Newsletter

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

Destiny has smiled on me yet again!—as the President of CANS, it is my honor and unique privilege to lead our wonderful group of neurosurgeons,  trainees, and families at the 2023 annual meeting.

Please join us to celebrate a proud moment for all California neurosurgeons as we hold our 50

Anniversary annual meeting on Martin Luther King weekend (13-15 January 2023) at the Mission Inn Hotel & Spa in Riverside, California.  This meeting will be our chance to look back at CANS’ contributions to our profession over the prior half-century and envision the immense possibilities of the next half-century.  As the largest state neurosurgical society in the USA, CANS remains nimble and diverse, welcoming new members and leading the change that lets us pace the societal exigencies of the most dynamic state in the nation.  

At the upcoming annual meeting, CANS 2023, we will focus on socioeconomic issues of relevance to our diverse and expanding membership.  As an organization that values advocacy for neurosurgeons and has an open-door policy for its executive functions—all members are welcome to participate in Board of Directors meetings—we are proud of our inclusiveness, and growth mindset.  For the first time, we are delighted to have four resident fellows, each from a different California neurosurgery residency program, and each ready and eager to advance our specialty’s interests.  The presence of these fellows (and the support that is implied from their Program Directors and home institutions), free membership for all residents from California’s eleven neurosurgery residency programs, and proactive efforts to recruit young neurosurgeons to our ranks, reflects the values of current and prior CANS leaders, and gives us a vibrancy that augurs well for the future of our organization, and profession.

Highlights of CANS 2023 include review of our history by Dr. Austin Colohan, our historian; presentations on how inclusiveness has enriched our organization; and discussion on the value of family and friends in allowing neurosurgeons to live balanced, committed, and meaningful lives.  We will also have a Presidents’ Panel, looking ahead to the vision for the next halfcentury of CANS.  We will inform and educate our membership about the consequences of AB 35, a recent law that has changed the medical malpractice landscape in California (with predictable domino effect on the rest of the country).  

As the most educated professionals in the world, every neurosurgeon has brilliant ideas that they were too busy to bring to fruition— whether a new retractor, aneurysm clip, brain implant, or concept that changes the world, we all have the capacity to innovate and improve the human condition (before, during, or after residency; during active neurosurgery career, or after retirement).  Accordingly, we will have a session titled “Funding Innovation in Neurosurgery”, with speakers discussing how we can build and foster innovation into neurosurgery residency training; we will also have the chance to
hear the ’inside story’ of “how I funded that idea” from two
contemporary leaders in neuro-innovation.

Physicians are notorious for being poor with money, and certainly nobody emphasized financial literacy in
medical school. As an organization whose focus is the socioeconomic aspect of our professional lives, I
am delighted to announce two breakout sessions at CANS 2023, which will be led by seasoned financial
experts: 1) Early Career Financial Planning; and 2) Retirement Planning.
We will also showcase inspiring examples of California neurosurgeons leading with revolutionary ideas that
are on the horizon, and which have the potential to change the world. Our devotion to the next
generation of neurosurgeons will again be manifested as the half-day to Resident Presentations from each
of our eleven neurosurgery residency programs, associated award presentations, and rapid-fire session for
qualified papers.
Of course, all members, guests, and exhibitors are encouraged to join us at the Friday (1/13/2023) evening
OPENING RECEPTION, and the Saturday (1/14/2023) evening BANQUET. Please register early, as a fun,
educational, informative, and collegial time awaits you!

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Report

I plan to start with the best breaking news! It gives me a great pleasure and pride to announce that our own Ciara Harraher and her husband Mike McDonnell were sworn in on October 28, 2022, as the newest US Citizens. Our
congratulations go not only to Mike and Ciara, but also to each of us. Our profession is the better because of Ciara, the culinary world is the better because of Mike and the US as a Country is the better because of Mike, Ciara and their children Gemma and Finn! My family and I are fortunate to call them friends and family. We are a Country of Immigrants that gets better and stronger with each newly minted immigrant citizen!

Also good news: Ciara and Mike will exercise their right to vote
in this midterm election!

I hope you will find many interesting and informative pieces of information in this issue.
Our President’s message gives you a glimpse into the exciting meeting agenda. “Looking Back & Looking Ahead.” The meeting will be held at the historic Mission Inn in Riverside, California. You would not want to miss this meeting. Plan early.

Our Women in Neurosurgery column is written about Kelly Mahaney and Laura Prolo and their all-female pediatric neurosurgery team at Stanford. While Stanford has clearly worked hard to achieve gender equity, we still see evidence that there remain various biases against female physicians at all levels. I bring your attention to a recent JAMA
Network Open publication titled “Patient Use of Physicians’ First (Given) Name in Direct Patient Electronic Messaging.” The authors found that patients are more likely to address the following physicians by their first name: women, doctors of osteopathy and general practitioners. Women physicians had more than twice the odds as men to be called by their first name after adjusting for patient gender, physician age, degree, level, and specialty. According to Diehl A, Dzubinski L. “We need to stop ‘untitling’ and ‘uncredentialing’ professional women.” Untitling (or uncredentialing) is a phenomenon in which an individual’s formal title is omitted in a professional context and is a subtle but important form of unconscious bias. https://www.fastcompany.com/90596628/we-need-to-stop-untitling-anduncredentialingprofessional-women

Another important short publication in AANS Neurosurgeon by Kristin M. Huntoon, PhD, DO, a research fellow at MD Anderson Cancer Center, asked the question: What is the Career Lifespan of a Neurosurgeon? The data suggests that the general career lifespan of an average neurosurgeon in the U.S. is 25.8 years. When the data is stratified according to gender, differences are noted. For female neurosurgeons, the age of FAANS certification was 40.1 years; for males, it was 38.9 years. Female neurosurgeons transitioned to a Lifetime membership at 60.1 years old; male neurosurgeons
transitioned at 64.9 years. Another hot topic issue is the passage of AB 35- Neurosurgery and CANS were not involved when CMA reached an
agreement with the plaintiffs’ lawyers – Governor Newsome signed the bill into law that will become effective on January 1, 2023. A member of CAPP who objected to this compromise was the “Cooperative of American Physicians.” Here is a link to their latest publication. Physician Today – AB 35 Under California Assembly Bill 2098, which was signed by Governor Gavin Newsom, physicians and surgeons can be charged with “unprofessional conduct” for “disseminating misinformation or disinformation related to COVID-19, including false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.” California’s Legislature was trying to balance free speech and public health. The legislation made the state the first to try to legislate a remedy to a problem that the American Medical Association, among other medical groups and experts, says has worsened the impact of the pandemic, resulting in thousands of unnecessary hospitalizations and deaths. Included in this issue are the final resolutions, accepted, modified or rejected by the CSNS during their fall meeting in
San Francisco, October 7-8, 2022. You will also find an essay about baseball and neurosurgery. Obviously, I was crushed when my Dodgers lost. I hope
you will indulge me. And last, but not least, and since I started on a happy note, I’d like to also end on a happy one: our hard working residents’ consultants ushered the Holiday season for us with a unique essay on which they all collaborated, giving us their perspectives about celebrating holidays while residents. As always, my editorial committee and I welcome your comments and critiques. Please contact me directly at
mabousamra@aol.com, or call me on my cell phone: 805-701-7007

CANS Fall Board Meeting October 2, 2022 By Zoom

CANS BOD Meeting

  • President Javed Siddiqi shared with the Board his vision of the Annual Meeting. The theme is 50th anniversary of CANS: Looking Back & Looking Ahead.
  • Secretary’s Report – Dr. Gantwerker: One new member application was reviewed. Joel Beckett, MD from UCLA, a former CANS consultant to the Board in 2017, was voted in unanimously.
  • Treasurer’s Report/Finance Committee – Report given by Dr. Gantwerker for Dr. Harraher: He reviewed what is currently in checking account and that the Finance committee successfully moved the CD’s held by CANS to the Franklin Templeton investments accounts. CANS is on solid financial footing.
  • Historian – Dr. Colohan reported that the vignettes have been going well for the newsletter. He is working on 50th anniversary presentation for upcoming annual meeting.
  • Siddiqi congratulated the four new CANS Resident Consultants to the Board for the June 2022 –July 2023 term. Lauren Stone, UCSD; Adela Wu, Stanford; Saman Farr, RUHS; Saman Sizdahkhani, USC.
  • Award Committee – Dr. Mark Linskey: Pevehouse Award to be awarded to Lawrence Marshall, MD from UCSD.
  • Publications committee – Dr. Moustapha AbouSamra o Kevin Chao resigned his position as chair. The Board expressed their gratitude for his hard work. Dr. Siddiqi appointed Dr. Anthony DiGiorgio as chair of the Website committee. Dr. DiGiorgio will share his vision and plans for this committee in the next newsletter.

The newsletter continues to be published as expected.

  • Annual Meeting Committee 2024 – Dr. Chen reported the 2024 meeting will be in Northern California, very likely in San Francisco.
  • CMA Specialty Delegation Meeting-Dr. Harraher. Dr. Gantwerker gave this report for Dr. Harraher. Two items: o The resolution to recognize Dr. Randall W. Smith’s great contributions to neurosurgery. 
    • MICRA modernization act – AB35, signed by the Governor and will become effective on January 1, 2023. Concerns were expressed that neurosurgeons and CANS were not included in the discussions between the plaintiff attorneys on the one hand and CMA and CAPP on the other. Dr. Siddiqi will add this topic to the annual meeting agenda.

Next Board Meeting – January 13th, 2023, prior to the Annual Meeting  !

CANS Members on the Move

During its 151st annual meeting the CMA House of Delegates elected our
own Ciara Harraher as a trustee from District VII that includes Santa Clara,
Santa Cruz, San Mateo, and Monterey.

Ciara will serve a three-year term
but may run for re-election two more times for a total of nine years. Ciara has
represented CANS at the CMA House with dedication and distinction for several
years, most recently as chair of the Specialty Delegation. Congratulations, Ciara,
and Thank you!

 

Ken Blumenfeld completed his six-year term as a Trustee from District VII. He, too, served with distinction. Ken is not done; he is still active at the AMA where he serves as an AANS Delegate, and at the AANS where he is completing his third year as a Regional Director.
He is also the vice chair of the NeurosurgeryPAC. Thank you, Ken.

Brian Gantwerker is serving on the CMA Council on Legislation. Dr. Siddiqi plans to appoint him as CANS representative on the CMA Specialty Delegation.
Moustapha AbouSamra completed his service on the CMA Council on Ethics, Legal, and Judicial Affairs. He started his service in 2009 and served as chairman of the Council the last four years. He, too, is not done. He was selected as the chairman of the newly appointed Collaborative Just Culture Technical Advisory Committee, a committee that will attempt to deal with the new realities created by AB 35. Anthony DiGiorgio will represent the CSNS on the scientific committee for the 2023 CNS annual meeting. This is an important position that allows CANS significant input in the socio-economic contents of the meeting.

 

Frank P. K. Hsu, MD, PhD

History of Neurosurgery at University of California Irvine

Historical Vignette

The Department of Neurological Surgery at University of California Irvine Medical Center (UCIMC) has its roots as far away as the southeast, beginning as a subset of surgery at the Birmingham Veterans Administration (VA) hospital, which opened in March 1946. A residency program was established in the late 1940s under Rupert Raney, MD (the man behind the quintessential Raney clips), and program relocated to the Long Beach VA hospital in the 1950s. The Neurological Surgery Division of the UCIMC Department of Surgery was established in 1969, and accreditation of the VA residency program was assigned to UCI in 1972. Residents continued to rotate through the Long Beach VA today. 

Eldon L. Foltz, MD (1919-2013) was recruited as a professor and the first Chief of the Division of Neurological Surgery at UCIMC. Dr. Foltz graduated from medical school at the University of Michigan and completed his internship in general surgery there. He then served in the U.S. Navy for 30 months on active duty in the South Pacific. He was the first neurosurgical resident at Dartmouth Medical School and he completed his residency training at the University of Louisville under the guidance of Dr. Glen Spurling in 1950. Dr. Foltz was an avid researcher in studying the limbic system and he worked as a post-doctoral fellow at the National Institute of Mental Health. His commitment to academic science led to a professorship at the University of Washington in 1965. In 1968, Dr. Foltz accepted the position at UCIMC, where he continued his work on studying cerebrospinal fluid dynamics and hydrocephalus. 

Dr. Foltz was followed by John Kusske, MD, who joined the UCI faculty in 1972 and played an integral role in the development of the UCI Neurological Surgery Department. Dr. Kusske served as Division Chief during the years of 1980 – 1984 and then as Department Chair from 2000-2004 and 2009-2012. Dr. Kusske graduated medical school at the University of California School of Medicine, San Francisco, and completed residency at the University of Washington, Seattle. Dr. Kusske expanded the neurosurgical volume at UCI by establishing relationships with nearby hospitals and he was instrumental to the specialty attaining its own departmental status. Dr. Kusske has been actively involved in many medical societies throughout his career, earning the 2000 Bryon Cone Pevehouse Distinguished Service Award and the 2004 AANS Distinguished Service Award for his contributions in organized medicine. He is known for his expertise in health care delivery and financial policy and he has consistently demonstrated a commitment to the mentorship and education of young neurosurgeons. The annual Kusske Lecture Series began in 2017 to honor Dr.
Kusske’s transformational leadership and dedication to the UCI Department of Neurological Surgery. 

Mark Linskey, MD served as Chair of the Department of Neurosurgery from 2004-2009 and then Program Director from 2010-2014. Dr. Linskey received his medical degree at Columbia University in 1986, attended residency at the University of Pittsburgh, and completed a neuro-oncology fellowship at the Ludwig Institute for Cancer Research in London. As Chairman of the joint AANS/Congress of Neurological Surgeons (CNS) guidelines committee, he helped develop treatment guidelines for patients with brain metastases in 2008 and 2009. Dr. Linskey also serves as the Western Regional Director of The Facial Pain Association since 2003. At UCI, Dr. Linskey helped to re-instate ACGME accreditation for the neurosurgery residency program in 2008. 

Frank P. K. Hsu, MD, PhD was named Acting Chairman of the UCI Department of Neurological Surgery in 2013. Dr. Hsu received his MD/PhD from the University of Maryland and completed residency at Oregon Health Sciences University
(OHSU). He completed fellowships in cerebrovascular and skull base surgery at the Barrow Neurological Institute and functional stereotactic and pain surgery at OHSU. Dr. Hsu served as Vice Chair of Neurosurgery at Loma Linda University Medical Center from 2003 to 2012 before being selected for the Chair position at UCI. Dr. Hsu has demonstrated exemplary leadership and clinical prowess, advancing the care of neurosurgical patients by fostering collaborations with other specialties in a team-based approach. The UCI Department of Neurological Surgery has blossomed under his leadership; the department recently welcomed Drs. Michelle Paff, Hansen Bow, and Ahmed Mohyeldin. The current, full-time faculty also includes Drs. Kiarash Golshani, Michael Oh, Jefferson Chen, Shuichi Suzuki, Mark Linskey, Ichiro Yuki, Sumeet Vadera, and Dennis Malkasian. The residency program has also expanded under his guidance, alternating between one to two residents a year, with rotations at UCIMC, Children’s Health of Orange County (CHOC), VA Long Beach Hospital, and San Antonio Regional Hospital. Fellowships are offered in Endovascular Neurosurgery, Skull Base Surgery, Epilepsy, and Neurosurgical Critical Care. Over 1800 neurosurgical cases are performed each year at UCIMC, and associated neurosurgery research is currently conducted in 3 labs and 10 clinical trials.

Picture of Katie O. Orrico, Senior Vice President

Katie O. Orrico, Senior Vice President

American Association of Neurological Surgeons/Congress of Neurological Surgeons

From the Washington Office

  • To Neurosurgical Leaders:

Attached for your information is the new report from Team Brunswick highlighting the Surgical Care Coalition’s (SCC)
activities from July through September. Recall that neurosurgery is a founding member of the SCC and is using this
coalition to help demonstrate the need for Congress to prevent an 8.5% Medicare payment cut on Jan. 1, 2023.

https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:2122f373-02b2-3f29-a890-07fe9ab66493

Among other things, the coalition has been working on getting surgeon/patient op-eds placed in newspapers across the country to demonstrate the value and importance of surgeons in the health care system. Thus far, two neurosurgeons have been featured in op-eds:

  • Burak Ozgur, MD, FAANS, a neurosurgeon from California, published an op-ed in the Washington Times on Aug. 29.
  • Maya A. Babu, MD, FAANS, a neurosurgeon from Florida, published an op-ed in the Orlando Sentinel on Sept. 2.

In addition, Alexander A. Khalessi, MD, FAANS, John K. Ratliff, MD, FAANS, and Maya A. Babu, MD, FAANS, were interviewed by Team Brunswick (which turned the AANS/CNS Washington Office conference room into a studio to shoot the interviews). These videos, which will be promoted via social media, are available as follows:

The report also highlights the Sept. 15 SCC-sponsored Congressional briefing to help educate staff about the Medicare physician payment system, pending cuts and the need for long-term reforms. In addition to the briefing, surgeons came to Washington, DC, to meet with key members of Congress. Jason M. Schwalb, MD and Kristopher T. Kimmell, MD, represented the AANS and the CNS, with Dr. Kimmell serving as one of the speakers at the briefing.

Call to Action!

Finally, if you have not yet done so, please click here to send an email message urging your Representatives to co-sponsor H.R. 8800, the Supporting Medicare Providers Act (H.R. 8800). Sponsored by Reps. Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.), this bill would prevent a 4.42% cut for all Medicare Physician Fee Schedule services (we also face a 4% Statutory Pay-As-You-Go Act cut, triggered due to new federal spending, which will be addressed separately).

  • Also

As part of our ongoing advocacy to adjust the global surgery codes to reflect updated evaluation and management (E/M) values, we collaborated with Reps. Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.) on a letter to the Centers for Medicare & Medicaid Services (CMS) urging the agency to apply the updated E/M values to these codes. In the letter, the Congressmen stressed that adjusting these values is necessary “to ensure that these physicians are compensated the same for providing equivalent services as defined by the Medicare statute.”  Earlier this month, the AANS and the CNS led a surgical coalition letter initiative, submitting a comprehensive comment letter<https://www.aans.org//media/Files/AANS/Advocacy/2022news/September/Surgical_Coalition_Global_Codes_Comments_090 622_FINAL.ashx> to CMS that expressed our ongoing frustration that the agency has refused to adjust the 10- and 90-day global surgery codes to reflect the increased E/M codes values for post-operative services performed during the global period.

                                                                     September 27, 2022

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard Baltimore, MD 21244

Dear Administrator Brooks-LaSure:

We write to express our concern with the current Center for Medicare & Medicaid Services (CMS) policy regarding the values of evaluation and management (E/M) office visits within global surgery codes. The CY 2023 proposed Medicare Physician Fee Schedule (PFS) once again fails to incorporate the adjusted values for the revised office/outpatient visit E/M codes into the 10- and 90-day global surgery codes, leaving surgeons systematically underpaid for these E/M services relative to other physicians performing the same services. This is the third rulemaking in which CMS seeks to perpetuate this disparity in pay for E/M services. We urge CMS to apply updated E/M values to the global codes in the upcoming CY 2023 Medicare PFS final rule to ensure that these physicians are compensated the same for providing equivalent services as defined by the Medicare statute.

We understand that CMS is concerned global codes may be misvalued. However, refusing to make payment updates for physicians doing equivalent work in the post-operative setting is not the answer — especially when CMS has reviewed and validated or made revisions to many of these codes through the misvalued codes process. Since 2015, the American Medical Association/Specialty Society RVS Update Committee (RUC) has reviewed 217 10- and 90-day global codes, resulting in a number of changes. For example, CMS agreed with a 2019 AMARUC recommendation to revalue the cataract surgery code after robust survey data found that ophthalmologists are providing three E&M post-operative visits, rather than four, within the 090- day global period. This represents a reduction in anticipated E/M post-operative visits. Yet, CMS continues to apply a blanket policy that inaccurately undervalues all global services, on top of the misvalued codes adjustment.

The cataract surgery example demonstrates that a well-established and effective process exists to evaluate global code values and their associated post-operative visits. We encourage CMS to avail itself of this mechanism to address potentially misvalued global codes — instead of trying to accomplish that goal by devaluing all post-operative visits.

The CY 2021 PFS marked the first time in over two decades that CMS revalued the office/outpatient E/M codes but did not also update the global code values. Since 1997, each time the values for office/outpatient visits increased, the agency also adjusted the 10- and 90-day global values to reflect the increases in the E/M portion of these codes.

We urge CMS to adjust the E/M component of the global codes in the final CY 2023 Medicare PFS rule to maintain relativity in the fee schedule and ensure compliance with the Medicare statute, so physicians are paid the same for providing equivalent services.

Thank you for your consideration, and we look forward to working with you on this important and timely issue.

Sincerely,

Larry Bucshon, M.D. of Congress
Ami Bera, M.D. Member Member of Congress

Kelly Mahaney and Laura Prolo

An All-Female Team at Stanford Medicine Children’s Health Shaping the Future of
Neurosurgery

Women in Neurosurgery

STANFORD MEDICINE
Lucile Packard Children's Hospital Stanford.

When Kelly Mahaney, MD, began training to be a neurosurgeon, she was the only woman in her department. She also remembers that, as a medical student, she met a neurosurgeon who told her, “We need more women in
neurosurgery.” 

“That was absolutely true then and is still true now,” she says. Though roughly half of graduating medical students in the United States are female, according to the Association of American Medical Colleges (AAMC), only 9.3% of
neurosurgeons are women. 

Dr. Mahaney is now the interim chief of pediatric neurosurgery at Stanford Medicine Children’s Health. She is also a part of something quite rare: an all-female pediatric neurosurgery team.

Laura Prolo, MD, PhD, pediatric neurosurgeon at Stanford Medicine Children’s Health, credits this milestone to the former division chief.

“We have such a fantastic team,” she says. “It’s been years in the making, and it didn’t just happen by accident. It was thoughtful effort to get to where we are.”

From left to right: Laura Prolo, MD, and Kelly Mahaney, MD, are pediatric neurosurgeons at Stanford Medicine Children’s Health.

Supporting women

Diversity is central to the culture at Stanford Medicine Children’s Health. Dr. Prolo has seen the supportive environment fostered through her 17 years at Stanford. Her mentors recruited and supported women and underrepresented minorities—they looked out for opportunities for her to lead, championed her dreams, and helped her thrive.

While most of her peers were men, “at Stanford, I never felt like I was treated differently than anyone else,” she says.

That was evident when Dr. Prolo was deciding whether to pursue neurosurgery.

“Having a family was important to me, and I brought up this concern to one of my mentors,” Dr. Prolo says. “His response was, ‘Of course, you can do both. You’re smart and you’re talented.’ Just that he had that faith in me was inspirational. It allowed me to think that I could do everything.”

There is still room to improve disparities that exist. Dr. Mahaney recognizes the continuous effort toward work-life balance as more of a “see-saw than a perfect balance,” but having the support of a very diverse neurosurgery department and other female neurosurgeons who excel in their roles has been transformative for her.

“We try to promote a community that is supportive of women as neurosurgeons and as mothers,” she says. “Anamazing example of this is a neurosurgeon colleague of mine who encouraged me to breastfeed my daughter when she was born. She taught me that we don’t have to choose whether to be great mothers or great neurosurgeons. She inspired me to find a way to make it work. I want to give the same support for my current and future colleagues who are finding their way in balancing motherhood and neurosurgery.” 

Fostering the next generation

Becoming a neurosurgeon is not an easy path. Drs. Mahaney and Prolo say that despite the long, demanding training,it’s an extraordinary and fulfilling career if it is your calling.

“We have the privilege of caring for young patients at what is often the most vulnerable time of their lives,” Dr. Mahaney says. “The impact we have on children is even greater, as their whole lives are ahead of them. This has been the biggest motivation for me: to give children with neurosurgical conditions a chance for a brighter future.” 

“Everyone on our team is incredibly supportive of each other and cares deeply about our patients,” says Dr. Prolo. “With the primary goal of providing the best possible care for our patients in mind, everything else falls into place.” 

So, for other women who find themselves called to care for the sickest patients, just know that there are others who have paved the way.
“It is possible to be a great neurosurgeon and be a great friend, daughter, sister, mother, partner,” Dr. Mahaney adds. “It is up to us to shape the future of neurosurgery—and I hope many more women will choose this path and shape it
with us.”

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Baseball and Neurosurgery
“We made too many wrong mistakes.”
Yogi Berra

Changing Times

In Baseball as in Neurosurgery, one can expect great triumphs, but also an occasional heartbreak … my favorite team, the Dodgers, had its best season winning a franchise record of 111 games, becoming the 5th team in the National and American Leagues history to win that many games in one season … our skipper Dave Roberts even went on National TV and predicted that we will win the World Series for the second time in three seasons … We finished the regular season 22 games ahead of the Padres, but we were paired with the San Diego team after they pulled an improbable win against the Mets in the Wild Card game, to play for the Division Title … They eliminated us in four
games … Upset? No, real heartbreak! 

There are many similarities between Neurosurgery and Baseball and between Neurosurgeons and Elite Baseball Players. But there are also major differences. In baseball, a batting average of over 500 is a good average, and
batting in the mid-600s is amazing, while in neurosurgery, such averages are dismal. Whenever we perform a surgical procedure, we strive for the perfection of a batting average of 1000; anything less than that is problematic. Neurosurgeons don’t usually have “neurosurgery cards, while baseball players have baseball cards that become
collectors’ items, sometimes selling for record amounts: A 1952 Mickey Mantle rookie baseball card in mint condition sold recently for $12.6 million. And, no, neurosurgeons have not achieved pay parity with elite baseball players. 

In this essay, however, I will explore the similarities between these two disciplines. I was inspired by an article I read in Hektoen International, a Journal of Medical Humanities, by Jayant Radhakrishnan, a retired Professor of Surgery and Urology, titled “Tutorial for surgeons by Lawrence Peter Berra.”

Lawrence Peter “Yogi” Berra (May 12, 1925 – September 22, 2015) became one of the best catchers in baseball by mastering every skill required of a catcher. This is no different from a neurosurgeon who is expected to master every skill required to perform a complex neurosurgical procedure from beginning to end.

Yogi had an interesting way of expressing himself; some of his aphorisms are memorable. My favorite is: “If I didn’t make it in baseball, I won’t have made it workin’. I didn’t like to work.” Yes, I really never considered neurosurgery work, it was my hobby and a way of life, and I doubt that I would have succeeded in doing anything else.

During our training, we watch our mentors perform elaborate and delicate surgical procedures, and we do this over and over so that we learn all the nuances. Berra said it best: “You can observe a lot by watching.” And “If you can’t imitate him, don’t copy him.”

He had the endurance that neurosurgeons need to complete long operations, take calls, see patients, and deal with their problems, day in and day out. In fact, at the age of thirty-seven, he crouched behind the plate for the entire seven-hour game on June 24, 1962, in which the Yankees beat Detroit in twenty-two innings.

He was also ambidextrous, or as he would say, “amphibious,” since he batted left-handed and threw the ball with his right. Being ambidextrous is very helpful to a neurosurgeon. I recall a time, early in my career in Ventura, when my late partner Paul Karlsberg who was assisting me in a case, said: “why don’t you use your left hand?” Because I am righthanded, I said. He advised me that I should teach myself to do certain common maneuvers with my left hand as this will eventually lead to safer, more efficient, and faster procedures. He was right, and for the remainder of my career, I used my left hand quite well to the benefit of my patients.

Yogi paid attention to details and expressed it by saying: “Little things are big.” In neurosurgery, if we don’t pay attention to minute details, we get into “big” trouble. And we must always remember that “It ain’t over till it’s over.”

Yogi said: “Make a game plan and stick to it. Unless it’s not working.” We, too, in neurosurgery, must have a game plan. During surgery, there is a certain order that must be followed, but anatomical variants and various other factors require us to be flexible.

He had detailed knowledge of what he needed to do and how to accomplish it. Every neurosurgeon must do the same; otherwise, the task at hand may not be accomplished. Berra expressed it this way: “You’ve got to be careful if you don’t know where you’re going because you might not get there.”

Both neurosurgeons and baseball players concentrate intently while “performing:” they can’t be doing other things. Yogi describes this fact this way: “You can’t think and hit at the same time.”

Neurosurgeons are best advised to acknowledge not knowing the answer to everything. “If you ask me a question I don’t know, I’m not going to answer,” said Yogi. And neurosurgeons should take such an opportunity to research the
issue and find the answers.

Much like the discovery of Penicillin that resulted from a lab error, in neurosurgery, we sometimes make mistakes that lead us to learn better techniques. So, the thing to avoid is making the “wrong mistakes.” Yogi Berra said, when asked why the Yankees failed to win a fifth consecutive American League pennant in 1959, “We made too many wrong
mistakes.”

“I tell the kids, somebody’s gotta win, somebody’s gotta lose. Just don’t fight about it. Just try to get better.” Yes, we don’t always succeed in performing flawless operations, but this simply means we must continue to improve our skills.

Neurosurgeons must be very precise when entering information into a patient’s medical records. Many of us wish in retrospect, that we had expressed ourselves differently because we didn’t mean exactly the way it was written. In his inimitable way, Yogi said: “I really didn’t say everything I said.”

As you can see Baseball is not only our National Pastime, but it also has a lot in common with Neurosurgery and with Life.

Yes, my Dodgers made too many “wrong mistakes.”

“Déjà vu all over again?”

I hope that we will win the World Series next year! Go Dodgers!

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 HOD

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.

Elections

  • 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

Awards

  • 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
away.

 

 

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
human.

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
about.

Photo of the Month

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

CSNS 2022 Fall Resolutions

FINAL – CSNS Resolutions 2022F
RESOLUTION I-2022F
Action: Not Adopted

Title: AANS and CNS should withdraw their memberships in the PAHCF (Partnership for America’s Health Care Future)
BE IT RESOLVED, that the CSNS ask the Boards of the AANS and CNS to join the AMA and ACR in canceling their memberships in PAHCF; and
BE IT FURTHER RESOLVED, that CSNS encourage the AANS and CNS to include more information about universal healthcare proposals in their publications and meeting programs in order for their members to gain a better understanding of such proposals and the urgent need for substantial and not incremental healthcare reform.
FISCAL NOTE: None

RESOLUTION II-2022F
Action: Not Adopted
Title: Sponsoring Institution Research Support for ACGME Accredited Neurosurgery Residency Programs
BE IT RESOLVED,
that the CSNS work with other neurosurgical professional organizations to require sponsoring institutions to provide significant monetary support for the research activities of the neurosurgery residency research endeavors; and
BE IT FURTHER RESOLVED, that the CSNS and other neurosurgical professional organizations work with the ACGME to require proof of significant monetary support for the research activities of the neurosurgery residency research and internal review board (IRB) support for clinical and basic science research endeavors as a requirement for continued ACGME accreditation.
Fiscal Note: None

RESOLUTION III-2022F
Action: Adopted Amended Resolution
Title: Informal consultation and clinical advice by neurosurgeons
BE IT RESOLVED,
that CSNS surveys the neurosurgery community to understand the practice of “informal” consultation in neurosurgery, and
BE IT FURTHER RESOLVED, that CSNS develops a white paper describing the results of this survey and to share the spectrum of current practice. This paper should include a discussion of recent relevant case law pertaining to “curbside” and informal consults of which neurosurgeons should be aware.
FISCAL NOTE: None

RESOLUTION IV-2022F
Action: Adopted Amended Resolution
Title: Increasing administrative support for CSNS resident and medical student fellows
BE IT RESOLVED,
that the CSNS create a formal job description, staffing, and financing proposal for a Program Coordinator role specifically for the management of the resident and medical student fellows to improve selection, onboarding, mentorship, and administrative processes supporting the overall fellowship experience, contingent upon negotiations with our parent organizations regarding available resources.
Fiscal note: $15,000 dollars/year

RESOLUTION V-2022F
Action: Adopted Amended Resolution
Title: Neurosurgical residency non-service time: Evaluation of program opportunities for research, enfoldedfellowships, away rotations
BE IT RESOLVED,
that the CSNS create a summary of neurosurgical training programs to assess the opportunities available for residents during their non-service time, including timing, duration, funding sources, research time, opportunities for enfolded fellowships at the home institution, opportunities for enfolded fellowships at away institutions, and the option to undergo their chief year during PGY-6.
Financial Disclosure: None

RESOLUTION VI-2022F
Action: Adopted
Title: The processes and framework of a lawsuit: A guide for the neurosurgical trainee
BE IT RESOLVED,
that the CSNS provide an accessible reference guide for neurosurgery trainees if they are to be named in a medical malpractice claim, that describes the processes of a lawsuit, the do’s and donot’s if named in a malpractice claim, and recommendations for how to avoid being named in a claim.
Financial Disclosure: None

RESOLUTION VII-2022F
Action: Adopted Amended Resolution
Title: Assess the current neurosurgery graduate medical education compensation variability, while adjusting for regional differences
BE IT RESOLVED,
that the CSNS study resident salary and benefit packages across the United States through either publicly available inquiry or by communication with individual program coordinators throughout neurosurgery GME to determine variability. This includes but is not limited to salary, reimbursement for neurosurgical academic activities, moonlighting, and union affiliation.
Financial Disclosure: $87 for Cost of Living Index sponsored by The Council for Community and Economic

Research (https://www.coli.org/products/)

RESOLUTION VIII-2022F
Title: Implementation of The Melany Thomas Senior CSNS Fellow Position
Action: Adopted Amended Resolution
BE IT RESOLVED, the CSNS leadership will choose one CSNS resident fellow each year to be recognized as the Melany Thomas Senior CSNS Socioeconomic Fellow. This awardee would then serve as the Senior CSNS Socioeconomic Fellow for the following year and hold a seat on the CSNS Executive Committee. This chosen fellow would be a voting member of CSNS and would be selected from CSNS resident fellows who express interest and apply.
Financial Disclosure: $2500, to be awarded as a stipend to the Melany Thomas Senior CSNS Fellow

RESOLUTION IX-2022F
Action: Adopted Amended Resolution
Title: Evaluation and analysis of non-spine surgeons performing endoscopic spine surgery
BE IT RESOLVED,
the CSNS study the public perception, clinical incidence of, and training pipeline for minimally invasive and/or endoscopic spine decompression surgery as performed by neurological surgeons and orthopedic spine surgeons versus other physicians.
FISCAL NOTE: $100

RESOLUTION X-2022F
Action: Not Adopted
Title: Creation of a Publication Advisory for Predatory Journals
BE IT RESOLVED,
that the CSNS create an electronic advisory for publication ethics that catalogues known predatory neurosurgical journals; and
BE IT FURTHER RESOLVED, that the CSNS create an interactive website to identify the optimal neurosurgical journal to publish research according to abstracting/indexing, categorization of scope/aims, and altmetrics such as impact factor, time to first decision, and time to final decision.
FISCAL NOTE: None

RESOLUTION XI-2022F
Action: Not Adopted
Title: From Student to Intern: Flattening the Residency Learning Curve
BE IT RESOLVED,
that the CSNS circulate a national study, surveying interns in neurosurgery to understand the greatest learning curves faced within the transition to neurosurgery residency; and
BE IT FURTHER RESOLVED, that the CSNS ask the parent bodies to disseminate the identified factors to
expand medical student training curriculum and opportunities.
FISCAL NOTE: None

Saman Sizdahkhani, Adela Wu, Lauren Stone, Saman Farr

Celebrating the Holidays in Residency

Residents’ Corner

As the weather grows colder and the days get shorter, several holidays are just around the corner. Please enjoy this Residents’ Corner feature as Dr. Saman Sizdahkhani starts off by suggesting several simple yet special ways to get festive for Halloween. Dr. Adela Wu reflects on her family’s style of celebrating Thanksgiving. In Dr. Lauren Stone’s piece, a few seconds are all it takes to capture the wonder of New Year’s Day. Last but not least, Valentine’s Day can be a controversial holiday, but Dr. Saman Farr presents a lovely, alternative perspective. No matter how you decide to celebrate, happy holidays from the 2022-2023 CANS Resident Consultants!

Halloween 
Saman Sizdahkhani
Fall marks the beginning of the holidays in more ways than one. We dust off our sweaters, leaves change color, pumpkin spice lattes emerge, and candy apples tempt us. For many, Halloween marks the first of the many festivities. Physicians are rarely the ones decorating the hospital, but plastic ghosts and pumpkins materialize overnight and boost morale. It can be challenging to prioritize celebrations like this while in residency – especially if you are on call. But it’s important to stop and smell the cinnamon. Do something small to bring yourself and others joy – bake, contribute candy, play a little dress up. If you have time off, make the most of it. Gather with friends, go to a party, or find some children to trick or treat with. One of my favorite things to do each year is head to a pumpkin patch and find a pumpkin, or two, to carve. This year I did something new – found a local haunted house and went with a group of friends. One thing I know for sure is that residency is long, but life is short – so make the best of it!

Thanksgiving
Adela Wu
Shrimp and chives dumplings. White jasmine rice. Steamed Dungeness crabs. Peking duck with crispy, fragrant skin. Beef stew broiled on the stovetop for twelve hours. Egg tarts from the local Chinese bakery toasted again in the oven. These weren’t the typical trappings of an all-American Thanksgiving. Throughout college, medical school, and residency, I’ve been far from home, while my parents still lived in the same place for the last thirty-five years in Arcadia, California. Delays due to weather or other inconveniences of holiday travel made the four-day Thanksgiving break especially hectic. For one, when I attended university in Rhode Island, I took a cab, a train, a bus transfer, and a plane to get home, every stop a chance for me to get stranded in a random city. But I knew at least one thing would be constant. No matter how far I was going, I would come home to warmth, family, and enough homemade food to fill my belly and my checked luggage for the trip back. In my culture, Thanksgiving wasn’t an obvious holiday for my family to come together to express gratitude. But, because it was a universal reason for each of us to take time off from school or work, Thanksgiving gave us time to spend with each other. Time, I realize with each passing year, that was as short as it was precious, especially with the schedule and demands of neurosurgery residency. So, for all the Thanksgivings I had been able to make it home in time so far, I am grateful.

New Year’s Day
Lauren Stone
Maintaining the spirit of holiday traditions has become somewhat of a pet project of mine during residency. I place a great deal of weight on traditions: they anchor long held values, prompt new reflections, and replay cherished memories. In short, they are too important to forget. I have spent a number of December 31-January 1 turnovers on overnight call. These nights run unslept but capped with an AM coffee. On my second year of New Year’s Eve call, I had a gap at 23:50. In that moment of pause, I remembered that some of my San Diego friends were going to see the fireworks in the bay. New Year’s Eve fireworks: this was a tradition, forgotten the year before but now an unexpected possibility. So, at 23:58, I made my way to the hospital rooftop. There was no need to watch the countdown, because at 00:00, San Diego Harbor, Mission Bay, and distant Pacific Beach were illuminated by fireworks. It was a sweeping view. I texted a few friends, sharing the moment, and stayed until my pager went off 23 seconds later. It was enough: a moment shared with San Diego, and a gentle acknowledgement of the continuity that runs between life phases. And interestingly, when I swapped stories the next day with those friends, our overall New Year’s experiences were not so different: an unslept night capped with an AM coffee and a new memory of San Diego fireworks.

Valentine’s Day
Saman Farr
Our family and friends play an important role in our lives, especially as residents. But while family love can be unconditional (or so it is classically defined—which can be a topic for a whole different discussion), it can become easy to forget the importance of romantic love. This is classically supposed to be passionate and spark a certain fire in
one’s life. Lucky for us, there’s a holiday that is dedicated to romantic love, to remind us to at least take a day to remember and celebrate this possibility of romance. 

Certainly this ‘so-called’ holiday has its detractors and is often accused of being a capitalistic money-making scheme (which itself is again a whole other discussion). But sometimes, it can be good to take things at face value, and holidays can certainly be one of those times. I remember with particularly fond memory the Valentine’s Day that I celebrated three years ago with my beloved. It was rather simple as far as memorable holidays go—we drove a couple of hours north to Solvang from southern California. And it wasn’t particularly costly, which can also be an important consideration for a resident budget. But the entire experience completely caught both of us off-guard, because it was a pleasantly romantic island of time in an ocean of otherwise mundane preoccupation with the daily grind.

It served as a reminder that it can be good to refrain from over-analyzing sometimes and take things at face value. Certainly, this can be difficult to do in our discipline, as we are trained to analyze every aspect and every detail of a
situation that we’re presented—because after all, lives can depend on it. But when it comes to the holidays, it might be best to just let Valentine’s Day be what it’s supposed to be, a day to take out of your busy calendar and dedicate
to sparking some romance in your life.

Quote for the Month​ of October

Quote of the Month

” You can’t live a perfect day without doing something for
someone who will never be able to repay you. “
John Wooden

CANS MISSION STATEMENT

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

Tidbits September

Tidbits September

October 1 – Jimmy Carter, our 39th President and the longest living president in the history of the US, celebrates his 98th birthday.

October 3 – The Supreme Court of the US starts a new term with its newest member Justice Ketanji Brown Jackson. She is the first black woman to serve on the highest court pf the land.

October 3 – Svante Pääbo, a Swedish geneticist, was awarded the Nobel Prize for Physiology. The Nobel committee said that he had “accomplished something seemingly impossible: sequencing the genome of the Neanderthal, an extinct relative of present-day humans.”

October 4-5 – Yom Kippur, the Day of Atonement, begins at sundown on October 4 and ends at nightfall on October 5. It is considered the most important and sacred of Jewish religious holidays. It falls on the 10th day of the Jewish lunar month of Tishrei.

October 4 – The Nobel Prize in physics was awarded jointly to American John F. Clauser, Austrian Anton Zeilinger, and Frenchman Alain Aspect, for their work on quantum information science that has significant applications, including in the field of encryption. They were cited by the Royal Swedish Academy of Sciences for discovering the way that
unseen particles, such as photons or tiny bits of matter, can be linked, or “entangled,” with each other even when they are separated by large distances.

October 4 – Loretta Lynn dies at 90. She was the Queen of Country Music. Her songs brought to light issues surrounding sex, adultery, divorce, and birth control. She blazed many trails for women in Country Music and received the most awards and honors of any female performer. President Obama awarded her the Presidential Medal of Freedom in 2013. Only in America can a coal miner’s daughter reach such fame and success.

October 4 – New York Yankees slugger Aaron Judge broke Roger Maris’ single-season American League home run record, hitting his 62nd of the year in a game against the Texas Rangers. And we know that Judge was tested for performance-enhancing drugs.
October 5 – World’s Teachers Day. It’s a day to celebrate all teachers around the globe and how they are transforming education. It commemorates the anniversary of adopting the 1966 ILO -International Labor Organization/UNESCO – United Nations Educational, Scientific and Cultural Organization recommendation concerning the status of
teachers. In it, the right to education was considered a fundamental human right. Unfortunately, teachers who are so essential to our families, our communities, our country, and the world are often underappreciated and underpaid. I am spending the day honoring the many teachers in my life, including my daughter and daughter-in-law, and
remembering my mother and mother-in-law.

October 5 – California Clean Air Day. This is the fifth annual observance. Unfortunately, I and many others did not know it existed.

October 5 – The Nobel Prize in Chemistry was awarded to Carolyn R. Bertozzi from Stanford University, Morten Meldal from the University of Copenhagen, and K. Barry Sharpless from the Scripps Institute for the development of click chemistry and bio-orthogonal chemistry — work that has “led to a revolution in how chemists think about linking molecules together,” the Nobel committee said. Dr. Bertozzi is the eighth woman to be awarded the prize, and Dr. Sharpless is the fifth scientist to be honored with two Nobels; he coined the term click chemistry in 2000. Their work could have important applications in treating and diagnosing illnesses.

October 6 – The Nobel Prize in Literature was awarded to Annie Ernaux, 82, the 17th female writer to win the prize. The French novelist wrote about her own life in an intensely personal way. Her books described in detail incidents from her own life, including a back-street abortion in the 1960s and a passionate extramarital affair.

October 7 – The Nobel Peace Prize was jointly awarded today to the Ukrainian human rights organization Center for Civil Liberties, the Russian human rights organization Memorial, and human rights activist Ales Bialiatski; The Ukrainian Center for Civil Liberties has been documenting alleged Russian war crimes in Ukraine; The Russian human rights group Memorial was shut down earlier this year by the Russian government, but it worked on verifying information on abuses and war crimes; The jailed Belarus rights activist Ales Bialiatsk has been fighting for democracy in Belarus for decades. The Nobel committee said it chose these laureates to honor them as champions of “human rights, democracy, and
peaceful co-existence.” A timely honor.

October 10 – World Mental Health Day. Working to make mental health and well-being for all, a global priority.

October 10 – Columbus Day. Sorry, I meant to say Indigenous People’s Day!

October 10 – The Nobel Memorial Prize in Economic Sciences was awarded to Ben S. Bernanke, the former Federal Reserve chair, Douglas W. Diamond, an economist at the University of Chicago, and Philip H. Dybvig at Washington University in St. Louis. John Hassler, an economist at the Institute for International Economic Studies at Stockholm
University and a member of the prize committee said, “The laureates have provided a foundation for our modern understanding of why banks are needed, why they’re vulnerable, and what to do about it.”

October 11 – The U.S. Preventive Services Task Force, a volunteer panel of experts who make recommendations about the likely benefits and harms of various preventive health services, recommended for the first time that primary care doctors screen all children ages 8 to 18 for anxiety. This highlights the ongoing concern about mental health crisis among American youth.

October 12 – World Arthritis Day. Many of us make our living helping patients with degenerative arthritis have better lives!

October 12 – The Food and Drug Administration’s broadened access to the updated coronavirus booster shots. The revised shot developed by Pfizer-BioNTech previously had been cleared for those 12 and older, while Moderna’s updated booster was available only to those 18 and older. The FDA action will expand access to Pfizer’s shot to children as young as 5, and to Moderna’s shot to children 6 and older. The more of our population is vaccinated and boosted, the better!

October 14 – National Dessert Day. Sweet!

October 15 – The Alaska snow crab harvest has been canceled for the first time ever.
Seven billions of the delicious crustaceans have disappeared from the cold, treacherous waters of the Bering Sea in recent years. The Climate is indeed changing!

October 16 – A pair of Levi’s jeans from the 1880s, found in an abandoned mine, sold at an auction for more than $87,000. They are in a remarkable good condition. While iconic of the American West, the jeans also bear witness to a dark episode in the country’s history. An inside pocket is printed with the phrase “The only kind made by White Labor.” Evidently, the company used this slogan after the introduction of the Chinese Exclusion Act in 1882, which barred Chinese laborers from entering the US.

While I understand the historic value of this pair of jeans, and thus the price, I can never understand paying good money for jeans with holes to make a fashion statement.

October 17 – Adults in the US can start purchasing their hearing aids over the counter. One potential benefit is lowering
the cost of this essential technology for many seniors.

October 17 – The Department of Education officially launched its app. for the federal student loan forgiveness
program. Those making less than $125,000 a year (or $250,000 for married couples) will be forgiven up to $10,000. The Dept of Education will also provide up to $20,000 in debt cancellation to those who received Pell Grants.

October 18 – Philanthropist MacKenzie Scott donated $84.5 million to Girl Scouts of the USA and 29 of its local branches, the largest donation the Girl Scouts have received from an individual since their founding in 1912. Scott is usually very private about her giving, which totaled around $12 billion since 2019. Way to go MacKenzie!

The Pillars of Creation, in the Eagle Nebula, is a star-forming region captured in a new image (right) by the James Webb Space Telescope that reveals more detail than a 2014 image (left) by Hubble.

October 19 – The James Webb Space Telescope captured a highly detailed view of the so-called Pillars of Creation: three looming towers made of interstellar dust and gas speckled with newly formed stars. The area, which lies within the Eagle Nebula about 6,500 light-years from Earth, had previously been captured by the Hubble Telescope in 1995, creating an iconic image.

October 20 – A team of economists from UCLA, Northwestern and Princeton Universities found that pandemic trends, such as increased work flexibility, helped push up US birth rates last year to 6.2% from pre-pandemic levels. This marks the first major reversal in declining fertility rates in the US since 2007. It appears that birth rates
can increase during economic downturns, contrary to longstanding economic assumptions.

October 23 – The National Assessment of Educational Progress, known as the nation’s report card, which tests a broad sampling of fourth and eighth graders and dates to the early 1990s, reported that U.S. students in most states and across almost all demographic groups experienced troubling setbacks in both math and reading.
In math, the results were especially troubling, representing the steepest declines ever recorded. Math scores for eighth graders fell in nearly every state. A meager 26 percent of eighth graders were proficient, down from 34 percent in 2019.
Reading scores also declined in more than half the states, continuing a downward trend that began even before the pandemic.

October 24 – Diwali, the Festival of Lights. This Holiday symbolizes the victory of light over darkness. While many Hindus celebrate Diwali, people of various faiths mark the five-day festival in India and other countries. In fact, while Diwali is rooted in religious tradition, the festival has also become a secular holiday in India.

October 25 – King Charles III asked Rishi Sunak to form the UK Government. Mr. Sunak, 42 and of Indian descent, became the third person to hold this position in two months, the youngest Prime Minister in more than 200 years and the first person in color. Mr. Sunak did his post graduate studies at Stanford. His appointment coincided with Diwali.

October 26 – The U.N. said that current conditions will push up global temperature by as much as 2.9 degrees Celsius – 5.2 degrees Fahrenheit – by the end of this century. The efforts to decarbonize are slowing, and as a result scientists warn that climate change will accelerate to catastrophic levels. Deeper emission cuts than previously planned are
required.

October 26 – A Day of Mourning for Mahsa Amini, 22, whose death 40 days ago while in custody of the morality police ignited Iran’s sweeping demonstrations. Iranian forces continue to crackdown on thousands of protesters. Protesters continue to gather across the country and chant Freedom! Freedom!

October 27 – The United Nations warned has that Somalia could soon face a disastrous famine, as the impacts of four failed rainy seasons and global inflation add to widespread food insecurity. The current situation is so disastrous that the U.N. Children’s Fund (UNICEF) estimates that a child has been sent to a hospital over malnutrition once every minute since August. As the region suffers under its most severe drought in four decades, as many as 6.7 million people, or 40 percent of Somalis, will require food assistance to prevent hunger over the next few months. Hunger has already killed thousands, and over 1 million more have been displaced as the drought kills livestock and decimates crops.

October 28 – A significant moment in college sports history unfolded when two men’s soccer teams met at little Gaelic Park in the Bronx. NY University, coached by Kim Wyant, hosted powerhouse University of Chicago, coached by Julianne Sitch. This is the first N.C.A.A. men’s soccer game in which both coaches are women.

October 29 – World Stroke Day. While much progress has been accomplished, much more needs to be done.
Neurosurgery needs to continue to be actively involved!

Calendar

Calendar

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 (emily@cans1.org) or fax (916-457-8202). !
he 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