheelchair with mindless episodes of “Judge Judy” droning on the television in the corner of the room.
But Death can be a tough sell when it comes suddenly knocking on the door. Living in a wealthy society with few constraints on healthcare spending (even for the poor), it is always tempting not to let it in. I suppose it is very human to hope that the Grim Reaper will just go away.
One nearly constant refrain from families in denial is, “… but she was just fine yesterday.”
I do not know precisely what happened to Queen Elizabeth last year. But two days before she died, she was photographed standing in her living room at Balmoral Castle, smiling and shaking the hand of the UK’s newest Prime Minster, Liz Truss. My morbid curiosity kicked in after Elizabeth died. I went back and looked at the photos on the internet … the Queen looked thin, and bluish discoloration was visible on her right hand, the one she was presenting for a shake (I enlarged the image to confirm what I suspected). Was she on blood thinners that were working a little too well? She did not exactly look spry but was upright and smiling. Did the Queen have a spontaneous brain hemorrhage or fall and hit her head, like Joan? Did she have cancer? Perhaps she just slept away and “woke up dead.”
This was one of the wealthiest women in the world whose “life of service” was tempered by a level of pampering that most of us can only imagine. Elizabeth was 96. Her own mother lived to be 101. It did seem that she might go on forever. But, of course, she could not. Her death, while sudden, was not a surprise; and she and her family were prepared.
Joan, in her late 80s, with a history of cognitive decline, lived in a nursing home before she showed up in the ED. She had an advanced directive that said that she did not want efforts to prolong her life if she was close to death. I clarified this with the daughter and Joan herself that afternoon. As often happens, Joan got seriously worse; and her daughter started to second guess this directive and asked that an aggressive approach be taken if her mom deteriorated further. Fortunately, Joan’s condition stabilized for a while. That gave her daughter time to reconsider things. After a couple of days, Joan went back to the nursing home. She died peacefully a week later, without a welter of tubes in her body. Problem averted, but we all know that it is not always so easy.
This is not a problem unique to California. And there may eventually be a legal remedy. It was recently ruled in Ontario (Canada) that, under both Ontario’s health care consent legislation and common law, physicians do not require consent to withhold cardiopulmonary resuscitation that they believe to be medically inappropriate (Wawrzyniak v Livingstone, 2019 ONSC 4900). This is a very narrow ruling, and it does not apply here. But look it up if you are interested.
Oh, and I do believe that the Queen, in death as in life, was an exemplar to us all. I hope that my family, similarly, allows me to have as natural a death as possible.
The three photos above show the beauty and diversity of Ventura, the editor’s hometown. In the first, the foreground is occupied by a field of lemon trees; in the second, you see the beautiful harbor with boats in the foreground; in the third, a crop field occupies the foreground, and if you look carefully on the right side of the photograph, you can see the editor’s newly rebuilt home. In the background sits the majestic Topa-Topa Ridge covered with snow.
Neurosurgery Resident/Neuroendovascular Fellow/UC San Diego Health
Fifty Years of UC San Diego Neurosurgical History: Shaping the Next 500!
My Journey
I am honored to share a brief history of Neurological Surgery at the University of California, San Diego. Through the past 13 years, I have had the privilege of being a part of UC San Diego as an undergraduate student at UC San Diego Revelle College, a medical student at the School of Medicine, and am now a 5th-year neurosurgery resident, and an enfolded fellow in neuroendovascular neurosurgery.
This institution has consistently supported my growth as a surgeon, scientist, and leader throughout my career at UC San Diego. The faculty and staff of our neurosurgery department tirelessly push the residents and students to be the best they can be. The technical training we receive is excellent, and we are encouraged to develop leadership skills to bring out the best in others and ourselves.
At UC San Diego, we have access to world-class research to augment clinical training, including UC San Diego’s own neuroscience program which annually ranks #1 in NIH funding, and institutions like the Salk. San Diego is adjacent to the U.S.-Mexico border with the responsibility of caring for people all people regardless of citizenship or health insurance status. The story of UC San Diego Neurosurgery began with the leadership and sacrifices of a small well-knit team that has continued to develop over the past 50 years.
A special moment during my medical school graduation at UC San Diego in June 2018, celebrating alongside newly appointed Department Chair Dr. Alexander Khalessi and my chief residents Dr. David Santiago Dieppa and Dr. Jeffrey Steinberg who would go on to be faculty at UC San Diego and experts in cerebrovascular care.
Dr. Alksne and Dr. Marshall’s Leadership
In 1968, the University of California, San Diego School of Medicine was founded. Three years later, in 1971, Dr. John Alksne led the Division of Neurosurgery as the inaugural chief launching the county of San Diego’s only academic neurosurgery program to date. Dr. Alksne received his medical degree and neurosurgical training at the University of Washington. Prior to arriving in San Diego, from 1964 to 1967, Dr. Alksne served as Chief of Neurosurgery at Harbor General Hospital at the University of California Los Angeles. He went on to serve as Chair of Neurosurgery at the Medical College of Virginia from 1967 to 1971 prior to his recruitment as the inaugural chair at UC San Diego.
Under Dr. Alksne’s leadership, he recruited the first faculty members – Dr. Hoi Sang “Ben” U as a cerebrovascular expert and in 1975, Dr. Lawrence Marshall joined the faculty at UC San Diego as an expert in traumatic brain injury. In 1980, Dr. David Barba began his neurosurgical training at UC San Diego serving as the first resident physician to be trained by the division.
Dr. Lawrence Marshall led the Division of Neurosurgery following Dr. Alksne. Many breakthroughs in medical and surgical management of traumatic brain injury were based on papers published from UC San Diego under Dr. Marshall’s leadership with significant influence in larger literature (Dr. Marshall’s work has been cited over 27,000 times). Dr. Marshall rapidly expanded the development of spinal neurosurgery at UC San Diego with the recruitment of Dr. William Taylor, our current program director, who would go on an innovate the extreme lateral interbody approach (XLIF) as well as the prone trans psoas approach (PTP) being a leader in minimally invasive spine surgery and single position surgery. Dr. Joseph Ciacci, our former residency program director, joined UC San Diego to develop the spine and oncology program, being a leader in stem cell research. Dr. Ciacci later teamed with scientists at the Sanford Stem Cell Initiative, a collaborative joint venture between Salk, UC San Diego, Sanford Burnham Prebys, and The Scripps Research Institute (TSRI) to develop UC San Diego’s first phase one clinical trial in the country for the direct injection of stem cells into adult patients with chronic spinal cord injury.
Dr. Carter’s Leadership
Dr. Bob Carter joined the UC San Diego faculty from Massachusetts General Hospital and Harvard Medical School. Dr. Carter focused on expanding neurosurgical oncology, neurovascular and endovascular surgery, and neurocritical care at UC San Diego to develop a subspecialty practice. Under his leadership, he doubled the size of the faculty and increased case volume, and further committed UC San Diego to basic science research. Dr. Carter recruited the current assistant program director and leader in Functional Neurosurgery, Dr. Sharona Ben-Haim, in the neurosurgery department. Dr. Ben-Haim serves as a national leader in functional neurosurgery, epilepsy, and mentorship through Women in Neurosurgery and Equity, Diversity, and Inclusion efforts. She is currently serving as the Chair-Elect for Women in Neurosurgery.
Dr. Carter continued as chief for seven years before Dr. Alexander Khalessi succeeded in his role.
Dr. Khalessi’s Leadership
Under Dr. Khalessi’s leadership, UC San Diego Neurosurgery became a fully independent department, and case volume and faculty recruitment rapidly expanded at an unprecedented rate. UC San Diego has since become a world expert in all domains of neurosurgery subspecialty with our diverse and talented faculty. UC San Diego continues to evolve as a global destination for health care. Under his leadership, UC San Diego became the third comprehensive stroke center in the country and continues to provide world-class cancer care through the only National Cancer Institute in the region.
Since 2018, the UC San Diego Department of Neurosurgery has advanced more than twenty slots in the US News and World Report (USNWR). Over the past three years, UC San Diego has enjoyed a stable position in the top quartiles nationally, most recently #21 in 2022. Our pediatric neurosurgery division at Rady Children’s Hospital remains among the nation’s best at #8 in USNWR. Our department remained regionally dominant and nationally prominent in all sub-specialty domains.
UC San Diego Neurological Surgery has been – and continues to be – a champion of the tri-partite mission of academic neurosurgery – providing high-quality clinical care, developing revolutionary science, and training the surgical leaders of the future. Our institution remains home to innovative and pioneering research and many well-respected neurosurgeons and neurosurgical trainees. The Department celebrates service to its patients, and past and present faculty strive to push the frontiers of neurosurgical care. Dr. Khalessi looks forward to the years ahead and to being part of UC San Diego’s mission of patient care, scientific innovation, and teaching and mentorship. Looking at the past 50 years gives him a deeper appreciation for our shared history and our vision for the future of moving the field of neurosurgery forward to provide the best for our patients.
CANS MISSION STATEMENT
To Advocate for the Practice of California Neurosurgery Benefitting our Patients and Profession
March is Women’s History Month: The Library of Congress, National Archives and Records Administration, National Endowment for the Humanities, National Gallery of Art, National Park Service, Smithsonian Institution, and the United States National Holocaust Museum join in commemorating and encouraging the study, observance, and celebration of the vital role of women in American History. The Smithsonian Women’s History Museum Act was passed by Congress in December 2022. The museum will be devoted to the documentation of women’s contributions throughout the nation’s history. The museum could take years to conceptualize, curate and build, however, it is so exciting to see this happening!
March 1 – Xylaxine, a sedative normally used by veterinarians to tranquilize animals — also known as “tranq,” is making its way into the illicit drug trade in California, and local officials are concerned its arrival could worsen an already alarming overdose crisis. A few overdose deaths have been reported in San Francisco and Los Angeles.
March 2 – The World Obesity Federation’s 2023 atlas predicts that 51% of the world – more than 4 billion people – will be obese or overweight by 2035. Rates of obesity are increasing quickly, particularly among children and in lower-income countries.
March 3 – is World Wildlife Day. It is the United Nations International day to celebrate all the world’s wild animals and plants and their contribution to our lives and the planet’s health. This date was chosen as it is the birthday of CITES, the Convention on International Trade in Endangered Species of Wild Fauna and Flora, signed in 1973. This World Wildlife Day is also a celebration of CITES as it turns 50. Over 41,000 species are endangered, and over 16,000 are threatened with extinction — that number is growing yearly.
March 3 – Barbara Bryant, the first woman to lead the Census Bureau, Dies at 96. Dr. Bryant was appointed by President George H.W. Bush in December 1989, as the agency was beginning the census of 1990. Some of the issues she tackled were the potential undercount of a substantial segment of the population, the slow adaption to the computer age, and a failure to adjust census taking to demographic changes like the proliferation of nontraditional households.
March 4 – The scientists studying the powerful earthquakes that devastated parts of Turkey and Syria this month are drawing similarities between the fault lines in that zone and the San Andreas Fault in California. The earthquake zones have this in common: one long, major fault and scores of smaller, secondary ones. Their studies may help predict future quakes in California. In California’s history, there have only been two quakes as powerful as the Turkish/Syrian one: the 7.9-magnitude San Francisco earthquake in 1906, and the Fort Tejon quake of 1857, which had a similar estimated magnitude; it affected an area from the central part of the state southward to the east of Los Angeles.
March 5 – The U.N. High Seas Treaty was signed when more than 190 countries reached an agreement in New York. This will set up protected areas to guard against risks from overfishing and deep-sea mining. 60 percent of the world’s oceans – high seas are outside territorial waters – are home to myriad ecosystems, diverse marine life, and species that have yet to be discovered.
March 7 – Oklahoma voters rejected the legalization of recreational marijuana following a late blitz of opposition from faith leaders, law enforcement, and prosecutors. I guess Merle Haggard was right: “we don’t smoke marijuana in Muskogee, Oklahoma, USA.”
March 7 – Chief U.S. District Judge Kimberly Mueller in Sacramento, California, ruled that California cannot ban the importation and sale of crocodile and alligator products. This is a victory for the state of Louisiana, which challenged the ban along with businesses in multiple states. “Federal law controls trade in those products and preempts California from barring trade in them,” Judge Mueller wrote in her ruling.
March 7 – The Massachusetts Supreme Court reaffirmed the right to be rude at public meetings. The ruling was based on the constitutional right to assemble in Massachusetts. The court concluded that “Decorum,” was not a top priority for cousins John and Samuel Adams when they drafted Article 19 in the Massachusetts Constitution.
March 8 – International Women’s Day is a global day celebrating women’s social, economic, cultural, and political achievements. The day marks a call to action for accelerating gender parity. People come together to celebrate women’s achievements or rally for women’s equality. The global campaign theme for 2023 is #EmbraceEquity. In 1908, 15,000 women marched through New York City demanding shorter hours, better pay, and voting rights. On March 19, 1911, International Woman’s Day was honored in Austria, Denmark, Germany, and Switzerland for the first time. The United Nations observed International Women’s Day for the first time in 1975. Purple, green, and white are the colors of International Women’s Day. Purple signifies justice and dignity, and loyalty to the cause. Green symbolizes hope. White represents purity. The colors originated from the Women’s Social and Political Union (WSPU) in the UK in 1908.
March 8 – The Hindu festival of love, color, and spring is one of the most joyous celebrations of the year. It’s a time when people don simple, inexpensive clothes and take to the streets to drench each other in clouds of colored powder and buckets of water. There’s singing, dancing, and of course, food.
March 9 – Oxnard resident Sonia Aguila was awarded the honor of “National Bilingual Teacher of the Year” during the National Association for Bilingual Educators’ annual conference. Aguila, also the 2022 California Bilingual Teacher of the Year, pairs her day job as a second-grade teacher at Canalino Elementary School in Carpinteria with side gigs as an education columnist and children’s radio show host. “Being bilingual is a superpower,” she said. Aguila, 47, was born in Santa Barbara but moved with her family to Mexico at age 5, then back to Santa Barbara six years later. A native Spanish speaker, she said she initially struggled to adapt.
March 10 – The FDA approved a Pfizer nasal spray for treating migraines that uses a different therapy from other nasal products on the market. It is the first and only nasal spray for migraines using a migraine inhibitor that attempts to block the release of calcitonin gene-related peptides. The spray will be sold as Zavzpret and should be available in July—good news for our country’s 40 million migraine sufferers.
March 12 – Daylight Saving Time Begins. The current March to November system that the US follows began in 2007, but the concept of “saving daylight” is much older. Daylight Saving Time has its roots in train schedules, but it was put into practice in Europe and the United States to save fuel and power during World War I. It was called “wartime.” The US kept Daylight Saving Time permanent during most of World War II. During the energy crisis of the 1970s, permanent Daylight Saving Time was tried again in the winter of 1973-1974. It was a popular move at the time when President Richard Nixon signed it into law in January 1974 … but only for a very short time. In the US, states are not legally required to “fall back” or “spring forward.” Hawaii, most of Arizona, and some territories in the Pacific and Caribbean do not observe Daylight Saving Time. There are advantages and disadvantages to “Spring Forward” and “Fall Back,” but, for now, they are here to stay.
March 13 – Former US Congresswoman Patricia Schroeder of Colorado died. She was 82. The cause was complications from a stroke. She was first elected to the US House of Representatives in 1972. She served in Congress for 24 years. She became known as a forceful voice, particularly on women’s reproductive rights and arms control issues. Reflecting on her tenure in Congress, she wrote a book titled, “24 Years of Housework…and the Place Is Still a Mess.”
March 14 – Pi Day. We all know Pi is the ratio of the circumference of a circle to its diameter, or approximately 3.14. If you’re a serious math geek, you will celebrate the day exactly at 1:59 a.m. or p.m. to reach the first six numbers of pi, 3.14159. One of life’s cosmic irony: it is Albert Einstein’s Birthday. But if you are not a math geek, you can always eat pie all day long.
March 15 – On this day in 1820, Maine was admitted to the Union as a Free State. It was part of the Missouri compromise. Missouri was admitted as a slave state at the Southern States’ insistence. Maine was influential in electing Abraham Lincoln, and the saying went, “as Maine goes, so goes the Nation.” Times changed, and now, we can say more accurately, “As California goes, so goes the Nation.” Or are times changing again?
March 15 – The Biden Administration approved the ConocoPhillips Willow project in the Western Arctic of Alaska, also known as National Petroleum Reserve; it is a region as large as Virginia. There is some scientific evidence that this project poses a serious threat to the Arctic region. If built, Willow will be the largest new oil extraction project on federal land in the United States. Expect a long and drawn-out court battle.
March 16 – Ventura County’s Lake Piru reached capacity, spilling for the first time since 2006, having received about 27 billion gallons of water. This season’s storms brought the lake from just 14,000 acre-feet – just under the minimum amount of water needed called a “dead pool” – to 82,000 acre-feet.
March 17 – St. Patrick’s Day ☘️. St. Patrick was actually born in Roman Britain. As a boy, he was captured and brought to the country by Irish pirates to care for sheep. At the time, Ireland was almost entirely Druid. He escaped from Ireland a few years later and returned to Britain. Saint Patrick went back to Ireland willingly to help spread Catholicism. He converted thousands of Irish people, becoming known as the patron saint of Ireland. He often used shamrocks, now commonly associated with the holiday, as a tool in his ministry to explain the Holy Trinity. On St. Patrick’s Day, I wear a button that says, “ My Heart is Irish,” which is the honest truth.
March 17 – National Match Day – Tamia Potter is the first Black woman, in about a century, to be accepted for a position in the neurosurgical residency at the University of Vanderbilt Medical Center in Nashville, Tennessee. According to the data from the Association of American Colleges, only about 5.7% of physicians in the United States identify as Black or African American, and only 33 Black women were in the neurosurgical field in the United States in 2018. Congratulations, Dr. Potter!
March 20 – Twenty years ago, the U.S. invaded Iraq in a massive “shock and awe” bombing campaign that lit up the sky. The invasion was based on what turned out to be faulty claims that Saddam Hussein had secretly stashed weapons of mass destruction. Such weapons never materialized.
March 20 – Earth is on pace for severe damage from climate change according to UN report authored by the world’s top scientists. The world’s temperature is likely to reach 1.5 degrees Celsius (2.7 degrees Fahrenheit) above preindustrial temperatures by the early 2030s. The report also indicates that it is still possible to hold global warming to relatively safe levels, but doing so will require global cooperation, billions of dollars, and significant individual behavioral changes.
March 20 – U.S. District Court Judge Cormac Carney, from Santa Ana, CA, blocked key California law provisions that drastically restrict the sale of new handguns in the state. He said that California’s requirements for new handguns are unconstitutional and cannot be enforced. Because of these restrictions, he wrote that “no new models of semiautomatic handguns have been approved for sale since 2013, and Californians are forced to buy older and potentially less safe models.”
March 21 – Spring Equinox and Nowruz. Nowruz marks the first day of the Zoroastrian calendar and always falls on the spring equinox; it means a new day in Farsi. Nowruz is celebrated all around the world. It is rooted in Zoroastrianism, a Persian religion that dates back further than Christianity or Islam. Over the 13 days of festivities, Nowruz celebrates nature, reinforces familial and community ties, and is based on the values of peace, coexistence, and respect. In Syria where I grew up, Mother’s Day is celebrated on March 21. In reality, every day should be Mother’s Day!
March 21 – Tens of thousands of Los Angeles school district employees will begin a three-day strike, forcing hundreds of campuses to close and canceling classes for 422,000 students; the district is the second largest in the Nation. The union representing 30,000 support workers in the Los Angeles Unified School District is seeking a 30 percent pay increase, saying that many employees make little more than the minimum wage and struggle to afford the cost of living in Southern California. The Los Angeles teachers’ union has asked its 35,000 members to walk out in solidarity and to avoid crossing the support workers’ picket lines.
March 21 – Japan won the World Baseball Classic defeating Team USA 3-2. The game ended in dramatic fashion, with Japan’s Shohei Ohtani striking out Mike Trout with a full-count slider to seal Japan’s third title. Ohtani pitching to Trout was something special – not only will the pair go down alongside baseball’s all-time greats, but they are also Los Angeles Angels teammates. Ohtani, who batted .435 and pitched to a 1.86 ERA, was also named the tournament’s most valuable player.
March 22 – Ramadan, the holiest month in the Islamic lunar calendar, begins as soon as the new moon is sighted. Muslims are expected to fast – no food or water – from sunrise to sunset for 30 days. Fasting during Ramadan is among the Five Pillars of Islam; however, one is exempt from fasting if traveling like Emirati astronaut on the International Space Station, Sultan Alneyadi. Ramadan Mubarak, and safe travels!
March 22 – The 22nd atmospheric river of this unusual season is drenching California and dumping much snow on the mountains; It is also wreaking havoc and causing landslides in some areas – a rare tornado hit the city of Montebello, CA, east of LA. Is our historic mega drought over?
March 22 – Dr. Bob Metcalfe, 76, an inventor of the Ethernet, was awarded The Turing Award by the Association for Computing Machinery, the world’s largest society of computing professionals. In June 1972, Bob Metcalfe, a 26-year-old engineer fresh out of graduate school, was asked to build a technology that could connect desktop machines across an office and send information between them. The result was Ethernet. Given since 1966 and often called the Nobel Prize of computing, the Turing Award comes with a $1 million prize. What would we do without the Ethernet?
March 24 – Governor Newsom stopped asking people to voluntarily cut their water use by 15%, a request he first made almost two years ago. Californians did not meet Newsom’s call for that level of conservation. As of January, cumulative savings were just 6.2%. Asked, “Are we out of the drought?” He replied, “Mostly, but not completely.”
March 29 – National Vietnam War Veterans Day
From The American Presidency Project, Proclamation 8829—Commemoration of the 50th Anniversary of the Vietnam War (2012):
“As we observe the 50th anniversary of the Vietnam War, we reflect with solemn reverence upon the valor of a generation that served with honor. We pay tribute to the more than 3 million servicemen and women who left their families to serve bravely, a world away from everything they knew and everyone they loved. From Ia Drang to Khe Sanh, from Hue to Saigon, and countless villages in between, they pushed through jungles and rice paddies, heat, and monsoon, fighting heroically to protect the ideals we hold dear as Americans. Through more than a decade of combat, over air, land, and sea, these proud Americans upheld the highest traditions of our Armed Forces.
“As a grateful Nation, we honor more than 58,000 patriots—their names etched in black granite—who sacrificed all they had and all they would ever know. We draw inspiration from the heroes who suffered unspeakably as prisoners of war, yet who returned home with their heads held high. We pledge to keep faith with those who were wounded and still carry the scars of war, seen and unseen. With more than 1,600 of our service members still among the missing, we pledge as a Nation to do everything in our power to bring these patriots home.”
March 30 – National Doctors’ Day. It was first celebrated in 1991. The red carnation is the symbolic flower. Light red carnation signifies Admiration.
March 31 – The end of COVID-19 federal emergency payments for food stamps. This will force many seniors to rely more on already over-burdened food pantries and other organizations that provide free meals. A federal spending bill passed last December ends the emergency food stamp allotments that started three years ago and pushed all benefits to maximum levels. Households already at the maximum received $95 more a month. The increase disappears on April 1.
California Medical Association’s 49th Legislative Advocacy Day, on April 19, 2023, in Sacramento
CSNS Spring Meeting Los Angeles, April 19-21, 2023
AANS, Los Angeles, April 21-24, 2023
NSA meeting, Chatham, MA, June 18-21, 2023
WNS Meeting Portola Hotel & Spa, Monterey, Sept. 29-Oct. 2, 2023
WFNS Cape Town, December 6-11, 2023
CANS, Annual Meeting, January 12-14, 2024 – Northern CA TBD
Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter. Submit your text to the CANS office by E-mail (emily@cans1.org) or fax (916-457-8202). v
The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.
