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CANS Influence on our National Organizations
May is the month of graduation, and I want to congratulate all of you who were fortunate enough to be able to attend one, whether it was for your child, grandchild, friend, or yourself!
I had the pleasure of attending one at my old alma mater (our daughter, Johns Hopkins University MPH ‘23) and took the opportunity to visit my old dorm building just about 40 years after I first set foot on campus. It was a most beautiful day, the campus lawn and foliage were still deep green, and the morning air was crisp and cool before ripening into the warmth of the afternoon. So many things changed on campus. I was surprised by how the environs were so much more immaculate and polished than in my day. New buildings have been built, and old ones have been impressively renovated. The old bones of the little school were still there, though. I remembered the halls where I took that first Intro Chem class and the one where I read the Divine Comedy. I told my family about how I used to study in one library, and when it closed, I’d pack my books and walk across the quad to another to continue studying. There were the halls where the second run and foreign movies were shown on Friday and Saturday nights. The place where the old Grad Club – dubbed the Sad Club- used to be, where you could pick up a slice of pizza and beer (as a senior) and play pinball.
While for many, college is remembered as the best years of their lives, I remember college as being far from my best. It was a time of intense work and self-doubt for me. The situation was definitely not helped by my general insecurities and awkwardness. I’m grateful for the experience; however, in some ways, small and big, my survival and success in college were the first steps that made it possible for me to do what I have done and live in my best years – now.
The Fraud Triangle
In last month’s editorial, I briefly mentioned the issue of pressure and falsification, which brings me to a different story.
Some of the numerous e-mails that appear in my inbox are from various news aggregation websites related to medicine. Not infrequently, there are reports of physicians who have broken various laws and to whom punishment has been meted out, including fines and jail time. We have a highly regulated profession and for good reason. We are in a position of public trust. From time to time, the reported names have involved fellow neurosurgeons. What causes these colleagues to abrogate trust and engage in such misdeeds?
In the middle of the last century, two academic criminologists, Edwin Sutherland and Donald Cressey, began studying white-collar criminality, specifically the factors underlying fraudulent behavior. One innovation in their work was to promulgate the understanding that criminal behavior was not limited to lower classes but also was a feature of upper and middle-class individuals, hence: “white collar crime.” Although we are very familiar with this concept now, it was the prevailing assumption in a bygone era that higher moral standards characterized the aristocracy. Sutherland and Cressey played a pivotal role in reshaping this aspect of the understanding of criminality and society at large.
After interviewing numerous embezzlers, the notion of a three-factor model was reached:
“Trusted persons become trust violators when: (1) they conceive of themselves as having a financial problem which is non-shareable; (2) have the knowledge or awareness of that this problem can be secretly resolved by violation of the position of financial trust, and (3) are able to apply to their own conduct in that situation a verbalization which enables them to adjust their conceptions of themselves as trusted persons with their conceptions of themselves as users of the entrusted funds or property” – from Cressey, D. R. (1953). Other people’s money: a study in the social psychology of embezzlement Glencoe, IL: The Free Press
These conclusions have subsequently been streamlined and broadened by other authors into what is presently known as the Fraud Triangle:
1: Pressure
2: Opportunity
3: Rationalization
Although this was developed to understand and prevent embezzlement, it is clear that a similar set of circumstances can exist within multiple nodes and levels of other organizations, including that of the healthcare system. To be clear, such pressures may not be exclusively financial, and the rewards may not be strictly financial either. For example, pressures may be exerted for the purpose of institutional priorities, and the rewards may be merely a gain of favored status resulting in increased power or reduced workload.
Whether fraud is committed may also depend on the individual’s corruptibility or guilelessness. Some may be quite willing to engage in fraud, while others may be incapable of such activity. Others may be entirely ignorant of the law or be easily manipulated within a culture that normalizes such behavior.
For example, within certain organizations, a grooming and testing process may be in place by which higher-level managers select subordinates who are more willing to participate in questionable activities.
Those that do not yield to pressure (which I hope are the majority of us) are of particular interest as perhaps having the most complex and difficult set of choices. Some may depart their situation either willingly or unwillingly. Some may accept the circumstances and maybe, at some point, suffer from moral distress and burnout.
While using the triangle as a schema provides an understanding of the circumstances of fraud, it does not appear to provide any guidance for a useful, let alone ethical, template of action. The sparse literature appears to be largely misguided, mostly concentrating on improving risk assessment and controls – a schema of “do nots” or punitive measures. The result is a process of punitive consequences that ultimately rely on a surveillance control scheme. This, while somewhat effective, results in other more difficult issues.
Pressures at all levels are generated as part of the normal functioning of the industrial healthcare system in its current state. Reliance on punitive systems of control coupled with economic exigencies have resulted in an increased burden on workers at all system levels. This, in turn, creates provider disengagement and, perversely, even greater levels of pressure and more potential motivations for fraud, waste, and abuse.
While practitioner sustainability is increasingly recognized as a serious issue in healthcare systems (witness the “quadruple aim” superseding the “triple aim” in healthcare), there seems to be little from the standpoint of concrete measures that apply to addressing the current predicament not only in healthcare but also society at large.
Is it possible to re-engineer the system? Let me know your thoughts.
CANS Newsletter Editor
Memorial Day: We just celebrated Memorial Day, initially called Decoration Day. Although today, the emphasis is on getting together with friends and families, enjoying a delicious BBQ, and very likely over-eating, the real intent is to remember those who paid the ultimate price in the service of our Country.
First Decoration Day. On May 30, 1868, James A. Garfield, Ohio Congressman, former Union Army General, and eventually the 20th US President, gave an oration during the first formal “Memorial Day Observance.” He said: “I am oppressed with a sense of the impropriety of uttering words on this occasion. If silence is ever golden, it must be here, beside the graves of fifteen thousand men, whose lives were more significant than speech and whose death was a poem, the music of which can never be sung. With words, we make promises, plight faith, praise virtue …We do not know one promise these men made, one pledge they gave, one word they spoke, but we do know they summed up and perfected, by one supreme act, the highest virtues of men and citizens. For the love of country, they accepted death and thus resolved all doubts and made their patriotism and virtue immortal.” Garfield’s presidency was cut short when he was shot and killed by a bullet. Ironically, we just observed the first anniversary of the mass shooting at Uvalde.
Gun violence continues in our country; instead of getting better, it is getting much worse.
Alex Tenorio, whose letter to the LA Times Editor about the increased numbers and severity of cranial and spinal injuries since the increase of the border wall height we published last month, was invited by the “California Endowment” to join key advocacy leaders to brief The US Congress on the effects of further border wall height extensions. Alex had a very productive meeting with White House officials and members of Congress last week. He met with the following members of Congress: Arizona Rep. Raul Grijalva, Michigan Rep. Rashida Tlaib, California Rep. Judy Chu, California Rep. Juan Vargas, and California Rep. Scott Peters. He briefed them on the humanitarian and economic costs of further construction of a 30ft border barrier, specifically at Friendship Park. T Alex met with two of President Biden’s Senior Policy Advisors on immigration who promised to relay his concerns to Susan Rice and Neera Tanden; they, in turn, will bring this to President Biden’s attention. Congresswoman Vargas plans to pen a congressional letter that will be circulated to other members of Congress and Senators. The letter will call for halting further construction at Friendship Park and will also be sent to President Biden.
I, along with many neurosurgeons nationally and in California, admire Alex dedication, determination, and perseverance. He will undoubtedly claim a leadership position in our specialty soon. Bravo, Alex!
Congresswoman Rashida Tlaib from
Michigan with Alex
Congresswoman Judy Chu from California, with Alex and the group.
CMA calls for nominations. Please refer to the “From CMA” column for details about applications to various councils. Applications are due annually, even if one is already a member of a particular council. CANS members’ participation is encouraged.
SB 815. Unless modified, it calls for a 60% fee increase and will transform the Board into a public member majority entity rather than the present physician-member majority. CMA urges a No vote. Please contact your legislators.
Also included in this issue are all the regular columns except for Women in Neurosurgery and Residents’ Corner. We hope to have them again next month.
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.
Errata
In my Editor’s Corner in the April issue of this Newsletter, I indicated that “The bottom line: no statistical differences, and patient selection remains crucial.”
Dr. Mummaneni, one of the principal investigators, sent this correction: “For the 5-year QOD spondylolisthesis cohort, there was a statistically significant difference between fusion vs. decompression at final follow-up. Fusion for spondylolisthesis had better odds of achieving MCID for ODI, patient satisfaction, and superior NRS leg pain scores at five years. We had over 80% follow-up at five years.”
Byron Cone Pevehouse, M.D., 1927–2010
This month we remember Byron Cone Pevehouse from two perspectives. The first is an obituary written by David L. Kelly and published in the Journal of Neurosurgery; the second was an editorial written and published in the 2010 April issue of CANS Newsletter by our late editor Randy Smith. Byron Cone Pevehouse was one of the founders of CANS. CANS names its highest award in his honor: The Byron Cone Pevehouse Distinguished Service Award – Editor.
An obituary reprinted from the Journal of Neurosurgery
Volume 113: Issue 5 https://doi.org/10.3171/2010.7.JNS101258
David L. Kelly, M.D.
Sadly, we lost a truly esteemed member of our neurological surgery profession when Dr. Byron Cone Pevehouse died April 16, 2010. His contributions to the specialty have been numerous, important, and long lasting.
Byron Cone Pevehouse (Fig. 1) was born in Lubbock, Texas, on April 5, 1927. He attended Baylor University, but his education was interrupted by service for 22 months in the Naval Hospital Corps in the Pacific. He received his B.A. and M.D. degrees at Baylor, finishing in 1952. Following an internship at the University of Colorado, he entered the neurosurgical residency program at the University of California, San Francisco. In 1957, he received the Research Award of the AAcNS, and in 1958 he won a National Science Foundation Fellowship to study at the Montreal Neurological Institute under Dr. William Cone. Thereafter, he spent 9 months in Europe at the National Institute of Health, Queen Square, London, as well as in Oslo and Madrid.
Photograph of Dr. Pevehouse taken in 1984.
Back in the US, Dr. Pevehouse became chief of Neurological Surgical Services at the San Francisco General Hospital and there initiated the residency training program. In 1967 he was appointed chairman of the Department of Neurological Surgery at University of Pacific–Presbyterian Medical Center, where he served for 23 years. He was promoted to the rank of clinical professor in 1978. He served as clinical professor of Neurological Surgery with Dr. John Jane Sr. at the University of Virginia between 1990 and 1997.
Dr. Pevehouse has made major contributions to many professional organizations including the Society of University Neurosurgeons (president, 1971), California Association of Neurological Surgeons (founding president, 1973–1974); Western Neurosurgical Society (president, 1981); AAcNS (president, 1982); AANS (president, 1984); ABNS (director, 1979–1985); and San Francisco Neurological Society (president, 1973).
Dr. Pevehouse’s awards and honors were numerous, having received the Cushing Medal of the AANS, and Distinguished Service Awards from the SNS, the California Association of Neurological Surgeons, and the American Academy of Neurological Surgeons. He was elected Distinguished Alumnus of Baylor College of Medicine.
Dr. Pevehouse served a primary role in developing the neurosurgical residency-matching plan, which he supervised for 15 years. He represented our specialty through the AANS in Washington, DC, during the development and implementation of the Medicare Fee Schedule.
He was recognized perhaps as the most visible and influential neurosurgeon by organizations such as the AMA and the American College of Surgeons, as well as some of the federal agencies related to health care. He was appointed in 1991 by President Bush as the Senior Consultant and Member of the National Committee on Vital and Health Statistics. For years he served as counsel to the presidents of virtually all the neurosurgical societies, providing historical perspective, guidance, and sage advice.
Dr. Pevehouse enjoyed photography, fishing, skiing, and tennis, and in addition, he was a wine connoisseur and collector as well as a numismatist. His first wife, Maxine Elizabeth Smith, died in 1978, and in 1981 he married Lucy Seguin Beck, a Houston attorney. The two of them had an exciting and vibrant life together. In addition, he is survived by his three daughters.
The many of us who took pleasure in his charming company, great humor, and incisive thinking will miss him sorely.
They Don’t Make ‘Em Like this Anymore.
Randall W. Smith, M.D., Editor
CANS Newsletter April 2010
All too often, men or women whose lives have made laudable contributions to the fabric of human endeavor are characterized as “giants” when they, at best, should be described as just fairly tall. On April 1 6th, neurosurgery, in general, and CANS, in particular, lost a true giant. Byron Cone Pevehouse was to California neurosurgery what John Adams and George Washington were to the creation of our republic. Like Adams, he played a crucial and dominant role in the formation of CANS in 1973. Like Washington, he was our first CANS President and led us in our fight for independence from the plaintiff’s bar by, along with a few others, creating MICRA and getting then-Governor Jerry Brown to sign it into law. That he did his homework on that one was reflected by the California Supreme Court upholding MICRA against an assault by the lawyers. He created the California Relative Value Scale, long used by neurosurgeons nationwide to determine reasonable billing procedures until the advent of the CPT system. He was the major force behind changing the AANS by-laws to create some geographical representation on their generally hierarchical Board of Directors. He devised the matching program for medical students applying for neurosurgical residencies. Although he subsequently served the wider neurosurgical community as President of the Western Neurosurgical Society, the Society of Neurological Surgeons, and the AANS, served on the American Board of Neurological Surgery, and was a recipient of the Cushing Medal, he is annually remembered by CANS as we bestow the Pevehouse Award upon a neurosurgeon who has contributed mightily to the betterment of California neurosurgery. Every recipient of that award has been worthy but never could match the award’s namesake.
About the only questionable decision he made was to retire to the Seattle area with his lovely wife Lucy some years ago, so we in California were deprived of seeing him except occasionally at national meetings.
Those of you who never met Cone and had a chance to sit and chat with him really missed a wonderful experience.
He was warm and kind, and considerate. This writer had some long conversations with him, and I should have taped them all. It was like going to neurosurgical practice school.
How can you characterize someone like him in a word? In Yiddish, the term is a mensch. In Spanish, macho. In American, it is a Giant.
CANS Newsletter Editor
Joanie and I were privileged and so lucky to visit Perú and Ecuador this month. We relished every minute and wish that each reader of this newsletter gets a chance to enjoy such a visit.
In Perú, we climbed the iconic Machu Picchu and learned much about the Incas and their civilization. In Ecuador, we were so fortunate to spend five days in the Galápagos Islands, a magical place where conservation is practiced with an almost religious zeal!
In this column, I will tell you about a traditional craft/art and how it is being preserved so that future generations can continue to enjoy it.
The demonstration included the kind of wool used. Alpaca, baby Alpaca and sheep, each requires special handling. Shawls made with baby alpaca wool are so soft; they are really treasures. Using only vegetable dies, available in the region, results in vibrant colors that survive the elements. Working in teams was an amazing demonstration of harmony. There was a sense of pride that the weavers quietly displayed.
After the demonstration, we were given the opportunity to buy some of the beautiful woven objects – veritable art pieces that take days and months to complete – directly from the artists. Each item has a tag with a photo of the artist who made it.
Proud Artist
This was followed by lunch in the beautiful courtyard of Nilda’s home located next door to the weavers’ workshop. The lunch consisted of a family-style meal that is typically served at weddings; this included a delicacy that we had to taste, Guinea pig.
Nilda holding the prized Guinea pig.
Nilda Callañaupa is a real visionary. She saw the need to save a dying tradition and an opportunity to help her fellow weavers – she is a master weaver – and jumped on the occasion.
We know that civilizations/empires die off; the Incas are a perfect example. After building amazing cities in Cuzco and Machu Picchu, they had to abandon them because of internal strife. The Spanish conquest came afterward. But ideas, art, craft, and, yes, religious beliefs live on and are worth saving. It is my understanding that up to a quarter of the population in Perú adhere to an Inca-inspired belief system that pays respect to Mother Nature and the forces that influence their agricultural life: Thunder and Lightning; they believe that thunder and lightning turn hail into rain, thus saving their crops. Even Catholicism is practiced with a strong indigenous flavor.
So, saving some of their believes, traditions, art, and craft is very important for the Heritage of our fragile world.
Bravo Nilda and Flora!
Sea Lion pup nursing – Santa Fe Island, the Galápagos, Ecuador
Photo taken by Moustapha AbouSamra, MD, on May 18, 2023, at 4:54 PM, iPhone 13 Pro.
“The Chatbot will see you now.”
“I know I’ve made some very poor decisions recently, but I can give you my complete assurance that my work will be back to normal. I’ve still got the greatest enthusiasm and confidence in the mission.”
– HAL 9000, 2001: A Space Odyssey, Stanley Kubrick (1968)
After returning from an unexpected and highly enjoyable trip to Dubai, UAE as an invited speaker and examiner at the ArabSpine and Dubai International Spine Conference, I had a chance to reflect on some enriching talks on the rise of AI. An entire morning of the conference was spent looking specifically at the role of Artificial Intelligence and how it may work (or not work) in spine surgery.
The advent of AI has long been prophesied, and, for all intents and purposes, it is here. Popular culture has often had messages of doom and destruction, with renegade artificial intelligence bots, computers, and cyborgs wreaking havoc on humanity. With 2001: A Space Odyssey, Tron, Terminator, Marvel Comics, and Star Trek addressing the bad of artificial intelligence. It always starts with a well-meaning, precocious scientist or group of scientists pushing the limits of what they hope will be an asset to humanity to bring convenience to our lives and allow us to fully realize our potential as a species without the mundane demands of life.
Invariably there is a moment, a singularity, when the program becomes self-aware and deems humanity unfit to be the dominant species, and begins the undoing of civilization and end of humanity. Many people have warned us that this moment is now closer than ever, with the head of Google’s AI program leaving the company and sounding the alarm about the irresponsible advance of technology. We have already seen the public’s concerns about the intrinsic bias seen in AI predictions of future criminal offenders biased against people of color. ChatGPT has taken and passed the bar and now even passed a neurosurgery board.
Proponents of AI openly fantasize about having AI automate many of the processes in medicine that we just don’t have the bandwidth or time for. The increase in prior authorization demands, repetitive patient calls and questions, and even billing issues all tempt the implementation of AI to simplify our lives. Many have sung the song praising the coming of AI. The almost cult acceptance of AI into our lives and vocations concerns many who see the clear connections between the now and the then when our own hubris wipe out our lives.
There are many characters in medicine, especially on our professional sites and social media, that cannot get enough of AI, especially the chatbot. The truth is, as my colleague Ciaran Bolger from Dublin gave a very informative, if not concerning, talk about AI and some of its basics – we already have AI very much in our clinical lives. Many of us use spine robots in our practice and also for deformity surgery. There is an AI algorithm baked into the segmentation and correction functions. Makes life easier, right? Google is somewhat based on AI. Keywords generate a snapshot, which is in turn generated by proprietary AI. The stock market has gone completely bonkers for AI. Chipmaker NVIDIAs stock, critical for AI (I love how I find out about this AFTER the bump – sigh), has doubled in the past six months.
AI is seemingly a messianic presence in our lives. The medical influencers are seemingly Gaga over HAL. I remain skeptical.
There are two reasons – and they align with the two main types of AI models. One is reinforcement-based. Much like a Pavlovian pet, the programming subroutine is programmed to run through routines for rewards. The other is inferential learning, based on neural networks.
The reinforcement-based model is very commonly used currently. It has operant limitations and cannot really “learn.” It is a sort of fenced-in model. It has inherent limitations and has been subject to bias. In 2020, LAPD stopped using a program called Pred-Pol. It was an initiative to use “predictive policing” (think Minority Report). It was mothballed as predicted and was biased toward minority targeting. It was a geographical predictor and predicted higher crime
levels, leading to a much higher police presence in communities of color. https://www.latimes.com/california/story/2020-04-21/lapd-ends-predictive-policing-program.
If you change the system’s rules, the algorithm cannot accommodate well, and the drone might crash or lose the chess game.
The second model is based on inferential learning. This is the scarier of the two. It can routinely accept change and is based on artificial neural networks. There are companies already implementing these programs in various capacities. It is also known as deep learning. See the below figure:
Source: https://www.nature.com/articles/s41524-022-00734-6
The deep learning model approaches actual thinking since we can now get to it. It can learn with changing parameters, and “the” deep in deep learning refers to the number of layers the data transformed. Data is processed through a series of operational mechanisms, and an answer or action is made. Usually, there are two or more layers of transformations.
AI, therefore, remains a black box except for those that program it. Some in the medical community have insisted that it will take over menial tasks such as prior authorization, billing, and even patient communication. This would lead to bots essentially getting your money and talking to your patients. Now some are completely enthused that this is a software revolution.
Imagine, then, a deep learning chatbot that decides it will change what surgery you are doing because of some information it thinks it has ascertained from various articles, some of which are not necessarily based on good data or perhaps that do not take into account certain salient characteristics of knowledge you have of your patient. And then there is the post-operative patient who is chatting with the bot, and the bot misses out on certain mild and potentially alarming signs or symptoms. The patient presents unannounced to the ER with a rip-roaring infection you could have caught weeks ago.
Others have espoused that AI could help find problematic trainees. I have even heard mutterings that Christopher Duntsch (aka Dr. Death) could have been spotted and potentially rehabilitated or fired. So again, we see the responsibility being transferred from the surgeons that train the trainee being held accountable to the chatbot being the program director. Others have espoused an AI observer watching the surgeons’ movements and making critiques or corrective maneuvers. The problem there should be blatantly obvious. And what if, like the Pred-Pol program, the bot targets those of minority backgrounds or exhibits gender bias and years go by before someone bothers to look? Because we all know it takes time to spot bias.
This trend toward never-ending clinical outsourcing, first out of the country, now out of humankind, is alarming. We need to discuss very openly and plainly what the guardrails will be. I do not doubt that the carnival barkers of AI are in charge and that this is coming. Frankly, I won’t be surprised when bad stuff starts happening; the blame will be diffused or pointed squarely back at physicians. We should not doubt that. The endless outsourcing erodes the patient-physician relationship and leads to less accountability and no patient improvement. And at the end, I believe it encourages an INCREASE in physician administrative burden with other things, as no doubt, once the bot starts beating the insurers, they will get their own bots or forbid bots from doing that which we have designed them to do, leading to additional steps. You then get more of what we see in prior authorization, with the insurers becoming bolder and bolder and less restrained.
The truth is that AI cannot show judgment and cannot use ethical or moral principles. It cannot self-correct or show compassion. If we, as clinicians, want to let it into our office and operating rooms and insinuate it even further into our lives, we must put on our big boy and big girl pants and accept what that choice will bring to us and our art. It also absolves us of the responsibility we have to our patients, and rather than one-upping the insurers and bureaucracies that hold us, hostage, we need to CHANGE how we do things and how we act in our current space.
ChatGPT and AI are not the answer. Maybe, just maybe, we shouldn’t go there.
CMA opposes bill that would wipe away long-standing protections safeguarding patients and providers
The California Medical Association (CMA) is urging physicians to contact their legislators and urge a NO vote on a bill that would create a dangerous precedent for patients and physicians across the state. SB 784 (Becker) would allow for permanent exemptions to California’s prohibition on the corporate practice of medicine (known as the “corporate bar”) for health care districts.
New DEA training requirement takes effect June 27
Physicians are reminded that effective June 27, 2023, prescribers applying for a new U.S. Drug Enforcement Agency (DEA) registration or renewing their DEA registration must attest to having met the new training requirements for DEA-registered prescribers of controlled substances. A new law requires all prescribers of schedule II – V controlled substances to meet a one-time eight-hour training requirement.
Hundreds of physicians gather in Sacramento for CMA’s 49th Annual Legislative Advocacy Day
Hundreds of physicians, residents and medicals students gathered in Sacramento on April 19 for CMA’s 49th annual Legislative Advocacy Day. This year’s event was by all accounts a wildly successful endeavor. CMA welcomed nearly 400 attendees, representing 45+ specialties and 24 component medical societies. Attendees participated in a total of 120 legislator meetings as champions for patients and the practice of medicine.
DHA reaffirms award of TRICARE West contract to TriWest Healthcare Alliance
The U.S. Defense Health Agency (DHA) has reaffirmed the award of the TRICARE West region managed care support contract to TriWest Health Alliance. DHA initially awarded the contract in December 2022, but the current contractor, Health Net Federal Services (HNFS), filed a protest with the Government Accountability Office. Although the protest has been dismissed, there is the possibility of further legal action that could delay implementation.
CMA publishes 2022 annual report
Stop unnecessary fee increases and keep the Medical Board of California a physician member majority
The California Medical Association (CMA) urges you to take action on SB 815, the Medical Board of California Sunset Review bill. Several proposed changes are alarming to physicians across the state, including:
If SB 815 is passed in its current form, it would have vast, negative impacts on the practice of medicine and health care delivery in California.
Your legislators need to hear from you on this issue now. Express your concerns about SB 815 and the impact it would have on physicians and patients across California, then ask your representatives to vote NO unless amended on SB 815.
The UCSF Institute for Health Policy Studies
The UCSF Institute for Health Policy Studies (IHPS) has been busy this past week. My colleague (and prior CANS speaker) Brian Miller gave grand rounds on May 17th, 2023. He spoke about hospital consolidation and policy prescriptions to combat this (video available online). His talk was excellent (although I’m biased) and generated some great discussion. The IHPS should be lauded for hosting a traditionally conservative speaker. I’m proud to be affiliated with the institution because of its willingness to engage with thought leaders across the political spectrum.
Additionally, the IHPS hosted its first annual health services research symposium on May 23, 2023. The symposium brought together faculty, students, and researchers from across the UCSF community to share their work on various health policy topics.
I had the pleasure of moderating an abstract session and participating in a panel on publishing outside of normal academic journals. I moderated the session on insurance, costs, and healthcare trends. It was spectacular. Of course, It was humbling to see the research being accomplished by many health services researchers at UCSF. I found the discussion to be very informative and engaging. The speakers were passionate about their work and could clearly communicate their findings to the audience. I also appreciated the opportunity to learn about the different perspectives on health policy. These will make excellent papers when they are published.
In my panel, we discussed the challenges and opportunities of publishing in non-traditional outlets, such as policy briefs, blogs, and social media (and the CANS newsletter). I was able to discuss my many failures along the way to becoming a little more comfortable with non-academic writing. Again, this was humbling. My CANS newsletter brings me great pride, as have my op-eds in The Hill, MedPage, The Washington Examiner, and American Spectator. Yet, my accomplishments were dwarfed by the other panelists. I learned a ton as a panelist.
We discussed the importance of reaching a wider audience with research findings, the challenges of writing for non-academic audiences, and the resources available to help researchers publish their work in non-traditional outlets.
The keynote and plenary speakers included both the incoming AMA president Jesse Ehrenfeld and outgoing AMA president Jack Resnick. Again, kudos to IHPS for having a diverse speaking panel. Ehrenfeld’s talk on the equitable adoption of AI hit home with me. I was able to ask a question and was amused when he took a jab at my receding hairline (he also answered my question).
Overall, I was very impressed with the UCSF Institute for Health Policy Studies Grand Rounds and Research Symposium. The grand rounds were incredible. The symposium was a great opportunity to learn about the latest health policy research and network with other researchers. I am excited to see how the work that was presented at both will inform future policy decisions.
Most importantly, I’m looking forward to adding a neurosurgeon perspective to the work at IHPS.
Dr. Albert Rhoton Jr.
Learning and innovation go hand in hand. – William Pollard
Education is the path to innovation. – Shala Brooks
Innovation takes many forms. It is not only the invention of new devices. It is not just the development of new technologies. Fundamentally, innovation is a manifestation of discovery and transformation. Dr. Albert Rhoton Jr. (1932-2016) was an exemplary figure in transforming the field of neurosurgery through his remarkable efforts in discovering new facets of neuroanatomy and microsurgery and teaching literally a generation of neurosurgeons in compassionate and competent patient care.
Born in rural Kentucky, Rhoton was influenced early on by the importance of education, as his mother worked as a teacher. He attended Ohio State University and Washington University School of Medicine in St. Louis and completed a neurosurgery residency and an NIH-affiliated research fellowship.
Dr. Rhoton had a sustained passion for neuroanatomy and became a true pioneer in the field. According to published profiles, he believed that “The brain is a source of mystery and wonder. The mind and brain are the sources of happiness, knowledge, and wisdom. Of all of the natural phenomena, none exceeds the fascination of the workings of the human brain” and that “The brain is the crown jewel of creation and evolution.” Beyond the wonder Rhoton held for the brain’s structure, he also saw the direct impact of neuroanatomical knowledge on the ability to provide better care for his neurosurgical patients.
With the advent of the operative microscope, Dr. Rhoton, as a newly minted faculty neurosurgeon, started establishing himself in microsurgical neuroanatomy at Mayo Clinic. He was then recruited to the University of Florida in Gainesville to become the Chief of the neurosurgery division, creating a world-renowned training program and the Rhoton Lab, a center for both teaching and research. The Rhoton Lab has been truly fruitful, with hundreds of publications on microsurgery and neuroanatomy and work that laid the foundation for the textbook “RHOTON – Cranial Anatomy and Surgical Approaches.”
Rhoton’s work also influenced novelty and improvements in surgical techniques. As always, Dr. Rhoton’s mission was to connect his neuroanatomy studies in the lab to achieve high-quality patient care: “We want perfect anatomical dissections because we want perfect surgical operations.”
Even today, Dr. Rhoton’s legacy is clear and continues to inspire neurosurgeons, anatomists, students, and more worldwide. From the Rhoton Collection to numerous teaching and research programs and fellowships, trainees and established surgeons learn from Dr. Rhoton’s surgical education and anatomical expertise innovations.
Competence without compassion is worthless. Compassion without competence is meaningless. – Albert Rhoton Jr.
Reference:
Matsushima T, Kobayashi S, Inoue T, Rhoton AS, Vlasak AL, Oliveira E. Albert L. Rhoton Jr., MD: His Philosophy and Education of Neurosurgeons. Neurol Med Chir (Tokyo). 2018 Jul 15;58(7):279-289. doi: 10.2176/nmc.ra.2018-0082. Epub 2018 Jun 20. PMID: 29925722; PMCID: PMC6048355.
Suffering, the badge of all our tribes
I am sitting in the lounge at Heathrow, waiting to board a plane to LAX. On the way over, we were delayed by about four hours, missed our connection, and got into Venice many hours late. It was brutal. And now, on the way back, a three-hour connection in Heathrow has been pulled out to six. At least we are in the lounge, sitting in comfortable chairs, eating passable food, somewhat removed from the fray. It is going to be a very long day. But it could be worse; I am not working.
I feel sympathy for the pilots and flight attendants who will be working on today’s flight. Many flight attendants are only paid for work done after the doors close. Pilot pay structures are more complicated. But the bottom line is that, whether on salary or not, delays cause most in-flight airline workers to have longer days without more pay. It is sort of like OR delays for surgeons … we are going to get paid the same, no matter how long we wait for it to start, and how long it takes to finish. Frustrations with delays can alter judgment. I am generally impressed with the way airline workers handle it.
This gets me thinking about when things are not going well in the OR, for whatever reason. Just as for the people who work on airplanes, there are many factors that are out of my control. And it is difficult to be patient when some of these things occur.
A few weeks ago, I was trying to do a biopsy of a brain tumor. Nothing to get excited about, but it had been a travail even getting him this far. The patient had been extremely difficult. Despite the tumor’s considerable size, he had few symptoms. But it was growing and looked bad. His wife was Jonesing for the biopsy for months, but he kept refusing. Recently, his cognition had failed a bit and he ended up in the hospital. We went through the same dance as before. He agreed to surgery, or his wife said he agreed. And then he would refuse to sign the form. Even with his recent decline, he was not so advanced that we could declare him incompetent. We did this little pas de deux, of consent and refusal, over a couple of days, but he finally assented.
It was a big enough tumor that it COULD have been biopsied blind. I had done a few like that, decades ago, without image guidance or a stereotactic frame, just using my eyes and hands to direct the biopsy needle to the right place. But I recognize that this is the 21st century, and so elected to use a frameless stereotactic system. Unfortunately, it became apparent, after we had started, that the support person from the image guidance company was not familiar with the equipment for the biopsy, though he had successfully helped me on a spinal case earlier in the day. He said that a colleague was coming. It had been a long day. There were consults in the ER waiting, and I was tired.
I had to cool my heels and wait for the relief pitcher. She showed up. It was still not smooth, though she seemed to have a better idea of what to do, and when I finally took the specimen down to pathology, after what had been an hour-plus delay, I was relieved to see that I had a good piece of tumor. I went back up to the OR and got some more tissue. The CT the next day looked fine, as did the patient. Two days later I had a final answer, GBM. Not good for the patient, but at least we both had survived the biopsy. I had avoided doing something stupid.
It is easy to be stupid. A few years ago, I heard of a neurosurgeon who was having similar difficulty with the image guidance system during a brain tumor biopsy. Rather than abort, he decided to proceed with a free-hand biopsy. Sadly, this individual was not a virtuoso surgeon; so, as you might imagine, it did not go well. A bad decision resulted in an ugly situation.
If surgeons surge ahead with faulty equipment or support, the only person physically at risk may be the patient. The pilot of an airplane is certainly more exposed in an equivalent situation, with their ass literally on the line. But that does
not mean that the proverbial plane cannot crash and burn, and the surgeon gets hurt. Patience can be painful, but so can impudence.
Despite the travel delays, it has been a great trip to Italy. Venice, in addition to other places, has been on my mind, and I am reminded of this line from The Merchant of Venice. Speaking of the burden of being a Jew, Shylock states … “Sufferance is the badge of all our tribe.” While our suffering as neurosurgeons may be petty, it is still real and better off “… borne with a patient shrug.” (Act 1, Scene 3).
The Eye of Horus
I just returned from an awesome trip to Israel, Jordan, and Egypt. It was a life-changing event both in understanding the Israeli-Palestine conflict and visiting iconic structures from 4000 years ago. At every turn, the next encounter blew away the previous one: placing prayer at the West Wall (Wailing Wall); attending Mass in Bethlehem (in Palestine or the West Bank) at the site where Christ was said to be born; Petra, Jordan, which cannot be seen entirely in a day; the Great Sphinx (see picture) and the Pyramids; the temples at Abu Simbel; and King Tut in the Valley of the Kings.
Some of what I learned surprised me, especially the origin of the time-honored Rx used on prescriptions. Most sources say the basis is from the Latin recipere (recipe), which means “to take”. However, ask an Egyptologist, and they will say the symbol comes from the Eye of Horus.
Horus was the god of the sky, war, and protector of kings. He was the son of Orisis and Isis. His head is pictured as a falcon, with its right eye representing the sun, and his left is the moon. That left eye was injured in a battle with his brother Seth and then healed by Thoth, the god of learning and magic. To the ancient Egyptians, this injury of the left eye explained the irregular phases of the moon. The Eye of Horus offers healing and protective powers.
(Pictures taken from sarcophagi at the Museum of Egyptian Antiquities, Cairo).
According to Karim ReFaey et al. (The Eye of Horus: The Connection Between Art, Medicine, and Mythology in Ancient Egypt. Cureus. 2019 May; 11(5): e4731.), parts of the eye of Horus represent each of the six senses (smell, sight, thought, hearing, taste, and touch). They argue that the Eye of Horus can be superimposed on the midsagittal section of the brain, where a part of all these senses is represented.
(Picture from the above-referenced article).
Additional assertions (Why do we use Rx for Medicine?) say that the Eye of Horus symbol for Rx then evolved later from the symbol for Jupiter (the number 4), who was also the god of the sky as was Horus.
The Eye of Horus is everywhere in Egypt, from the ancient hieroglyphics (the picture is from the temple of Kom Obo in Aswan) to jewelry and the logo on the tails of the planes for Egypt Air.
Indeed, after Ra, the god of the sun, Horus was of utmost importance.
We even see a derivative of the Eye of Horus on U.S. currency. It is better known as the Eye of Providence, but its origins likely date back to ancient Egypt.
Looking at the Rx on a prescription pad will never be the same again for me regardless of its origin.
May is the Asian/Pacific American Heritage Month.
May 1 – May Day or International Workers’ Day in many countries – in the US, we celebrate workers on Labor Day on the first Monday in September. May First has been associated with workers since the 1880s when labor movements/unions worldwide were fighting for fair work conditions.
May 2 – The union representing thousands of television and movie writers announced that they were going on strike for the first time in fifteen years. Expect reruns of your favorite shows until the strike is over.
May 2 – Teachers’ Appreciation Day. The week of May 2-8 is dedicated to appreciating teachers. They deserve much more!
May 3 – The Journal of American Geriatrics Society published a study of 18,000 adults, ages 50-65, who were enrolled in the Health and Retirement Study by the University of Michigan, the National Institute on Aging, and the Social Security Administration. The findings suggest that regular internet use could lower the risk of dementia in older adults by 50%. Please see May 23.
May 3 – The FDA approved the first vaccine for RSV to protect older adults against the respiratory syncytial virus known for attacking babies. Now, grandparents don’t have to worry about spending time with their grandbabies.
May 4 – Happy Star Wars Day. “May the Force be with You.” Carrie Fisher, who played Princess Leia received a star on Hollywood’s Walk of Fame posthumously. And as my favorite character, Master Jedi Yoda, said: “Do, or do not. There is no try.”
May 5 – Tedros Adhanom Ghebreyesus, The World Health Organization W.H.O. director general, announced: “It is with great hope that I declare Covid-19 over as a global health emergency.” This came more than three years after the start of a pandemic that killed millions of people worldwide and changed the daily life of every human on this planet in ways previously unimaginable.
May 11 – The US Covid-19 public health emergency expires. More than 1.1 million Americans died.
May 11 – Title 42, the policy that allowed officials to promptly expel migrants illegally crossing the border during the Covid-19 pandemic, expires.
May 12 – International Nurses Day and the birthday of Florence Nightingale, the founder of modern nursing.
May 14 – Mother’s Day! Mother. Mommy. Mama. No matter what name you use to call your mother, and no matter what language you speak, it sounds wonderful, and she loves it.
May 22 – Arizona, California, and Nevada proposed a plan to significantly reduce their water use from the drought-stricken Colorado River over the next three years. This is a potential breakthrough in a year-long stalemate that pitted Western states against one another. The plan would conserve an additional 3 million acre-feet of water through 2026 when current guidelines for how the river is shared expire. Bureau of Reclamation Commissioner Camille Touton called the proposal an “important step forward.” She said the bureau would pull back its proposal from last month, which could have sidestepped the existing water priority system to force cuts while analyzing the three-state plan. Adopting the bureau’s earlier proposal could have led to a messy legal battle. The 1,450-mile river provides water to 40 million people in seven U.S. states, parts of Mexico, and more than two dozen Native American tribes. It produces hydropower and supplies water to farms that grow most of the nation’s winter vegetables.
May 23 – The U.S. surgeon general, Dr. Vivek Murthy, gave an extraordinary public advisory about the risk of social media use for young people. Although we don’t fully understand the effects of social media, he noted that there is evidence that it can “have a profound risk of harm to the mental health and well-being of children and adolescents.”
May 25 – the first anniversary of the mass shooting at Robb Elementary School in Uvalde, Texas.
May 25 – JAMA published the first research base on the follow-up of more than 13,000 adults at more than 200 study sites as part of the National Institutes of Health’s RECOVER initiative, which stands for Researching Covid to Enhance Recovery. They list the following symptoms: Post-Exertional malaise, or the worsening of health after mental or physical activity; Fatigue; Brain fog; Dizziness; Gastrointestinal symptoms; Heart palpitations; Changes in sexual desire or capacity; Loss of or change in smell or taste; Thirst; Chronic cough; Chest pain; Abnormal movements.
May 29 – Memorial Day!
CANS MISSION STATEMENT
To Advocate for the Practice of California Neurosurgery Benefitting our Patients and Profession
The 17th Annual UCSF Spine Symposium will be held June 16-17, 2023 at the Hilton San Franisco Financial District. It would be great to see you there.
It will be an interactive course, with all lectures followed by case discussions.
More information can be found here: https://spinesymposium.ucsf.edu/
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Registration link: https://spinesymposium.ucsf.edu/registration
UCSF Spine Symposium June 16-17, 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 – 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 (emily@cans1.org) or fax (916-457-8202).
The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.
or to the CANS office emily@cans1.org.
