Volume 50, Number 10

Inside This Issue

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

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

CANS President

CANS’s 50th Anniversary Annual Meeting: Looking Back & Looking Ahead

President's Message

For several years now, even before he passed away, I have had a recurring dream of searching for my friend Satish Keshav. Satish and I were schoolmates at Oxford University, where he arrived from South Africa and I from Canada. We became fast friends, discovering an immediate kinship on many fronts, among them his living through Apartheid and my history of spending a huge proportion of my youthful energy protesting that crime against humanity. Dr. Keshav died suddenly in January 2019, at age 57, leaving behind a wife and three young kids. He was a few months older than me; we had last seen each other in Oxford in 2017 but kept in touch regularly. In my recurring dream, the familiarity of the location, Oxford, adds to my anxiety in knowing where to look for, but not knowing how to find, Satish. I try the phone book and all the addresses I had for him. I ask mutual friends about his whereabouts to no avail; as my departure time nears, the desperation of my search reaches its zenith. The fact that I know the city so well adds stress to the dream, as there is some urgency in my (unsuccessful) search. I never mentioned this dream to Satish when he was alive, but I assume my dream is my subconscious reminding me of the immensity of the missed opportunity to spend more time with my friend and, indirectly, with my own family. Certainly, whenever we met or when we communicated via email and text, because of the madding pace of our professional lives, we reiterated the importance of seeing each other regularly, spending quality time, and getting our spouses and kids to share our closeness; our intentions were pure; our regret recurrent; and now, it is too late. Last night I had this dream again, and this morning I decided to write this President’s Message about missed opportunities and associated regret. I share this very personal experience in the hope that others may find something compelling in it that is relevant to their own lives. Most neurosurgeons live magical lives, with a chance to rescue our patients from disability and death and with the privilege of spending time with each other at recurring conferences, which offer us a chance to re-connect and refresh while also keeping up with a rapidly evolving specialty, not to mention traveling to some incredible places. I have included my wife and kids in my professional travel, and my kids have grown up attending CANS, where my colleagues have witnessed their evolution. Satish Keshav was an accomplished
gastroenterologist, and sadly our professional paths never crossed:

As CANS approaches 50 and I approach 60, I am insightful enough to appreciate the blessed life I have led and the incredible opportunities I was given by kismet.  Whenever I speak to fellow neurosurgeons about the “r” (retirement) word, I sense some stress around the topic—could I be projecting?  As neurosurgeons, we are natural planners: we plan our subspecialty education early in residency; we plan pending surgeries in excruciating detail, usually well before we arrive in the OR; we use evidence-based medicine to seek the best course for our patients.  While it may be my imagination, it appears to me that, on the personal front, neurosurgeons steer clear of planning about the “r” word–from a reluctance to use the word to a lack of admitting to giving it much thought to the desire not to acknowledge the reality of life’s exigencies, I can count on one hand (with fingers left over) the number of neurosurgeons who (in the absence of a health-related retreat) are willing to admit to a rigorous, systematic, and analytical process of planning their egress from our profession. 

Certainly, the fact that our patients and profession need us offers us a pretext to keep going with the attractiveness of instant gratification and re-validation of self-worth from each surgery, all the while justifying delaying gratification for our personal and family priorities–I hope the upcoming CANS annual meeting (Riverside, CA, 13-15 January 2023) will offer me (and my neurosurgeon friends) another reminder that we are human. It is ok to occasionally think about ourselves (even at some risk to an even greater legacy).  “Quality of Life” and “mental health” are an intimate part of every neurosurgeon’s lexicon, but usually in the context of what is best for our patients; living committed lives of regular sacrifice, we do not think enough about those terms in the context of our own lives.  Among socioeconomic issues discussed at CANS 2023 will be early career financial planning, as well as late-career retirement strategies—both necessary elements for our own QOL and mental health.   As the most formally educated people on the planet, and generally as a privileged bunch with the luxury of choice, there is much to consider beyond neurosurgery and even seeking expert help.   Perhaps my search for Satish Keshav is really behind the high-achievers discomfort with, and perceived impotence about, a zero-sum-game between imperfect professional and personal fulfillment?

Inn & Spa, Riverside, CA
For the CANS 50th Annual Meeting
January 13-15, 2023
Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Report

We just celebrated Thanksgiving. Indeed, each of us, all of us collectively, have many things for which we are thankful. CANS, as an organization, is grateful for having survived and thrived fifty years of eventful neurosurgical milestones. One of our board members, Anthony DiGiorgio, his wife Traci, and their daughter Dorothy just welcomed their son/brother Frank! Congratulations! And to add the icing on the perfect cake, Anthony just passed his Boards! Congratulations again! We are grateful!

On a personal note, my family and I are grateful that after almost five years since losing our beloved home to the vicious wild Thomas Fire of December 5, 2017, we are getting ready to move back into our rebuilt house. We are looking forward to making what we lovingly refer to as 557 home again, full of family and friends, grandkids and their friends, laughter, noise, music, the sounds of the Ventura breeze, the spectaculars sunrises and sunsets, dancing, and, yes, the aromas of cooking … The fact is: as we designed this house, we placed the kitchen in its very center.

I hope you will read our president’s message if you haven’t already. Javed wrote a touching and deeply personal note and used his essay to encourage us, his busy and hard-driving colleagues, to lead a balanced life; many of us tend to ignore our personal and spiritual lives as we concentrate on our professional lives.

In his heartfelt essay, Brian Gantwerker recalls his vigorous training and determination to stay true to who he is.

The “Women in Neurosurgery” column is a reprinted interview – with permission – with Melanie Hayden Gephart from Stanford. Melanie points out that if there’s something that you want to do, you do it!

In his academic corner, Anthony DiGiorgio gives examples of how regulations of various aspects of healthcare spending can adversely affect access to care.

In her Brain Waves Column, Debbie Henry engages us in a discussion about Democracy; she gives a personal example of how a simple majority may interfere with the action – and some may say freedom – of one individual…

In my Changing  Times Column, I address some things California physicians and physicians, in general, may do to mitigate climate change.

Last, please find in this issue an announcement about the CANS 50th Annual Meeting at the Historic Mission Inn and Spa, January 13-15, 2023, and information about registration for the meeting and hotel reservations.

As always, my editorial committee and I welcome your comments and critiques. Please contact me directly at, or call me on my cell phone: 805-701-7007.

Enjoy this wonderful Holiday Season!

Picture of Brian R. Gantwerker, MD, FAANS, FACS

Brian R. Gantwerker, MD, FAANS, FACS

CANS Newsletter Editor

Rebirth & Refashioning

“…life is the principle of self-renewal, it is constantly renewing and remaking and changing and transfiguring itself, it is infinitely beyond your or my obtuse theories about it.” -Boris Pasternak, Doctor Zhivago

Private Practice Corner

This has been an eventful year: an election, new rules, new regulations, and continued struggles to carry on taking care of patients.  The pandemic, far from over, has waned somewhat, but things have reverted, for the most part, to a semi-normal routine.  As summer has waned, autumn has come. 

As a boy, I lived near a forest.  We used to drive to my grandparents’ house, about 20 minutes away.  My father would always drive us through the route that took us under the canopy of trees stretched on either side of the road.  The orange, red, and yellow hues would whiz by, and a thick carpet of leaves would whoosh up behind us as we headed toward their home.  There was a vague sadness watching the trees begin their slumber.  As summer turned into fall, I knew that winter and the frozen stillness of the lengthy Chicago cold months were coming.  Seasons melted into other seasons, and time passed.

Before I knew it, I graduated from medical school and left for Ohio.  I had not planned to move there, as at the last minute, I tried hard to stay in Chicago.  Until the day I left for Cleveland, I had clung to every moment, person, and memory of the place where I was born.

My program was a proving ground.  The call was highly anxiety-provoking, and we all had to buck up to get through it.  The peds ER, the adult ER, the VA, and one of ten outlying hospitals clawed at you, sometimes simultaneously and with similarly acute and dying patients.  Triage became a way of life – for all of us.  Conferences were exceptionally hard for me, as I was smart and knew a fair amount about neuroanatomy, but I got flustered and anxious.  I said things I knew were wrong, and then people began making assumptions about my depth of knowledge.  By my third year, I had mini panic attacks Wednesday mornings.  My nerves and confidence were in rough shape.  I felt like I was full of thumbtacks that could easily poke me in the guts and rattle around audibly as I wandered the halls, sleepless and on call. 

My personal life fell apart, and I drifted further and further into the crucible.  One could see once a kind and fun-loving fellow trainee turn.  I wanted to know if the professors deemed the survival instinct or dormant egomania necessary to make a functional neurosurgeon.  That was not me.  I was shy but funny.  The chubby guy who loved chatting up the nurses and clinical staff.  The one that was sent up to calm down irate patients and family members on the floor, while the others toiled and sought glory in the operating rooms. 

The more I resisted becoming what they wanted me to, the harder it got for me.  Being a nice guy was not high on the list of survival skills.  In my third year of training, I visited my grandparents at their home on Memorial Day weekend.  My grandfather, a retired insurance salesman and WWII army vet, liberator of Bergen-Belsen, had been in and out of the hospital.  His lungs were noisy, and he wasn’t feeling well.  I remember putting my ear to his back and listening.  I thought he should go to the hospital.  I left for Cleveland the next day.  He was admitted to the hospital at the same time.

In the operating room, I was finishing up a shunt with our peds neurosurgeon, a kind woman who had mentored me and was a compassionate and intense person.  My mother phoned the operating room and told the circulator to call her when I was done.  She never called me during the day. 

I finished the case and called her.  She broke the news abruptly, the world slipped away, and my legs gave out from under me.  After almost fainting, I began sobbing.  The man that had been my rock and guidepost was gone.

My chairman at the time allowed me to go home to the funeral.  The fact that I had to ask my chief for permission seemed odd.  Nevertheless, I went home to be with my family again.  While I slept in my childhood bed, I began having a crisis.

What the hell was I doing anyway?  I should have been home – with him.  Wasn’t this all a mistake?  I felt like I was dying inside, and my world, this schema of being a well-respected neurosurgeon, seemed to cave in on me.  Remembering something one of the professors I had interviewed with had told me:  “You’re not committed to this.  You are doing this because you see this as yet another challenge.”

It all seemed to be coming true.  What is the use of all this?  I should just quit, start over again, or do something else.  This is what my ego had wrought up to this point – being far from my family and having only loss handed to me:  loss of myself, of my loved ones, and any life or happiness I had back home.  Preparing myself to tell my chairman I would resign, my grandmother said something to me I have never forgotten.

“You will finish this.”

Not known for her timeliness or compassion, but rather her caustic sense of humor and penchant for Lladró figurines, she had come with this timely encouragement.  I was stripped bare, thinking this career would consume or wreck me.  Refusing to stop being me and knowing that not adapting would ensure more difficult times ahead, I was at a crossroads.  Fully expecting to not even go back to Ohio after the funeral, she had come with exactly what I needed – a push. 

The car ride back was five hours of quiet.  Somehow, I had to come to a detente to complete this. 

Returning to the grind after his death was unceremonious.  I still felt disconnected.  Meeting my future wife came not long after, and then, I lost my grandmother after a month-long illness in a Marietta, Georgia, ICU about two years later.

My negotiated peace with my career came with stipulations.  Number 1: I would never forsake the kernel of who I was; Number 2: I would do what was asked of me to finish – adopt their language, their habits, and whatever style, proclivities, or dogma they wanted me to as long as it did not interfere with number 1.

So, I was remade and saw how specific battles were left unfought.  I could still be me, making sure the patients were always well-attended, continuing to listen to my inner grandpa when it came to their well-being, and being more attuned to the attending staff’s subtleties and their demands met was part of my internal treaty. 

I got through it, as all of you who are reading this did as well.  The day I walked out of the administrative building with my wife on our way to the airport for our flight to Phoenix, my legs nearly crumbled again.  The unburdening of my soul from the weight of the losses I had experienced came as a wave.  I broke down.  Completing training was, at the time, one of the hardest things I had done. 

What I took away with me, though, is that I was still me.  My compassion and love for my patients, that nagging feeling if I felt something wasn’t right, and the desire to constantly improve remained untouched.  I will always be grateful to those who trained me, even if we disagreed on specifics. 

And I will never cease to be grateful to those who shored me up and told me not to stop.

Have a wonderful Thanksgiving.


Neurosurgery Leads Amicus Brief in New Surprise Billing Lawsuit

The No Surprises Act, which went into effect on Jan. 1, bans surprise medical bills for out-of-network care and establishes a process for resolving payment disputes between health plans and providers. Unfortunately, the final rule implementing the law continues to give preference to the qualifying payment amount — or median in-network rate — which unfairly favors insurers when settling out-of-network payment disputes. When resolving payment disputes, the law requires arbiters to consider several factors equally — not just median in-network rates — including the physician’s training and experience, the severity of the patient’s medical condition, prior contracting history, health plan market share and other relevant information.

On Oct. 19, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) spearheaded a physician-led amicus brief, along with the Physician Advocacy Institute, supporting the Texas Medical Association’s (TMA) new lawsuit challenging these rules. Other medical groups, including the American Medical Association, also filed amicus briefs supporting the TMA lawsuit.

Click here to read neurosurgery’s amicus brief and here for the accompanying press release.

Neurosurgery Opposes Bill to Expand Non-Physician Scope of Practice
On Nov. 3, the AANS and the CNS joined the American Medical Association (AMA) in a letter to House Energy and Commerce Committee and Ways and Means Committee leaders opposing H.R. 8812, the “Improving Care and Access to Nurses Act.” Known as the “I CAN Act,” the legislation would allow non-physician practitioners to perform tasks and services outside their education and training, which could result in increased utilization of services, increased costs and lower quality of care for Medicare and Medicaid patients.
Click here to read the AMA-led letter.

CMS Releases Final 2023 Medicare Physician Fee Schedule Final
On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the final 2023 Medicare Physician Fee Schedule rule. Overall, neurosurgeons face a 4% decrease, due primarily to the expiration of temporary financial relief provided by Congress last year to mitigate steep payment cuts in 2022. In addition, neurosurgeons face a 4% Statutory Pay-As-You-Go Act sequester cut absent Congressional action. 

Provisions of interest to neurosurgeons include: 

  • Restoration of the American Medical Association/Specialty Society RVS Update Committee-passed values for interbody spine fusion CPT® codes 22630 and 226

  • A one-year delay of a new policy requiring physicians to see patients for more than half of the total time of a split or shared evaluation and management visit to bill for the service. For 2023, CMS will continue to allow physicians and qualified health care professionals to use medical decision making to determine the substantive portion of the split/shared visit.

Changes to relative weights of the fee schedule components (i.e., work, practice expenses and professional liability insurance (PLI) expenses) that will decrease the value of physician work and PLI expenses, thus leading to future reductions in neurosurgical payments. The final changes will reflect an updated practice expense data collection initiative currently underway.

A more detailed summary of the final rule will be forthcoming. In the meantime, click here for a press release about the final rule and here for a fact sheet.

Neurosurgeon Appointed to AMA CPT® Editorial Panel
Joseph S. Cheng, MD, FAANS, has been appointed to serve on the American Medical Association’s CPT Editorial Panel. The CPT Editorial Panel is tasked with ensuring that CPT codes remain up to date and reflect the latest medical care provided to patients.

Neurosurgical Resident Picked for White House Fellow Program
Jeffrey Nadel, MD, a neurosurgical resident from the University of Utah, has been named to the 2022-2023 White House Fellows class and is working at the U.S. Department of Veterans Affairs. He joins 14 other individuals selected to participate in this prestigious program and follows in the footsteps of neurosurgeons Jeremy Hosein, MD (2018-2019); Lindsey B. Ross, MD (2016-2017); Anand Veeravagu, MD (2012-2013) and Sanjay K. Gupta, MD (1997-1998). 

The White House Fellows Program was created in 1964 by President Lyndon B. Johnson to give promising American leaders “first hand, high-level experience with the workings of the Federal government, and to increase their sense of participation in national affairs.”

Neurosurgeon Elected to Prestigious National Academy of Medicine

On Oct. 17, the prestigious  National Academy of Medicine  announced  the election of another neurosurgeon to its ranks: James M. Markert, MD, MPH, FAANS, chair, department of neurosurgery, University of Alabama, Birmingham. He was recognized as a world expert on oncolytic viruses, an author of the first-ever paper on genetically engineered oncolytic viruses, the primary author on the first-in-human trial of an oncolytic virus and senior author on the first use of an IL12-expressing virus for human glioma. Dr. Markert is currently conducting adult and pediatric brain tumor trials.

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

Climate Change/ What Should Physicians Do?

Changing Times

During the 151st Annual Meeting of the CMA House of Delegates, I attended a session called “Understanding the Climate Health Crisis and How California Physicians Can Make an Impact.”

It was an informative session with great panelists. I am happy that CMA is taking this issue seriously. In fact, along AMA, they declared Climate Change a Healthcare emergency, and for many good reasons.

Let me be clear: Climate Change is REAL. This past August, California experienced an unprecedented heat wave with temperatures 10 to 20 degrees above average, prompting Governor Gavin Newsom to declare a state of emergency. This is only one example of many.

António Guterres, The UN Secretary-General, in a speech to the International Climate Summit CPO27 held in Egypt November 7-18, described the world as if it were “on a highway to climate hell with our foot on the accelerator.”

On the international front, there is some progress: the deliberations of the latest U.N. climate summit – COP27 – held in Sharm-El-Sheikh, Egypt, resulted in one key breakthrough: the agreement to set up a “loss and damage” fund, which would offer vulnerable nations financial assistance in dealing with the climate crisis. But developed countries failed to commit to phasing out, or even phasing down, all fossil fuels, alarming climate scientists and experts who warn that stronger action and sharper cuts are necessary to limit global warming.

Here in California, physicians can, indeed, make an impact. And they don’t even have to resort to shenanigans similar to the headline-grabbing attempts to deface famous artwork. The offenders made sure not to inflict permanent damage by throwing tomato soup at Gogh’s “Sunflowers.”

Credit…Just Stop Oil, via Associated Press

or Claude Monet’s, by throwing mashed potatoes at “Grainstacks” and gluing their hands to the wall.

After throwing mashed potatoes at a painting by Claude Monet, on exhibit in Potsdam, Germany, the climate protesters each glued a hand to the wall on Sunday. Credit…Letzte Generation, via Associated Press

But these radical activists were trying to prove a point: do we care more about a piece of art or about our home planet? It is an interesting point, but I don’t condone their strategy.

We do know, however, that climate change is harming human health. We also know that people facing inequities “hurt first and most;” this became clear during the pandemic. And in addition to communicable diseases and chronic diseases, we now have climate diseases.

Here are some obvious causes:

  • Drought – decreased available food, dust storms, and valley fever.
  • Extreme heat – heat-related illnesses, cardiovascular failure, and death.
  • Severe weather and floods – Injuries, fatalities, loss of homes, and increased fungi and molds.
  • Wildfires and wildfires smoke – Injuries, fatalities, loss of homes, and cardiovascular and respiratory diseases.
  • Air pollution and increasing allergens – asthma, allergies, and cardiovascular and respiratory diseases.
  • Changes in vector ecology – Lyme disease, west Nile virus, hantavirus, malaria, and encephalitis.
  • Food systems impact – malnutrition, food insecurity, higher prices, and foodborne illnesses.
  • Water quality impacts – harmful algal blooms, campylobacteriosis, cryptosporidiosis, and leptospirosis.
  • Degraded living conditions and social inequities – exacerbation of racial and health inequities and loss of employment.
  • Environmental degradation – loss of jobs and income, forced migration, and civil conflicts.

Climate change affects not only the physical but also the mental health of people:

  • Depression, stress, and anxiety.
  • Strains on social relationships.
  • Complicated grief.
  • Substance abuse.
  • Post-traumatic stress disorder- PTSD.
  • Loss of personal identity.
  • Helplessness and fatalism.

There are estimates that the price tag of the annual healthcare impact of climate change is about $820 billion. Consider:

  • Premature deaths from heat waves, wildfires, and smoke.
  • Medical care for the treatment of physical and mental health conditions.
  • Rehabilitation and home healthcare.
  • Prescription drugs.
  • Lost wages and productivity.
  • Downstream health costs such as delayed care and homelessness.

What can physicians do?

  • Each one of us must become more educated and versed in how climate change affects the health of our patients, our patients’ families, our own families, and our own health.
  • We must be proactive and start conversations with our patients and teach them about the detrimental effects of climate change on their health. We are fortunate that we continue to be trusted by our patients. And consequently, this trust gives us added responsibilities.
  • We must consider our own practices and eliminate medical waste as much as possible. I admit that this is easier said than done.
  • Single-use items are considered necessary to fight infection. Is this true? Should we revisit this concept? On my most recent visit to Nepal, I witnessed how in their neurosurgical cases, everything is re-sterilized and reused. The good news is that their infection rate is not significantly different from ours. This is probably true in many other countries.
  • In surgery, and particularly in our beloved neurosurgery, we tend to love our toys, and we always want the latest and the greatest sending perfectly good and functioning equipment to landfills. Some may say this is false because efforts to donate such equipment to third-world countries are often made. The truth is: once in a hospital in a third-world country, and without the capability of maintenance and upgrade, the once coveted equipment is quickly shelved or relegated to a basement storage space.
  • We should consider joining grass root organizations, such as Climate Health Now, to leverage healthcare workers’ voices in the fight to mitigate the effects of climate change. There are many other organizations from which to choose. Physicians for Social Responsibility is another established group that comes to mind; it was awarded the Nobel Peace Prize in 1985.

Yes, we, the physicians of California and the World, have a significant role in fighting Climate Change. And we must act now.

Quote for the Month​ of November

Quote of the Month

” The smallest deed is better than the grandest intention.

From CMS

Review & Dispute Reminder: Program Year 2021 

Program Year 2021 Open Payments data is available for review and dispute through December 31, 2022.

On June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) published Program Year 2021 Open Payments data along with updated and newly submitted data from previous program years (2015-2020). The Program Year 2021 records are available for review and dispute in the Open Payments system through December 31, 2022, so be sure to review data attributed to you as soon as possible! 

Review Now

Covered Recipient review of the data is voluntary, but strongly encouraged. If you believe any records attributed to you are inaccurate or incomplete in any way, you may initiate a dispute and work with the reporting entity to reach a resolution. To review and dispute records from earlier years that are no longer available within the Open Payments system, you must contact the reporting entity directly. 

Records are only available for review in the Open Payments system until the end of the calendar year in which they are first published; you can see previous years’ data by searching the data at

For more information on the review, dispute and correction process visit the Open Payments Covered Recipient Review and Dispute page at

Picture of Melanie Hayden-Gephart, MD

Melanie Hayden-Gephart, MD

If there’s something that you want to do, you do it

Women in Neurosurgery

Stanford Medicine – Neurosurgery

Stanford’s Department of Neurosurgery faculty is nearly 25% female, an unprecedented level compared to other Neurosurgery programs around the country, and the world. But there is still much room to improve parity, and to make the path to success in this field less burdensome and stigmatized for women. In this series, women across the Department share their experiences as females in the fields of science and medicine. From what got them hooked on science as children, or motivated them to become doctors, to their determination to overcome the bumps they faced on the road to becoming neurosurgeons, we suspect their stories will resonate with many women, regardless of their chosen profession. We hope that by sharing their stories, we may inspire more young girls to pursue careers in science and eliminate some of the myths associated with women pursuing one of the most complex and demanding professions in medicine. 

When Were You First Interested in Science?

When I was a little kid, I really liked a lot of projects that involved problem solving. I took a biology course in high school, and I became very quickly interested in how the brain works, and how we can figure out different ways of understanding the transition between what a cellular process is, and what is a higher order of cognition and awareness – that transition was always very interesting to me. When I was in college I majored in neuroscience. I really liked math and science, and that challenge of having a question that no one really knows the answer to and trying to prove yourself either right or wrong. 

Who Encouraged You To, or Discouraged You From, Pursuing Science?

I had a lot of encouragement from my family from the beginning. I’m a very motivated and enthusiastic person, and I think in the same way that I work with my kids to direct their powers for good, my family also made sure that I could put my enthusiasm into a productive stream. But encouragement on a professional level, well, there wasn’t very much of that. Particularly in medical school when I was thinking about doing neurosurgery, the first dozen people I talked to about it said, “absolutely not!” There was no filter or concern to be politically sensitive about it, they basically just said “well, women can’t do neurosurgery, so you should do something else.” I haven’t listened to that voice, that societal voice on what women can or can’t do, and I wasn’t about to then either. That said, I wanted to make sure that this was something that I really intrinsically liked, because I knew it was going to be very challenging, but I also wasn’t going to let other people tell me how to balance my life. During those first few years in medical school, I had no real role models, at least not for women in neurosurgery. Once I committed to the specialty, many faculty were very supportive, and Stanford has been as well. 

How Did You Respond to Those Who Discouraged You?

People would also say, “well, you can’t do neurosurgery because you can’t do it part time,” as if by being a woman I only wanted to work part time. When I was a medical student, a female neurosurgeon I met, who was no longer practicing, said “well, you can do neurosurgery, but then you definitely can’t have kids,” and she didn’t know, but at the time that conversation took place, I was actually three months pregnant with my first child. I think that as with all points in your life and your career, you must filter the advice that you get. I would think, ‘well, I’ve done a good job of maintaining balance in my life while doing all these other productive things, so I think I can also manage this and fulfill my other goals.’ If there’s something that you want to do, you do it. You know that there are going to be sacrifices and compromises, but ultimately this was the correct decision for me. I think about the things that people have said or done to try to prevent me from getting where I am now, and all I can do is make sure that I’m doing the best job that I can every day and try to set an example for the next generation of scientists and physicians.

Do You Think There Are Advantages or Disadvantages to Being A Woman In Science?

I think that the experience is different but not disadvantageous, particularly the experience of being a physician or scientist when you have little kids. Juggling neurosurgery and kids has been helped by my incredibly supportive partner, who has watched all of this develop from undergraduate studies to faculty position. Neurosurgery and science are challenging careers, requiring leadership and resiliency. There are unique experiences to women in child rearing, and I think that gives an opportunity for perspective, and to recognize holistically the different types of support that patients, trainees, or employees may need. 

Were There Times You Felt You Were Treated Differently in Professional Settings Because You’re Female?

Yes. I am still very frequently asked by patients if I’m the physician or the surgeon, and people are still taken aback when they meet me and realize that I’m a woman. I’m still regularly referred to as the nurse or social worker by patients, hospital staff, and sometimes even by other physicians. In a sense this is a societal reflex. I’ll tell you an interesting story; I was reading a book about a doctor to my kid back when he was about kindergarten age and we were talking about the book and he said, “well, that person can’t be a doctor, cause it’s a girl.” I found that comment so interesting, because here’s a child who knows that his dad is a teacher and his mom is a doctor, and yet, somehow, all the rest of the input that he gets from life tells him that women aren’t doctors. So, then I asked him, well “what do I do?” and he said, “you fix people’s brains” and he recognized that conflict within himself. These ideas are culturally hard-wired from an early age. 

How Do We Teach the Next Generation to Combat Negative Cultural Inputs?

I have three children, two boys and a girl. I try to be reflective and cognizant of my inherent biases – to teach my sons as much as I teach my daughter about what women can accomplish. Girls very early on receive the message they’re not good at math and science. It has to be a conscious reinforcing of your kids’ strengths. Be reflective and thoughtful about how you may be perpetuating inherent biases, or how the same behavior will be perceived. Listen to how people talk, interrupt, or remain silent. When it comes to our kids, I focus on encouragement, awareness, persistence, open conversation, and building confidence. 

Have You Seen Inherent Biases Play-Out at Work?

Yes, I’ve had assumptions about my role on the medical team, as I’ve mentioned. I’ve also had assumptions about my career goals, like if I was interested in basic science research or not, without asking me. These are not malicious, but ingrained, and need conscious correction. 

Do You Have Hope That Things Are Changing for The Better For Women?

I’ve traveled to, and lived in, lots of places around the world, and very frequently I’ve thought to myself ‘I’m very glad that I grew up a woman in the United States.’ I know for sure I would not have had even the smallest bit of opportunities that I’ve had in my life if I had been living most other places in the world. The challenges I faced do not compare to women who have to fight for their right to speak, vote, have access to healthcare, and control over the number of and timing of having children, education, and other basic human rights. In the US, I think it would be helpful to remove the stigma around needing to take a leave for your child by implementing policies where men and women have equal time off to take care of their families. People have things that happen in their lives that have nothing to do with having children, and they take the same or more time off then someone else took off to have a child, but for some reason the choice to take time off to have a child is looked down upon.

What Can Be Done to Improve Parity In Leadership? 

I think there would be more women pursuing leadership positions in science or medicine careers if they had more female mentors that they see living and working as role models. We’ve got hard-wired societal biases, and most of us are oblivious to them. You need to make a concerted effort to have women trained and elevated to leadership positions, and to be thoughtful negotiators. I think that Stanford does a good job of that in that they have female faculty mentorship and leadership training. I’ll tell you another story. One day as a resident I ran into a female Stanford medical student who I hadn’t seen in some time, so I asked her what type of specialty she decided to pursue. She answered that she chose orthopedic surgery. She then said to me, “you know, I’ve never told you this, but you were a big reason I decided I could do surgery. I saw you once, operating in the middle of the night, eight months pregnant, and I just thought to myself, if Melanie can do this, I can do this.” I didn’t have a formal mentoring relationship with this student, but just by the fact that I was there, it was enough for her to say ‘I can also do surgery and be a mom. I can meet all of my goals’. 

Picture of Melanie Hayden-Gephart, MD

Melanie Hayden-Gephart, MD

If there’s something that you want to do, you do it

From CMA

Urge Congress to stop the Medicare payment cuts
Physicians are facing another round of Medicare payment cuts. Unless Congress acts by the end of the year, physicians face more than 8.42% in Medicare payment cuts in 2023 due to a confluence of statutory and budget neutrality payment cuts.

New AMA resource helps physicians fight inappropriate E/M downcoding
AMA has created a new resource to support physician practices in navigating payor E/M downcoding programs. The document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding and documentation tips to support successful appeals.

CMA climate health panel discussion now available on-demand
CMA hosted a panel discussion on the climate health crisis last month during the association’s annual House of Delegates meeting in Los Angeles. The event—“Understanding the Climate Health Crisis and How California Physicians Can Make an Impact”—which was also streamed live via Zoom, is now available for on demand viewing.


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

Deborah C. Henry, MD

A Personal Observation About Democracy

Brain Waves

I took Government in the summer of my tenth grade of high school. It was a required class, and since I did not want to waste my electives during the regular school year on a boring subject, I planned to get it over quickly in the fewer weeks of summer. I thought I knew government; the teacher surprised me with ideas I would have never broached on my own. Perhaps the most enlightening topic of discussion was his perfect government: a dictatorship.

Now don’t stop reading.  He made his points. A dictatorship offers one voice, one vision, and one way to get things done. Everyone “agrees.” Theoretically, it is an ideal form of government.

Democracy is messy. All are allowed to disagree. There are many visions, many voices, and more than one way to accomplish things. It is like neurosurgeons and orthopedic spine surgeons arguing about the correct way to treat back pain from a dark disc or minimal spondylolisthesis. Some will always operate, some will never operate, and most are in that big, bell-shaped curve in between.

I spent significant time thinking about democracy by observing Dr. Randy Smith at CANS Board meetings. Our in-person events in Oakland at the Hilton Airport Hotel were always at the end of the building near an exit door. During breaks, Randy would head toward the exit doors, pull out a cigarette, and puff until it was time to return. It gave me pause to think how he was relegated to the outdoors because of democracy. In fact, I was possibly one of the voices who put him there.

I was born before smoking was recognized as a precursor to lung cancer. My mom allegedly smoked until she was pregnant with me. She only quit because if she both smoked and drank during her pregnancy, she would become ill. She chose to give up smoking.  My dad smoked pipes and cigars. Though my sisters, brothers, and I could handle the cozy smell of the pipe, we could not tolerate the stench of the cigar. He would have fancy stogies shipped to him in the mail. Once, thinking it was a package of cigars in the box that came in the mail, my sister hid them, only to find out later that it was perishable food. Because of the cigar smells, none of us siblings smoke. We all hated eating in restaurants when the person beside us was smoking.

In 1990, San Luis Obispo, after hearing community debate, became the first city council worldwide to ban indoor smoking. The State of California followed suit in 1995, banning smoking in restaurants and most indoor workspaces; the restriction extended to bars in 1998. According to the CDC, as of June 2022, 35 states have banned smoking in restaurants, 29 states prevent smoking in bars, and 28 states have comprehensive indoor smoking bans. Thus, there are 15 states with no bans. (It looks a bit like the democratic/republican state map). I am certain that if I were ever asked to eliminate smoking on a ballot, I would choose to do so (as I did with Prop  31 recently).

Back to Dr. Smith. As I watched him puff, I thought about democracy. It takes slightly over 50% to put an issue in the minority. Smokers are in the minority. Their rights are not protected in the Constitution, as are the rights of free speech, free religion, and gun ownership. Our recent election showed the importance of 50%. Those receiving the majority were elected; those who did not, were not elected. We are led to believe that this split of 49/51% polarizes us. I beg to differ. It gives us all a voice. After all, that is what democracy is all about. Thank you, Randy, for making me appreciate this. 

Picture of Dan Miulli, DO, FACOS, Program Director

Dan Miulli, DO, FACOS, Program Director

History of the Neurological Surgery Program at Riverside University Health System

Historical Vignette

In the late 1990s, the number of students enrolled in osteopathic medical schools increased dramatically, and osteopathic residency programs were needed. Many county hospitals, such as Arrowhead Regional Medical Center (ARMC), were a place of last resort for many patients. Due to constraints of previous healthcare funding, these hospitals sought to augment care with residency programs. In San Bernardino County there was, and still is, a large need for primary care physicians and specialists. When ARMC moved from its 1910 facility to its state-of-the-art facility in 1999, it started its journey as the West coast’s flagship facility for many osteopathic residency programs. Dr. Javed Siddiqi, against all odds, fought to start a neurological surgery residency program. With the help of Dr. Dev Gnanadev, the ARMC Chief Medical Officer, and Dr. Don Krpan, who was the president of the American Osteopathic Association (AOA), and Dean and then Provost of Western University, they succeeded. The requirements were tough, but the pathology, volumes, and academic environment at this county hospital, ARMC, and Riverside County Regional Medical Center, now Riverside University Health System (RUHS), were enough to overcome the odds. In 1999 ARMC was granted an osteopathic neurological surgery residency with an MD program director. Initially, one resident per year was approved, then more residents as the faculty, case volumes, residency specialties, and academic experiences increased.

The base hospitals consisted of ARMC, RUHS, and Kaiser Fontana. In the early years, the residents and faculty also went to Desert Regional Medical Center and Redlands Community Hospital. Each facility provided a unique and exceptional educational experience. The goal of the neurosurgery faculty was to meet, surpass, and excel in providing the healthcare needs of all neurosurgical patients in San Bernardino and Riverside counties, independent of the patient’s income, lifestyle, or pathology. Dr. Dan Miulli joined Dr. Siddiqi in 2001 as neurosurgical faculty, then as Director of Medical Education (DME), first at RUHS and afterward at ARMC, where he became the Associate Program Director, and finally the Neurological Surgery Program Director in 2014. Soon the program became affiliated with other prestigious training sites of Children’s Hospital LA and Kaiser LA, rounding out its exceptional training and faculty. With the growing academic experience, caseload, and 29 faculty, the program grew to 21 residents.

Dr. Siddiqi, after stepping down as ARMC program director, saw the need to increase the neurosurgery presence in the Coachella Valley. At the previous training site for the ARMC neurosurgery residents, he began a new AOA Neurological Surgery Residency program with the assistance of Dr. Miulli, then as the Administrative DME.

The foreseeable change in July 2015, under the Single Accreditation System (SAS), did not allow for more than one base hospital. A very difficult decision was made to move this AOA Neurological Surgery residency program from its primary site, the AOA’s West-Coast flagship hospital, ARMC. With the redevelopment and expansion of GME at the rebranded RUHS, the program’s primary site was moved. The program, now at RUHS, applied for initial accreditation in February 2016 and received ACGME Continuing Accreditation in January 2022. Although the case volume, faculty, pathology, and academics provided enough for more than three residents per year, the program remains approved for one resident per year.

Despite the dwindling number of residents from 21 to 7, currently, at 13, the program and faculty produce over 70 peer-reviewed publications per year. The residents are life-long learners, with each of the over 40 graduates taking pride in neurosurgery fellowships. The neurosurgery residents provide comprehensive and holistic care due to the environment of the county hospitals, managed care hospitals, and private hospitals. The county hospitals are level-one trauma centers. ARMC is a comprehensive stroke center and has a dedicated Neuro ICU. The county hospitals continue to provide tertiary care and remain a safety-net facility for all those needing the most advanced neurosurgical care. With the faculty, staff, and patient assistance from Kaiser hospitals, Children’s Hospital of LA, and now Loma Linda hospital, the RUHS Neurological Surgery Residency Program is poised to help the healthcare family even more.  

Photo of the Month

California Brown Pelicans, Solimar Beach Ventura. Photo taken by Moustapha AbouSamra, MD at 4:40 PM, November 15, 2022 iPhone 13 Pro

From CMA

CMA files brief with U.S. Supreme Court in critical Medicaid case
The California Medical Association (CMA) has filed an amicus brief with the United States Supreme Court in a case—
Health and Hospital Corp. v. Talevski—that could strip Medicaid beneficiaries and providers of their right to access the
courts to enforce state compliance with Medicaid requirements.

CMA publishes November 2022 physician voter guide
Mail-in-ballots for the November 8, 2022, California General Election will soon arrive in the mail. We hope that you will mail in your ballot or show up to the polls to help ensure the voices of physicians are heard loud and clear. Download the CMA November 2022 General Election Physician Voter Guide, which includes CMA’s positions on statewide ballot measures and endorsements for two CMA-supported physicians running for their first terms in office.

Gov. Newsom vetoes dangerous optometrist scope bill after hundreds of physicians speak up
Governor Newsom vetoed a dangerous bill (AB 2236) that would have allowed optometrists to perform eye surgeries that require use of a scalpel or an injection and “anterior segment lasers” if they met minimal specified education and training conditions that are far inferior to the requirements that ophthalmologists must meet. CMA’s grassroots network of physicians had mobilized to make sure that Gov. Newsom understood this bill’s potential consequences.

Gov. Newsom signs important health care bills
As the 2021-22 legislative session came to a close, Governor Gavin Newsom took action on a number of important bills
supported and sponsored by the California Medical Association. For more information, see the articles listed below:

  • Governor signs CMA-sponsored bill giving physicians time to interpret test results for patients
  • CMA bill to provide more eRx flexibility for low volume prescribers signed into law
  • Governor signs bill to protect patients and the sanctity of the physician-patient relationship
  • Governor signs bill requiring coverage of COVID-19 therapeutics

CMA supports Texas physicians in surprise billing lawsuit to ensure there is a fair dispute resolution process
The Texas Medical Association (TMA) has filed a second lawsuit against the federal government over its misguided implementation of the No Surprises Act, which guides the resolution of payment disputes between out-of-network physicians and insurers. CMA strongly supports TMA’s important legal action to ensure the Independent Dispute
Resolution process is a meaningful avenue to dispute payment for services subject to the No Surprises Act.

CMA applauds new legislation that protects senior patients’ access to care
A bipartisan group of Congressmen have introduced legislation that will implement annual inflation updates so that Medicare physician payments keep pace with the actual costs to provide care and operate a medical practice. The bill was introduced by physician Congressmen Raul Ruiz (D-CA), Michael Burgess (R-TX), Ami Bera (D-CA) and Larry Bucshon (R-IN).

Cigna will not move forward with implementation of its modifier 25 policy
As a result of CMA advocacy, Cigna announced in July it was reevaluating the policy to require the submission of medical records with all Evaluation and Management claims with CPT 99212-99215 and modifier 25 when a minor procedure was billed as a precondition of payment, as well as delaying implementation. Cigna also agreed to meet
with CMA and the American Medical Association to discuss further.

PHC announces 2022 Leadership Award recipients
Each year, Physicians for a Healthy California (PHC) celebrates the commitment, compassion and contributions of physicians and organizations that have positively impacted the health of their communities. PHC proudly announces the four winners of the 2022 PHC Leadership Awards.

UnitedHealthcare revises initial fee schedule mailing
UnitedHealthcare (UHC) in August announced it would begin migrating some physicians to an updated commercial fee schedule beginning in October 2022. As part of the first stage of this transition, UHC issued a Notice of Amendment to approximately 3,000 providers tied to the UHC 2008 commercial fee schedule. Half those providers notified may not, however, actually be impacted by the first phase of the fee schedule update.

Research supports expansion of insurance-covered trauma screening nationwide
California’s expansion of screening for childhood trauma is being hailed as a model for other states, according to a brief recently published in the Journal of the American Board of Family Medicine. The brief—written by researchers from UC Davis Health and other University of California institutions—say the screenings have the potential to
demonstrate the current prevalence of Adverse Childhood Experiences (ACEs) and how they affect health outcomes for adults.

Blue Shield launches new “episode of care” payment model
Blue Shield of California is launching a new value-based, shared savings payment model for specialty care physician practices. The program aims to transform how specialty care services are delivered by shifting away from traditional fee-for-service to value-based care in an “episode of care” arrangement. The focus of an episode of care
arrangement is providing coordinated, collaborative care across the health care continuum to help ensure patients receive the highest quality care while managing costs.

Physicians no longer required to report all cases of COVID-19
The California Department of Public Health (CDPH) has revised COVID-19 reporting requirements for health care providers. Under the new requirements, effective October 4, 2022, physicians and other health care providers must still report patient hospitalizations and deaths due to COVID-19, but they are no longer required to report every confirmed or suspect case.

National Academy of Medicine publishes National Plan for Health Workforce Well-Being
The capacity and well-being of the U.S. health workforce has been under threat for years by an epidemic of burnout, and two years of the COVID-19 pandemic has further exacerbated this issue. Recognizing the devastating impact this could have on the U.S. health system, the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience recently launched the National Plan for Health Workforce Well-Being.


CMA 151st Annual House of Delegates Meeting

Hundreds of physicians gather for CMA’s Annual House of Delegates
The California Medical Association’s (CMA’s) 151st meeting of the House of Delegates (HOD) convened October 22-
23, 2022, in Los Angeles.
More than 500 CMA physician delegates meet annually at HOD to establish broad policy on current major issues that have been determined to be the most important issues affecting members, the association and the practice of medicine. This year, the delegates discussed three major issues: Physician Workforce, Health Care Reform and Mental Health. The final reports and actions of the HOD will be published soon.
See below for our news from this weekend’s House of Delegates.


  • Santa Cruz internist Donaldo Hernandez, M.D., takes office as CMA’s 154th president
  • Redwood City ob-gyn Tanya Spirtos, M.D., becomes CMA president elect
  • Los Angeles physician Jack Chou, M.D., elected CMA Speaker of the House
  • San Francisco dermatologist Lawrence Cheung, M.D. elected CMA Vice Speaker of the House


  • Ferndale physician receives CMA’s Frederick K.M. Plessner Memorial Award
  • Chico family physician receives CMA’s Gary S. Nye Award for Physician Health and Well-Being
  • Glenn County pediatrician receives CMA’s Compassionate Service Award
  • Sacramento pediatrician receives CMA Speaker’s Recognition Award
  • Los Angeles psychiatrist receives CMA Young Physicians Section Young at Heart Award

Other News

  • CMA House of Delegates approves new Community health Centers forum
  • CALPAC sets new all-time fundraising record at 2022 House of Delegates

Deborah C. Henry, MD

Washington, D.C. has preserved our heritage

Brain Waves

I just returned from my fifth visit to our nation’s capital. My first trip was circa
1990 when I was a neurosurgery resident in Syracuse. I drove the 6 hours in my
gray Honda Prelude stick shift. Enroute, I needed to pick my sister up at Dulles
Airport (since that time, I’ve learned to fly into DCA-Reagan Airport). I was
travelling at a snail’s pace in rush hour traffic on the highway, windows open to
save on air conditioning cost, and a map fluttering in my lap as I tried to figure
out the way to the airport when a guy shouts from the car in the next lane,
“Where are you going?” He directed me to the correct exit. My first experience
in our Nation’s center was that people are incredibly nice.

The next trip was an AANS sponsored leadership conference. Three other
Southern Californians joined me: Randy Smith, John Kusske, and Pat Wade. It
was a quick trip loaded with visits to Senator offices, meeting with their interns,
and interactive events learning how to be interviewed on television. The short
take on interviewing was to talk with your hands and beware of conflict promoting questions.

The third journey was the 2007 AANS 75th Annual Meeting. The spectacular opening reception was held at the National Air and Space Museum on the National Mall. It was still a time of plentiful food and liquor with an outstanding venue. My son Stephen was 5 and loved seeing Dorothy’s ruby slippers brought over from the National American History Museum for the occasion.

Stephen was 10 when he traveled with me to the 2011 Congress Annual Meeting in October. I had bid and won a silent auction trip to DC that supported the community college I was teaching at part-time. The trip also included a personalized guided visit of the Capitol with a hotel stay nearby. In the rotunda and National Statuary Hall, we saw the California statues of Ronald Reagan and Father Junipero Serra, the latter a polarizing yet timely persona for school children (including mine) learning of the California Missions. Stephen walked down the same hallway as the President does to give the State of the Union address on our way to visit the House Chambers. We toured the underground tunnel and sat in the electric people mover. Later, when up in the Washington Monument, a power outage occurred, and we were stuck at the top in the dark. We hoped we’d be allowed to walk the steps down with the park rangers and see the impressive stairwell, but twenty minutes later power returned and thus, we were confined to seeing the stairwell from the glimpses on the elevator ride.

This October the trip was with my two sisters-the one who was with me in 1990 and one who had never been. Despite the remnants of Hurricane Ian, we walked our 20,000 steps a day. We were up the Washington Monument when the Marine One helicopter landed and took off from the South Lawn of the White House, Joe Biden a tiny dot from so far



I finally made it to the Lincoln Memorial, the Viet Nam Memorial, WWI and WWII Memorial, and the Korean Memorial.



I saw the new FDR and MLK memorials and walked around the Tidal Basin to the Jefferson Memorial. The Capitol that
was so easy to enter in 2011 is now surrounded with barriers and scaffolding. Yet, one cannot leave this city without
immense respect for our 235-year-old democracy. Washington, D.C. has preserved our heritage. Let us preserve our
democracy. Don’t forget to vote.

Picture of Brian R. Gantwerker, MD, FAANS, FACS

Brian R. Gantwerker, MD, FAANS, FACS

The Right Stuff

Private Practice Corner

“The exaggerated esteem in which my lifework is held makes me very ill at ease. I feel compelled to think of myself as an involuntary swindler.”
Albert Einstein

Impostor syndrome is common to many high achieving people. It plagues even the
most accomplished in their daily lives. For many of us, it’s a result of childhood or
other life traumas, others it’s an anxiety driven issue. In medicine, our collective
disbelief in our abilities has been oftentimes used against us and even weaponized. It
has resulted in generations of physicians unprepared for the deeply complex mind
games the financial stakeholders in medicine have and continue to play with us.

For physicians, the moment we get into medical school is oftentimes surreal. Few of us
knew without a doubt what we were getting into. When I found out I had been
accepted, I was just getting back from a rare celebratory evening my senior year of college. My last year, I had actually moved into the fraternity house in order to save some money and be closer to classes. I had a great roommate, Al, who was a type I diabetic. He has since passed away from complications at a very young age. He
was always very supportive and we hung out a lot. We got back around 2 or 3 in the morning to our room. Back then, no one has a cell phone (that I knew) and we still used answering machines.

There was a single message on it.

I played it and it was a friend who had graduated two years before me and happened to be on the admissions committee for the medical school. He told me (against policy) that they had just finished their meeting and he’s gotten home late but wanted to let me know that the result of the meeting was that I was going to be offered acceptance to medical school. Not waitlisted, but actually admitted. It was a surreal moment.

Medical school was beyond difficult for me because, although I consider myself someone intelligent, I had to work really, really hard to cram things into my brain. I had flashcards, mnemonics, notes, and crib sheets in the margins of my book, highlights up the wazoo and so forth. And I would be the first doctor in a couple generations in my family.

When I got accepted into a neurosurgical residency, again it felt surreal. My program was noted to be a very difficult one and I knew it was not going to be easy, but yet I was still over the moon. I was not super excited to be going to Cleveland but as it turns out that fork in the road as lead to an unbelievable number of good things in my life. Getting to practice in California again, something I never thought I’d be able to do. We grew up very middle class, my parents frequently bought us clothing from K-mart (think of Walmart but with the distinct smell of fried food) and my mom kept a ledger on legal paper of which bills to pay when, so as to make sure we had money left in the bank.

But I was also extremely privileged. Though they were not “high earners,” my parents supported me during college, and I had to ultimately take out loans for medical school. But I don’t think this is atypical for any of us that are reading this. Undoubtedly some of you probably had an even tougher time and perhaps had to pay your own way through college and/or medical school.

As neurosurgeons, we are taught to hold everything we do – from a drain stitch, a pedicle screw, or placement of an aneurysm clip – to the highest of standards. As a group, we are arguably the most critical both of self and colleagues in our field. Being acutely self-aware and highly attuned to almost any aspect of life we can sometimes forget we are

If bad things happen, and if you do what we do long enough, they absolutely will, your confidence can be shook. I had a case of an older man with a very large herniated lumbar disc and a significant chronic scoliosis. At the time, I did a reasonably good discectomy but got a durotomy. The series of complications that happened afterwards really got to my core. A colleague even openly threatened to interfere with my care of the patient. Things eventually turned out well and the patient ended up going to colleague who did not operate any further. It took me a few months to really settle back down confidence-wise. No further action was taken by either party.

Looking back, I would have handled the case much differently but also had cut myself some slack afterwards. Dural tears can and do happen, oftentimes despite our best efforts to avoid them.

In our current climate and with the pending expansion of award for malpractice and the diminution of our standing in the social structure of things, it is easy to also feel ineffectual. Rising costs of practice – from rent, payroll, equipment, insurance, gasoline – and the pending deep cuts to Medicare and the private insurers who will follow suit and the inane asymmetrical enforcement of the No Surprise Act – NSA in favor of the insurers – it is easy to feel cast away in the deepest of waters.

And at the end of it all, being in private practice, you start questioning almost all of your decisions. I know that in my business, I have reached an inflection point. There are decisions I am making now that will truly reverberate over the coming years.

Feeling I am not really in charge of my or my business’s destiny and that I am not able to effective in my specialty writ large is something with which I have to battle regularly. Moreover, even if I could control things, am I really deserving of that power? What makes me qualified to make these decisions? Do I need to go to get an MBA? Hire a
consultant? What the hell am I doing here?

The existential terror hounds all of us in private practice. The temptation of running into the arms of the sharp-beaked kraken of the deep, called employment is strong. The initially warm blanket of a steady paycheck and predictability sounds great.

But the fact is that by starting a business you have already answered the question by having the audacity to begin. I know that the circumstances are bad, and the trade winds are not blowing favorably. I may not know my contribution margin, or have an MBA, but I know how to take care of patients and be accountable for my outcomes.
Spending time with and educating my patients on what their experience will be like, has helped build (among other things) the practice.

I have learned not to let fear of failure or the machinations of the insurance-governmental axis, on whatever their endgame is, guide my decisions. The truth is, things will change, and continue to change. Remaining steadfast or perhaps just stubborn is what separates those that might and those that can survive.

My wife has always said: “never make a permanent decision based on a temporary situation.”

And my wife is a wise woman.

Picture of Anthony DiGiorgio, DO

Anthony DiGiorgio, DO

Another Successful Conference

Academic Neurosurgeons’ Corner

CNS and CSNS were in our hometown this month.
That always makes for a hectic meeting. This one was special for another reason,
though. Quite a few students & residents whom I mentored had successful
submissions. I can use this post to brag like a proud parent.

Arati Patel, MD presented our work on the electronic medical burden among
neurosurgery residents. I’ll have another post on this in the future, as our paper is pending publication.

Another resident, Vijay Letchuman, MD, gave an oral presentation for our work examining outcomes after lumbar spine surgery in Medicaid patients using the Quality Outcomes Database.

Pre-med student Evelyne Tantry gave an oral presentation for her work examining traumatic brain injury patients. She examined the National Trauma Data Bank to see which factors predisposed TBI patients to extreme length of stay. This built on previous work done by our group.

Med-student Austin Lui put together an excellent poster on socioeconomic outcomes after spinal cord injury. Using our prospective TRACK-SCI data, he showed that Medicaid patients have less access to rehab services after SCI. This leads to less improvement over time.

Another medical student, Oleksandr Strelko, also examined Medicaid disparities, but in traumatic brain injury. This also showed that Medicaid patients lack access to rehabilitation after TBI as well.
There’s clearly a theme emerging.

In addition to being proud of the work our research team is doing, I was fortunate to be at the CSNS meeting. The vibrant debate and discussions around a few controversial resolutions was stimulating, as always. A ton of good work is coming out of the CSNS, and, as the new chair of the Public Relations Committee, I’ll be summarizing much of it in the newsletter next month. I’m also thrilled to be representing the CSNS on the scientific committee for the 2023 CNS annual meeting.

I’m hoping to keep the socioeconomic content coming. Thank you, dear reader, for indulging my boasting this time

Photo of the Month

Passion Flower - Passiflora Incarnata Photo taken by Moustapha AbouSamra, MD. July11,2022, 11:30 am, Ventura,CA. iPhone 13 Pro
Picture of Anthony DiGiorgio, DO, MHA

Anthony DiGiorgio, DO, MHA

Healthcare Spending and Access to Care

Academic Corner

Any readers of my work know that my policy research centers around access to care.  One of the big factors affecting healthcare access is cost.  However, the current debate surrounding healthcare spending in the United States is missing an important point: increased spending is not necessarily a bad thing. In fact, many industries have experienced increased spending over the past few decades, and these industries are not typically seen as being in crisis. For example, spending on education has nearly tripled since 1980, while spending on entertainment has quadrupled. The home remodeling industry has grown 50% over the past decade.  Yet few people would argue that these industries are in crisis. The reason is simple: Americans value these services and are willing to pay for them. The same is true of healthcare. Americans value having access to quality medical care, and they are willing to pay for it. The problem is not that Americans are spending too much on healthcare; it is that the costs of providing healthcare are rising while labor productivity is falling.  The increased costs haven’t led to increased access.

In many industries, increased aggregate spending has come with increased output.  Labor costs have decreased as productivity increases.  For industries like consumer electronics, more devices are being produced at higher quality for less money.  In agriculture, fields that required thousands of farmhands now need just one person with a few GPS-operated pieces of equipment.  Now, nearly every American has a smartphone, and even with the recent inflation, Americans spend less of their total income on food than at any time in history.  People everywhere have access to inexpensive electronics, food, entertainment, and travel.

In healthcare, the opposite has happened.  In inflation-adjusted dollars, per capita, annual healthcare spending has gone from $1,875 in 1970 to $12,531 in 2020.

Part of the reason is negative labor productivity in healthcare compared to other industries.  For example, over 20 years, Johns Hopkins Hospital has gone from 3,000 employees to 12,000.  During that time, the number of beds and discharges hasn’t changed.  Much of that is administrative overhead dealing with government regulations (metric reporting, compliance, CMS billing rules) and private insurance (billing and adjudication).  Much of it is simply poor electronic health record design.

Other regulations drive up costs without increasing productivity.  For example, the 340B program, which I detailed in a post on Sensible Medicine, pads the bottom lines of hospital corporations.  This program, originally intended to provide discounted drugs to hospitals that service vulnerable populations, has been co-opted into a revenue stream for the hospital industry.  Millions of 340B revenue go directly from Medicare to hospital pockets, yet physicians will get a Medicare pay cut next year.

When costs go up without an increase in productivity, patients suffer.  The dismal labor productivity increases the prices patients must pay, either in increased premiums or reduced wages (since employers are left holding the price tag).  Those Medicare cuts will worsen access to care as more providers opt out of Medicare.

So, in my research on healthcare policy, I concentrate on regulations that increase costs without increasing access.  Regulations like 340B, meaningful use, public financing payment policy, and market consolidation.  Look for more to come soon.

Tidbits November

Tidbits September

November 1 – On this day in 1765 the Stamp Act officially went into effect throughout the American colonies – taxation without representation – and the seeds of independence were sown. Maybe this is the true meaning of All Saints Day!

November 2 – in 1988, 23-year-old Cornell student Robert Morris accidentally released the world’s first computer worm. He had designed a code to replicate itself slowly but remain hidden in other computers without doing any damage. Due to a programming error, however, the code replicated itself too quickly and slowed computers nationwide to a crawl. Even NASA was affected. Our computers have been vulnerable ever since.

November 3 – On this day in 1534, The British Parliament passed the Act of Supremacy, making the kingdom’s divorce with Rome official. With its passing, Henry VIII became the head of the new Church of England. The reason? He was simply infatuated with the queen’s lady-in-waiting Anne Boleyn and wanted a divorce from Queen Catherine of Aragon, but the Pope refused.

November 4 –  On this day in 1922, a British archaeologist discovered Tutankhamun’s tomb. King Tut who died at age 19 about 3300 years ago after a short 10 year reign, became one of the most famous pharaohs of all time. Excavation crews uncovered a stone step in Egypt’s Valley of the Kings, which eventually led to four interior chambers with thousands of preserved objects, including a nesting sarcophagi containing the mummified remains of the young king.

November 6 – The start of COP 27, the International Climate Summit held in Egypt. Many heads of states are in attendance. There are many thorny issues to be tackled during this summit, November 6 – 18. Unfortunately, China, Russia, India, and Canada are not participating.

November 8 – The anniversary of the Camp Fire, the deadliest wildfire in the history of California.

November 8 – On this day in 1895, German scientist Wilhelm Conrad Röntgen was working in his Würzburg laboratory. While studying cathode radiation, Röntgen had set up an experiment in which he covered a gas-filled bulb with black cardboard. Despite this shield, a chemically coated screen about nine feet away began glowing. Perplexed, he labeled his discovery “X-rays” as “solving for X” in a mathematical equation. On December 28, Röntgen published an article On a New Kind of Rays … The first clinical use of X-rays occurred in Dartmouth, Massachusetts. For all his work, Röntgen received the first Nobel Prize in Physics in 1901.

November 8 – Midterm Elections. More than 3.8 million Californians and more than 42 million American Citizens voted early.

November 10, 1969 – Sesame Street premiered 53 years ago. I loved all the characters, Big Bird, Bert, Ernie, Kermit the Frog, Cookie Monster, Oscar the Grouch, Grover, Count von Count, Elmo, and even Big Bird’s imaginary friend Snuffleupagus. Millions of children around the world still do.

November 11 – Veterans Day, initially designated as Armistice Day. It is a day to celebrate peace and the veterans who fought to make the world a safer place. Why November 11? Because on the 11th hour of the 11th day of the 11th month of 1918, the guns fell silent after four brutal years of fighting in World War One, also known as the Great War.  The actual War ended with the signing of the Treaty of Versailles on June 28, 1919, exactly five years after the assassination of Austrian Archduke Franz Ferdinand set off the conflict. 

November 14 –  133 years ago, in 1888,  the New York World reporter Nellie Bly boarded a transatlantic steamship, vowing to circumnavigate the globe in record time. Phileas Fogg’s escapades in “Around the World in Eighty Days,” the 1872 novel by Jules Verne, inspired her. Besides ships and trains, she relied on rickshaws, sampans, horses, and donkeys to venture eastward through Europe, North Africa, India, and Asia. Bly took a 65-mile detour to Amiens, France, to meet Verne. She accomplished her goal in 72 days. When there is a will, there is a way!

November 14 – Nearly 48,000 unionized academic workers at all 10 University of California campuses walked off the job, calling for better pay and benefits. The strike by researchers, postdoctoral scholars, tutors, teaching assistants, and graders threatens to disrupt classroom and laboratory instruction across the statewide university system just weeks ahead of final exams in December.

November 15 – The World’s population reached eight billion people, according to a projection by the United Nations and other experts. The Earth has warmed almost 0.9 degrees Celsius (1.6 degrees Fahrenheit) since the world hit the 4 billion mark in 1974 and added one billion people in twelve years. The UN indicated: “This unprecedented growth is due to the gradual increase in human lifespan owing to improvements in public health, nutrition, personal hygiene, and medicine. It is also the result of high and persistent levels of fertility in some countries.” Much of the population growth comes from the poorest countries, especially in sub-Saharan Africa.

November 15 – On this day in 1805, Meriwether Lewis and William Clark’s 4100 miles cross-country expedition reached the mouth of the Columbia River near present-day Chinook, Washington. The journey wouldn’t have been possible without the help of Sacagawea, a Lemhi Shoshone guide who acted as an interpreter and escorted the explorers through unfamiliar land. President Thomas Jefferson had commissioned Lewis and Clark to explore the newly acquired Louisiana Purchase. The expedition began on May 14, 1804, and lasted 18 months and one day. It is of interest that we are celebrating Native American Heritage Month in November.

November 16 – After several postponements, the Artemis I mission was finally launched, from Kennedy Space Center in Florida, paving the way for NASA to return astronauts to the moon for the first time in 50 years. The rocket carried the Orion spacecraft, an un-crewed capsule, which is set to orbit the moon and collect critical data along the way. It will complete its journey in about 25.5 days and splash down in the Pacific Ocean off the coast of San Diego on December 11. So happy we are back on track to return to the moon.

The Orion spacecraft shared its first view of Earth more than nine hours after launch and 57000 miles away from Earth.

November 16 – On this day in 1945, The UN Educational, Scientific, and Cultural Organization – UNESCO was founded. The preamble of its constitution laid out the organization’s crucial task ahead. It stated: “It is in the minds of men that the defenses of peace must be constructed.” UNESCO’s first mission focused on education by rebuilding libraries, museums, and schools destroyed during World War II. As the group welcomed developing nations as members in the 1950s, its purpose evolved to tackle a wider set of challenges, such as illiteracy and poverty. In the 1970s, UNESCO formed its famous World Heritage list for protecting important cultural and natural wonders. Today, the list includes 1,154 sites across 167 countries. 

November 17 – Yale and Harvard law schools announced they are bowing out from U.S. News & World Report’s rankings of best law schools. They were critical of the publication’s methodology. Given their elite status, the move could signal a greater shift away from college rankings. Yes, the methodology is still important!

November 18 – At 12:01 PM, in 1883, four new time zones became effective in the continental US–Eastern. Central. Mountain. Pacific. They were referred to as “railroad time.” Before that, U.S. railroad schedules kept track of more than 300 local time zones determined by each town’s specific “solar noon.” “Railroads” were the instigating economic force behind the change. Practicality always wins.

November 19 – on this day in 1863, The Soldiers’ National Cemetery at Gettysburg, PA, was dedicated. 50,000 soldiers who died at Gettysburg, one of the bloodiest battles in the Civil War, were forever committed to the American consciousness by President Abraham Lincoln’s brief – 271 words –  memorable address. “To highly resolve that these

dead shall not have died in vain – that this nation, under God, shall have a new birth of freedom – and that government of the people, by the people, for the people, shall not perish from the earth.” Nothing compares to eloquence and … brevity.

November 20 – Andy Hackett from Kidderminster in Worcestershire landed the Carrot, an elusive 30kg/67 lbs. leather carp-koi hybrid released into a fishing lake 20 years ago. The carrot, called after its orange color, was caught at Bluewater Lakes in Champagne, France. Hackett spent 25 minutes bringing the fish in. The fishery manager, Jason Cowler, said: “We put the Carrot in about 20 years ago as something different for the customers to fish for. Since then, it has grown and grown, but it doesn’t often come out. She is very elusive.” Imagine the surprise!

November 22 – President John F. Kennedy was assassinated that day in 1963. I was in Damascus, Syria, and I remember listening to the tragic news on BBC. I also remember waiting in a long line to sign a condolence book at the American Embassy in Damascus. I was 16.

November 23 – The European Space Agency – ESA – made history by selecting John McFall, a 41-year-old Briton who lost his right leg when he was 19, to be among its newest batch of astronauts. McFall is a surgeon and a Paralympian, having competed in the 2008 Beijing Paralympics and having. won the bronze medal in the 100 meters, said, “ESA commits to sending an astronaut with a physical disability into space … This is the first time … a space agency has endeavored to embark on a project like this. And it sends a … strong message to humanity.” He went on to say this is “a real turning point and mark in history.” McFall hopes to “bring inspiration … that science is for everyone.” Having a disability does not mean you are disabled!

November 24 –  On this day in 1859, “On the Origin of Species” by English biologist Charles Darwin was first published. It is no exaggeration that this book changed the way we see life!
Thanksgiving! – On the last Thursday of 1864, President Abraham Lincoln declared that God had favored Americans “not only with immigration but also with the emancipation of formerly enslaved people.” He also said that God “has been pleased to animate and inspire our minds and hearts with fortitude, courage, and resolution sufficient for the great trial of civil war into which we have been brought by our adherence as a nation to the cause of freedom and humanity, and to afford to us reasonable hopes of an ultimate and happy deliverance from all our dangers and afflictions.” We are thankful that our beloved Country survived the civil war and many other conflicts over the years. And we are hopeful that Peace and Goodwill among men and women will always prevail, modeled after the harvest celebration that the Pilgrims and the Wampanoags shared at Plymouth in the fall of 1621.

November 25 – The Convention on International Trade in Endangered Species of Wild Fauna and Flora – CITES – conference ended in Panama. Along with protections for over 500 species, delegates at the United Nations wildlife conference rejected a proposal to reopen the ivory trade. An ivory ban was enacted in 1989. Susan Lieberman, the vice president of international policy at Wildlife Conservation Society, said: “Good news from CITES is good news for wildlife as this treaty is one of the pillars of international conservation, imperative at ensuring countries unite at combatting the global interrelated crises of biodiversity collapse, climate change, and pandemics.” An International Wildlife Trade Treaty was adopted 49 years ago in Washington, D.C.

November 25-26-28-29 – Black Friday. Small Business Saturday. Cyber Monday. Giving Tuesday. Marketing ideas were created, encouraging consumers to buy more and spend more. Notice that there is no Sunday Rest.



Annual Meeting Agenda/Links

CANS Annual Meeting Agenda – Outline
Mission Inn and Spa, Riverside, CA, January 13-15, 2023
Please Register Today!

 2-4 pm CANS Board Meeting (open to all members)

6:30 – 8:30         Opening Night Reception (Attendees, Guests & Exhibitors)


SATURDAY           Meeting | Exhibits
6:30–7:40           Continental Breakfast
7:45-7:50            Javed Siddiqi,  M.D.                         President’s Report
7:50-7:55            Brian Gantwerker, M.D. Secretary’s Report
7:55-8:00            Ciara Harraher, M.D.                       Treasurer’s Report


  • Session 1: Plenary Session #1 – 50th Anniversary Panel: CANS LOOKBACK
    8:00-8:20      50 Years of CANS:  Austin Colohan, MD
    8:20-8:40      DEI in CANS: Odette Harris, MD
    8:40-9:00      Evolving perspectives on family priorities in CANS: Langston

                       Holly, MD
9:00-9:20    Inclusion of Osteopathic Neurosurgeons in CANS: Dan Miulli, DO
9:20-9:45    Panel discussion/Q&A

9:45-10:15         Special Topic: Consequences of AB35 for Neurosurgeons: Robert Fessinger (Defense Attorney, CAP-MPT)

10:15-10:25               Q&A


10:25-10:30               50th Anniversary Acknowledgement Video: Congressman Ted Lieu


10:30-11:00               Break: in Pavilion – in Exhibit Hall


  • Session 2: Plenary Session #2 – Panel: Funding Innovation in Neurosurgery
    11:00-11:10 Neurosurgeons as Innovators: Historical Perspective: Javed Siddiqi, MD & Adela Wu, MD

11:10-11:30 How Can I fund that idea #1:  John Adler, MD
11:30-11:50 How Can I Fund that idea #2:  Doug Ethell, PhD
11:50 – 12:10              Incorporating Innovation into Neurosurgery Residency Training: Alex Khalessi, MD
12:10– 12:30               Q & A

12:30 – 1:30 Lunch with Exhibitors



1:30 – 1:50      Locum Tenens as bridge to regular job: Jerry Noel, DO

1:50 –  2:10      Insights into my own early career financial planning: Brian Gantwerker, MD

2:10-  2:40           Planning for Early Career Neurosurgeons: estate planning, disability insurance, life insurance, etc. Steve Graeber

2:40 – 3:00         Q & A

1:30-1:50    Retirement: gradual vs. cold turkey:  Gary Goplen, MD

1:50-2:10    Retirement Transition paradigms: locum tenens:  Deb Henry, MD
2:10-2:30    Financial Strategies for Retiring Neurosurgeons:  David Maupin
2:30-3:00    Q & A


  • Session 4: PLENARY SESSION #3–PRESIDENTS’ PANEL: Next Half-Century of CANS

3:00 – 3:20 Value of Mentorship:  Mark Linskey, MD (Mentor Perspective)

3:20 – 3:40 Value of Mentorship:  Saman Farr (Mentee Perspective)

3:40 – 4:00 Generational Planning for CANS Leadership: Joe Chen
4:00 – 4:20 Value of CANS to its Membership: Praveen Mummaneni
4:20 –4:45  Q & A

6:30 PM               Cocktails
7:00 PM               Formal Dinner

Mission Inn Historian15 minutes

Presidential Address: SIDDIQI 15 mins (with Marco Lee Intro for 10-15 mins)

Intro of Dr. Joe Chen, Incoming President, by Dr. Siddiqi ( 5 mins)

| Meeting
7:00-7:30            Breakfast – Exhibit Hall

  • Session 1: Updates &  State-of-the-Art Neurosurgery

7:30 – 7:40          CMA update:   Brian Gantwerker, MD

7:40 –  7:50         CSNS Update:  Patrick Wade, MD (not yet confirmed)

7:50 –  8:00         Washington Committee Update: Alex Khalessi, MD (not yet confirmed)

8:00 –  8:20         Revolutionary Ideas #1: DRONES in the BRAIN Bill Lauden, MD  (Not yet confirmed)          
8:20 – 8:40          Revolutionary Ideas #2: SURGICAL CURE FOR ALZHEIMERS  Doug Ethell, PhD

9:00-9:30            Break-Exhibit Hall



11:20-11:30         Q & A | Awards


11:30 – 11:46    RAPID FIRE SESSION


Click HERE to register

HERE to Book your hotel room

Click HERE to submit your Abstract (Residents)


CANS, Annual Meeting, January 13-15, 2023 – Riverside, CA The Mission Inn
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

Any CANS member who is looking for a new associate/partner/PA/NP or who is looking for a position (all California neurosurgery residents are CANS members and get this newsletter) is free to submit a 150 word summary of a position available or of one’s qualifications for a two month posting in this newsletter.  Submit your text to the CANS office by E-mail ( or fax (916-457-8202). v

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


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CANS Board of Directors

CANS Board of Directors