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
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!
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
email@example.com, or call me on my cell phone: 805-701-7007
The newsletter continues to be published as expected.
Next Board Meeting – January 13th, 2023, prior to the Annual Meeting !
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.
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.
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.
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:
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).
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
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.
As you know, on Jan. 1, 2023, neurosurgeons face a minimum 8.42% Medicare payment cut, including a:
To help mitigate these cuts, Reps. Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.) have introduced the Medicare Providers Act (H.R. 8800), which would prevent the 4.42% MPFS cut. The legislation also contains a “Sense of Congress” that urges policymakers to take administrative and legislative actions to:
Please contact Congress and ask your Representative to co-sponsor H.R. 8800.
Click here to go to neurosurgery’s Advocacy Action Center to email your Representative asking them to co-sponsor the bill. A sample message, which can be personalized, is provided.
Note that we are also working with key champions to introduce additional legislation that would provide physicians with an inflation update based on the Medicare Economic Index. Furthermore, we are collaborating on efforts to halt the 4% PAYGO cut. Congressional leaders have acknowledged the need to address these cuts, although, at this time, we do not know the magnitude of relief physicians will get in a year-end legislative package.
Thanks for engaging in this grassroots advocacy activity!
Cedars-Sinai’s humble beginnings started with the establishment of Kaspare Cohn Hospital in 1902, predecessor of Cedars of Lebanon, and the 1918 opening of a 2-room hospice by the Bikur Cholim Society, which preceded Mount Sinai. Both Cedars of Lebanon and Mount Sinai were created by Los Angeles Jewish community to meet the growing health needs of the times.
The first neurosurgery at Cedars of Lebanon was performed by Carl Rand, MD and Mark Glaser, MD in 1931. Dr. Rand was chief of neurosurgery at Los Angeles County Hospital. By virtue of his skills and reputation, he was a staff consultant in many hospitals in the area. Dr. Glaser was a respected neurosurgeon with clinical interests in head injuries and neuralgias.
In the 1940’s, Neurosurgery at Cedars of Lebanon boasted the presence of Dr. Tracy Putnam. He, along with Dr. Houston Merritt, pioneered work on phenytoin for epilepsy. He was a founding member of the National Epilepsy Foundation and Chief of Neurosurgery at Cedars of Lebanon from 1947 to 1958.
Dr. Emil Seletz became Chief of Neurosurgery at Cedars of Lebanon in 1958. He designed a non-rigid brain cannula for ventriculography, a universal Kerrison punch handle and set, and a lighted guillotine hook for sympathectomy. Dr. Seletz was also an accomplished sculptor. His sculptures have been displayed in the White House and the Ford Theatre in Washington DC.
Dr. Maxwell Andler was Mount Sinai’s Chief of Staff and later served as Chief of Surgery at Cedars-Sinai Medical Center. He was one of the three neurosurgeons who operated on Senator Robert F. Kennedy when he was shot in 1968 at the Ambassador Hotel in Los Angeles. He served as an Army Air Corps flight surgeon, was a prisoner of war in World War II, and was awarded the Bronze Star for his service and bravery.
In 1961, Cedars of Lebanon and Mount Sinai Hospital merged to become Cedars-Sinai Medical Center where a number of neurosurgical luminaries would practice. Dr. Sanford Rothenberg and Dr. Louis Conway described laboratory work in which a stent was passed through an arteriotomy to the orifice of a presumed aneurysm. This procedure foreshadowed some of the endovascular work done today. Dr. Rothenberg served as chief of neurosurgery at Cedars-Sinai.
Dr. Elliott Blinderman was instrumental in the passage of California’s mandatory motorcycle helmet law. He was well respected neurosurgeon with a wide range of clinical interests.
Dr. Milton Heifetz was appointed Chief of Neurosurgery in 1967. He invented the Heifetz aneurysm clip system, one of the most technologically advanced aneurysm clips of its time. Dr. Heifetz went on to develop a wide spectrum of neurosurgical tools and micro-instruments and is widely recognized for his contributions to neurological surgery. He wrote many books on his various interests such as ethics, astronomy, and Haiku poetry.
Dr. Charles Carton served as co-Chief of Neurosurgery at Cedars-Sinai from 1975 to 1977. With funding support from the NIH and the National Heart Institute, he pioneered and developed a rapid non-suture ring anastomotic method, a procedure for repairing small vessel leaks in the brain with special adhesives. Cedars Sinai became a level 1 trauma center in 1984. Dr. Marshall Grode and then Dr. Martin Cooper lead the department.
In 1997, Dr. Keith Black established the Maxine Dunitz Neurosurgical Institute. Under his leadership, Cedars Sinai’s residency program in Neurosurgery was approved in 2005. Neurosurgery became an academic department in 2006, and we now accept two residents per year. Graduates from Cedars Sinai have taken academic positions at Johns Hopkins, UC San Diego, and SUNY Upstate.
The neurosurgery research program includes projects in human cellular neurophysiology, translational medical imaging technology, reversing immunosuppression from brain tumors, and activated T cell therapies.
Over time, Cedars Sinai purchased Marina del Rey Hospital and has partnered with Torrance Memorial Hospital, Providence Tarzana Hospital (under construction), and Huntington Memorial Hospital. There are two faculty at Torrance with a plan for faculty at Providence Cedars Sinai Tarzana. Currently, the main Cedars Sinai Medical Center has 27 neurosurgical attendings, including 12 full-time academic faculty members who provide comprehensive neurosurgical services with subspecialty care including brain tumor/ skull base, CSF leak, endovascular, functional/ epilepsy, spine, and pediatric programs.
My main policy research interest is Medicaid. I’ve primarily worked at safety net hospitals and my elective population is nearly 100% Medicaid. I’m intimately familiar with the shortcomings of the system. One of which is the lack of patient choice.
California was one of the first states to move Medicaid into a managed care system. As opposed to fee-for-service (FFS), where a provider submits CPT codes to the government, managed care has the government contract with a private entity (a managed care organization or MCO) as an intermediate. The MCO receives a risk-adjusted rate from the government on a per-member (capitated) basis. If the MCO drives down costs, it gets to keep the difference, but it is also responsible if costs exceed what it’s paid by the government. It gives more budget predictability for the government and, in theory, more cost-conscious management since the MCO is entitled to any residual money.
In California, the individual counties decide their MCO system. The various counties can choose between four different MCO models. I won’t belabor the details here, but the different models essentially determine how many MCOs will be available in each county, and if they are run by the county or outsourced to private companies.
In a piece recently accepted by Inquiry, Michael Tawil & I examined the landscape of patient choice within this system. We found that, despite having 26 unique MCOs in the state, California’s setup severely limits patient choice. Few counites offer more than one or two MCOs. When we used the US government’s standard measure for market competition, the Herfindahl-Hirschman Index (HHI), all the California counties came in at being “highly concentrated.” Only Sacramento and San Diego were even close to the “moderately concentrated” threshold.
Of course, highly concentrated markets and lack of patient choice is systemic in the US health insurance industry. There are nationwide regulations which prohibit a truly competitive insurance marketplace. However, in the private insurance market, California is one of the more competitive states. It gives its citizens relatively more choice when compared to other states.
Competition and consumer choice are, as the federal trade commission puts it, “the fuel that drives America’s free-market system.” President Biden reiterated this in his July 2021 executive order promoting competition in the American economy. Competition ensures better quality and lower prices for consumers. It ensures better pay and more freedom for workers. This thinking transcends party lines.
A competitive insurance marketplace means that companies must vie to keep the price low and the quality high. If one company gouges on price without offering better services, people have other options. For physicians, it means some leverage if a company has a reputation for denying claims or paying below cost. More competition just improves choice (for patients and doctors) which drives better quality and lower cost.
In the Medicaid marketplace, however, the current California model restricts choice. If Medicaid patients are unhappy with their coverage, they have few options. Instead of relying on competition to ensure quality, California tries to regulate it into existence. The result is massive fines for programs that don’t meet arbitrary quality metrics, like how many resolution letters a plan sends to members who file grievances. As Thomas Sowell said, “competition does a much more effective job than government at protecting consumers.”
Highly successful companies in competitive industries thrive because they have high-quality products at low cost with happy employees. They do this not because of government regulations on price, quality, and performance metrics. They do this because they know that if they charge too much, offer shoddy products, or mistreat their workers, their customers and employees will turn elsewhere.
California offers at least some choice to those seeking private insurance. However, it restricts choice within Medicaid. Don’t those patients deserve a choice as well?
The New 2023 CPT code set includes burden-reducing revisions.
Building on its efforts to reduce administrative tasks in medicine—a driver of burnout and a central pillar of its Recovery Plan for America’s Physicians—the American Medical Association (AMA) today released the 2023 Current Procedural Terminology (CPT®) code set. The nation’s leading data-sharing terminology for medical procedures and services, the 2023 CPT code set contains burden-reducing revisions to the codes and guidelines for most evaluation and management (E/M) services.
Based on the 2021 revisions made to the E/M codes for office visit services, the new modifications make coding and documentation easier and more flexible for other E/M services, freeing physicians and care teams from time-wasting administrative tasks that are clinically irrelevant to providing high-quality care to patients. The new modification to the E/M codes extend to inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services, and prolonged services.
“The process for coding and documenting almost all E/M services is now simpler and more flexible,” said AMA President Jack Resneck Jr., M.D. “We want to ensure that physicians and other users get the full benefit of the administrative relief from the E/M code revisions. The AMA is helping physicians and health care organizations prepare now for the E/M coding changes and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”
The AMA has developed an extensive online resource library of videos, guides, and educational modules to help with the transition to the revised E/M codes and guidelines. Please visit the Implementing CPT Evaluation and Management (E/M) revisions web page for a complete list of AMA resources.
Other changes to the CPT code set
Modifications to the E/M codes are among 393 editorial changes in the 2023 CPT code set, including 225 new codes, 75 deletions and 93 revisions. With 10,969 codes that describe the medical procedures and services available to patients, the CPT code set continues to grow and evolve with the rapid pace of innovation in medical science and health technology.
Changes to the CPT code set are considered through an open editorial process managed by the CPT Editorial Panel, an independent body convened by the AMA that collects broad input from the health care community and beyond to ensure CPT content reflects the coding and data-driven demands of a modern health care system. This rigorous editorial process keeps the CPT code set current with contemporary medical science and technology so it can fulfill its vital role as the trusted language of medicine today and the code to its future.
Responding to the fast pace of innovation, a new appendix has been added to the 2023 CPT code set with a taxonomy for artificial intelligence/augmented intelligence (AI) applications. The new AI taxonomy provides guidance for classifying various AI-powered medical service applications, such as expert systems, machine learning, or algorithm-based solutions, into one of three categories: assistive, augmentative, or autonomous.
“The new AI taxonomy establishes foundational definitions and a shared understanding among stakeholders that clearly describes the technical features and performance of AI applications, as well as the work performed by the machine on behalf of the health care professional,” said Dr. Resneck. “This shared understanding will help guide the CPT editorial process for describing the range of AI products and services.”
Other important additions to the 2023 CPT code set respond to new medical services sparked by emerging uses of virtual reality technology in therapy (0770T) used for skill-building for social communication, emotional regulation, and daily functional skills in people with neurodevelopmental disorders, as well as
procedural dissociation services (0771T-0777T) used in place of anesthesia during procedures to increase tolerance and reduce pain and anxiety.
The list of CPT codes for remote monitoring services continues to grow with the addition of a new code to report cognitive behavior therapy monitoring (98978) beyond the walls of a medical practice for a range of physical and mental health disorders.
The evolution of new medical techniques and technology also prompted the creation of 15 new CPT codes (49591-49623) to report anterior abdominal hernia repair services. The update addresses correct reporting for “hybrid” abdominal hernia repair procedures where parts of the procedure are perform via an open approach and parts of the procedure are performed via laparoscopy or with the use of a robot.
CPT content & resources
To assist the health care system in an orderly annual transition to a newly modified CPT code set, the AMA releases each new edition four months ahead of the Jan. 1 operational date and develops an insider’s view with detailed information on the new changes in the 2023 CPT code set.
The AMA invites the health care community to stay up to date on the significant CPT code changes for 2023 by attending two virtual events this November, the Outpatient CDI Workshop and the CPT and RBRVS Annual Symposium. Meeting agendas and registration are available on the AMA website.
For more information, a special section for CPT education has been created for the AMA Ed Hub™, an online learning platform containing CME and education, including a module series covering an overview of CPT coding basics and other topics. The CPT Network is also available for authoritative CPT coding guidance.
Coding books and products are available from the AMA Storefront on Amazon, including the CPT Professional 2023 codebook with updated medical illustrations to represent the full diversity and identities of the people in our society. Continued updates to the illustrations represent one step in the AMA’s collective efforts to equip all physicians and health care workers with the tools and resources needed to ensure inclusion and belonging, as well as to advance equity.
The 2023 CPT codes and descriptors can be imported straight into existing health care software solutions using the downloadable CPT 2023 Data File. The data file contains the updated code set’s complete descriptor package, including descriptors for consumers and physicians, and the complete official CPT coding guidelines.
As private practitioners, we are generally not viewed as an important part of the healthcare ecosystem. With over 50% of physicians employed as of 2020, private practice is an ever-shrinking demographic. Our influence on both policy and practice also summarily diminishes.
At least, that is what conventional wisdom states.
What private practice represents in the community is the front line for patients and their access. Many times, we are the first contact for many complex patients. Sometimes, things are so urgent that transfers to higher levels of care may delay much-needed intervention.
So, we really are part of the ecosystem, then, at least for the time being. As the inexorable progression of healthcare-change goes, we may not be. In fact, there may come a time when the umbrella of hospital employment may be the only way that we are allowed to practice.
Some of us work in truly underserved environments. The payer mix may be well over 50%
indigent, or on state insurance, making it difficult to afford to keep our doors open. We don’t say no to the Emergency Room because it is our obligation and often a matter of life and limb to answer the call.
In the office setting, however, it becomes supremely difficult, especially with HMO patients, to get their continuity of care right. Bales and bales of authorizations, oftentimes in clunky or downright governmental bureaucratic morass to get a simple test authorized and ordered. We, the surgeons, are there with anxious or even angry patients who wonder why we can’t just take care of them.
Insurers, both commercial and governmental, have galvanized this patient’s anger and weaponized it against physicians. The pandemic and the various rhetoric – ranging from denial of its existence to claiming the implantation of 5G chips in the vaccine to hysterics in public places has not helped enjoin any trust in our profession. By painting us as the barrier to care access, they have successfully controlled the narrative.
Many people in the public healthcare debate have also pointed fingers at physicians saying we are too highly paid. One such person matriculated from 2 fine institutions and has a large social media following. Of note – he is a physician.
He further states, using data from a Medscape article, that we are some of the most highly compensated in the world. The very next page shows that we also carry the most debt of any physicians in the world. Of note – he did not include that in his treatise.
By painting doctors as being greedy, not wanting to treat undesirable patients, and overall being awful people, insurers and other stakeholders have been very successful at putting doctors on the defensive. To be sure, we have bad actors. Witness every week an email blast from Becker’s detailing some new malfeasance from a doctor running a pill mill or involved in a kickback scheme.
But are we really solely to blame? I am not so convinced. Physicians’ practices need to make money to stay open. The difference between the insurers and us is that we care what happens to our patients, be it someone we are meeting for the first time or someone who has been our patient for eight years.
How can we better offer access and equity to everyone? It is most likely not signing up with every insurance, as they are incredibly good at disconnecting the process of getting the authorization from actually getting paid – even with the same exact codes. Perhaps we can focus more on efforts to make sure the insurers that are making 5 billion dollars a quarter in profit be brought to heel. Maybe we can also push the states to bring the payments for Medicaid and Medi-Cal up to the same rate as Medicare payments (although those are falling too).
Why should patients suffer while insurance CEOs complain that the cost of care is so high while they jaunt off to Davos in their meetings? Why should hospitals claim they are “bleeding red” as they plan an over 600-million-dollar expansion and their CEOs bring home nearly 8-figure salaries?
We, unfortunately, lost control of the narrative and, ultimately, our ability to determine how we can quickly, effectively, and consistently get patients taken care of. And no one political party is to blame; the inability of either to properly legislate access and keep our system from imploding is a clear demonstration. We saw a narrowly averted 10% cut from the previous administration. And now the over 8% Medicare cut looming as of January 2023 to the tripling of malpractice payouts in the state simultaneously.
The importance of getting patients’ care is paramount. We do it because it’s our job. It is not our job to save the system from itself, but it will be to help the patients that will suffer because of the innate inequity that this will bring. Hopefully, an opportunity will present itself, with physicians more confident in pushing back against the self-perpetuating grift machine that currently powers healthcare in America.
We all just hope there are enough of us left willing to put up with this dreck and help those that need us.
The California Department of Health Care Services (DHCS) recently announced the results of its first ever competitive Medi-Cal managed care procurement, which according to DHCS will redefine how care is delivered and which commercial payors will participate in California’s Medi-Cal managed care program beginning in 2024.
Deeply alarmed about the growing financial instability of the Medicare physician payment system, the California Medical Association (CMA) recently surveyed physicians about the financial health of their practices and how Medicare payment rates are impacting access to care in their communities.
A CMA-sponsored bill to provide exemptions to e-prescribing requirements for low volume prescribers has passed the state legislature. Assembly Bill 852 will also provide exemptions for practices affected by federal, state or local emergencies or disasters. The bill passed the State Senate by a vote of 32 to 2 and is now on Governor Newsom’s desk.
A CMA-supported bill to require the installation of trauma bleeding control kits in newly constructed public and private buildings has passed the Senate floor unanimously (37 to 0) and now goes to the Governor’s desk. Assembly Bill 2260 will make California the first state in the nation to add accessible first responder tools in non-residential areas where people gather.
CMA President Robert E. Wailes, M.D., issued the following statement regarding the appointment of Diana Ramos, M.D. as California Surgeon General: “The California Medical Association couldn’t be prouder of the appointment of Diana Ramos, M.D., as California Surgeon General. As a physician, and in her many leadership roles, Dr. Ramos has worked tirelessly to address health disparities and ensure everyone has access to care.”
CMA partnered with the California Primary Care Association and Magellan on a webinar to help physicians understand the DHCS phased implementation plan for Medi-Cal Rx. The one-hour webinar was recorded and is now available for on-demand playback.
Each year during the CMA House of Delegates, we honor and reflect on our physician colleagues who are no longer with us. If you would like to honor a CMA member who passed away since October 2021, please submit an “in memoriam” resolution and photo by Monday, September 19. A sample template is available if needed.
Reminder: Medi-Cal to reinstate prior authorization for 11 drug classes on Sept. 16
Medi-Cal Rx prescribers will again be required to submit prior authorizations (PAs) for new start medications in 11 drug classes for patients 22 and older effective September 16, 2022. According to DHCS, new start prescriptions for pediatric patients 21 years of age and under are excluded to prevent additional administrative obligations for providers of specialty pediatric services who have been significantly impacted by the transition to Medi-Cal Rx.
The American Medical Association (AMA) has announced an editorial update to Current Procedural Terminology (CPT)®, that includes eight new codes for the bivalent COVID-19 vaccine booster doses from Moderna and Pfizer-BioNTech. The new product and administrate codes assigned to each bivalent COVID-19 vaccine booster are now included in the CMA COVID-19 Vaccine Toolkit for Physician Practices and CMA COVID-19 Vaccine Reimbursement Quick Guide.
DHCS has published an FAQ that answers common questions about the health care worker retention bonuses authorized under legislation recently signed by Governor Newsom to stabilize and retain California’s health care workforce and recognize the sacrifices our health care workers have made over the course of the pandemic.
HHS expected to renew public health emergency in Oct.
Although the COVID-19 public health emergency declaration is slated to expire at the end of October, it is expected that U.S. Health and Human Services (HHS) Secretary Xavier Becerra will issue another extension. HHS has previously indicated that when a decision is made to terminate the declaration or let it expire, the agency will provide 60 days’ notice prior to termination.
The California Medical Association applauds the bipartisan introduction of the “Supporting Medicare Providers Act of 2022” (HR 8800) by physician Congressmen Ami Bera, M.D., (D-CA) and Larry Bucshon, M.D. (R-IN). This bill would stop 4.42% of the cuts related to budget neutrality adjustments in the Medicare Fee Schedule.
CMA applauds House passage of prior authorization reform to protect patient care
A bill that will reform prior authorization for Medicare managed care plans has unanimously passed out of the U.S. House of Representatives on a voice vote. The legislation – the Improving Seniors’ Timely Access to Care Act of 2022 (HR 3173) – provides comprehensive reform of the Medicare Advantage prior authorization process by streamlining the health plan bureaucracy to help Medicare patients get the care they need – when they need it
CMA publishes guide for patients impacted by 2022 wildfires
CMA has updated its guide to help patients navigate certain required services. This guide includes phone numbers to call if patients are experiencing difficulty refilling prescriptions, replacing medical supplies or obtaining access to care, as well as links with more information about other services each payor is offering.
A few years ago, I was paired with an attending for a day of microdiscectomies. It was my intro to MIS with cases one, two, and three back to back. Progressing to the microscope phase of procedure one, the unfamiliar working view hijacked my composure. I just needed to avoid missing “something” important and prevent “something” catastrophic from happening.
So, case one progressed with a workflow of 100% microscope zoom capacity, drilling, zoom out, reset 100% zoom on the untouched lamina, drill more, et cetera.
Case finished. Case two, now at microscope stage, my attending stopped me mid zoom.
Why don’t you try reorienting your view? Take in the whole tube view at once?
But I won’t see the field well enough. I’ll drill too deep. I’ll miss something.
I did. And admittedly, the procedure was smoother and – having tried it before – more familiar the next time.
Aren’t you glad you zoomed out?
Learning to maneuver the microscope is more than a technical exercise. To use this technology well, the surgeon must answer, “why are we doing this” and “what view will allow optimal economy of movement to do it well.” Framing scope work with these intentions results in a purposeful approach to surgery where the chosen perspective supports the ultimate goal of the procedure.
Similarly, donning a role in neurosurgery requires intentional framing. Early in residency, the “why am I doing this” can become clouded by the complexity and newness of the work. Unfamiliar context, dexterity demands, external expectations, self-doubt, and imposter syndrome conspire against the “personal economy of movement needed to do it well.” For many, including myself, this perpetuates the microdiscectomy microcosm: in light of what is unfamiliar and challenging, zooming into the work seems like the best way to avoid missing “something” important or causing “something” catastrophic.
Now in my fourth year, I see those default responses to training as necessary but also a threat to long-term sustainability.
Over time, the ”personal economy of movement” needed to navigate roles alongside neurosurgery becomes constrained when our zoom is stuck in one position. In my own life, this has meant more challenges transitioning from neurosurgery work into existing relationships and activities. Present in person, but perhaps not always in spirit. These moments are opportunities for pause, re-centering the view, and checking the zoom depth. Sometimes, this process identifies that the current working field does not support the ultimate goal.
Why don’t you try reorienting your view?
There is no avoiding the intensity of neurosurgery – this is what draws many of us to the vocation. However, practice is necessary to hone this intensity into an identity that permits the flexibility of multiple, simultaneous roles. Child. Spouse. Parent. Community member. Citizen.
Residency is the substrate for this skill to mature, resulting in a defined view of the essence of neurosurgery, “why I am here,” and “the economy of movement” needed to re-center and re-focus.
It’s a circular point: Intention is informed by experience. Experience is informed by intention.
Admittedly, the process becomes smoother and – having tried it before – more familiar the next time.
Aren’t you glad you zoomed out
Title: AANS and CNS should withdraw their memberships in the PAHCF (Partnership for America’s Health Care Future)
Submitted by: George L. Bohmfalk, MD., Moustapha Abou-Samra, MD., Fredrick Boop, MD.
WHEREAS, the AANS and CNS Health Care Coverage position statements call for health insurance coverage for every American and less complicated administrative systems; and
WHEREAS, those statements do not include specific opposition to a single-payer system; and
WHEREAS, the PAHCF is an organization formed for the express purpose of obstructing legislation that might lead to single-payer healthcare, expanding Medicare, or creating Medicare for All in particular; and
WHEREAS, the founding members of the PAHCF coalition were the Federation of American Hospitals, which represents investor-owned hospitals, and two powerful lobbies, AHIP (the trade association representing the private health insurance industry) and the Pharmaceutical Research and Manufacturers of America, all of whose primary motivation is to promote and support profit-taking in the healthcare industry; and
WHEREAS, AANS and CNS are reportedly non-paying members of the coalition, thereby providing PAHCF only the prestige and imprimatur of organized neurosurgery; and
WHEREAS, such endorsement of PAHCF’s mission to protect those industries profiting from our unsustainable healthcare system taints the esteem and jeopardizes public opinion of neurosurgeons; therefore
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 CONFLICTS OF INTEREST: None PRIOR RESOLUTIONS: None
AANS and CNS Health Care Coverage Position Statement.
The Case for Medicare for All. Public Citizen (February 4, 2019)
How Would Medicare for All Affect Physician Revenue? Christopher Cai, MD. Journal of General Internal Medicine 37:671–672 (2022)
An Economist’s View of Healthcare Reform. AANS Neurosurgeon (January 1, 2009)
Health Care and Insurance Industries Mobilize to Kill “Medicare for All.” Pear, Robert, The New York Times (February 23, 2019)
Partnership for America’s Health Care Future. Wikipedia entry.
PAHCF members listing on their website.
AMA drops out of industry coalition opposed to Medicare expansion. Politico (August 15, 2019)
Assigned Committee(s): Coding & Reimbursement Committee Medico-Legal Committee Medical Practices Committee Neurosurgeons as Medical Directors Rep Section
TITLE: Sponsoring Institution Research Support for ACGME Accredited Neurosurgery Residency Programs
Submitted by: Mick Perez-Cruet MD MS, Daniel Michael MD PhD, Jason Stacy MD, Medical Legal Committee
WHEREAS, the ACGME accredits Neurosurgery residency programs; and
WHEREAS, continued ACGME accreditation of these programs requires a year of research to teach residents the principles of basic and clinical neuroscience including hypothesis formulation, experimental design, data collection and statistical analysis; and
WHEREAS, continued ACGME accreditation of a neurosurgical residency brings benefits to the sponsoring institution including national recognition and financial gain 1;
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.
1. Shahlaie K, Harsh IV GR: The financial value of a neurosurgery resident. J Neurosurg 135:164– 168, 2021.
Fiscal Note: 0
*An email discussion and vote by the Medico-legal Committee was held to support this resolution
Assigned Committee(s): Medico-Legal Committee Young Neurosurgeons Rep Section Communication and Education Committee
“This content represents the business of the CSNS meeting and does not represent CSNS, AANS, or CNS policy unless adopted by this body and approved by the parent organizations”
TITLE: Informal consultation and clinical advice by neurosurgeons
Submitted by: Vincent Y. Wang, M.D., Ph.D., Jason Stacy, M.D., Ann Parr, M.D., on behalf of
Neurotrauma and Emergency Neurosurgery Committee and Medico-legal Committee
WHEREAS, neurosurgeons often give clinical advice to other physicians regarding neurosurgical conditions and are often considered as the gatekeeper for whether to accept a patient transfer due to a neurological issue, and
WHEREAS, access to clinical and radiological data in such incidences are often limited, and
WHEREAS, practice of documentation of these conversation between the neurosurgeons and the counterpart parties is highly varied, and
WHEREAS, in the recent case of Warren vs Dinter (Minn A17-0555) it was ruled that “a physicianpatient relationship is not a necessary element of a claim for professional negligence” but that “A physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician’s acts”, exposing consultants—like neurosurgeons– to potential liability when giving advice to other physicians, therefore
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 to advise the neurosurgery community about the best practice for these types of “informal” consultation.
Fiscal Note: none
*The NTENS Committee supported this resolution via email notification *The Medico-Legal Committee supported this resolution via email notification
Assigned Committee(s): Neurotrauma & Emergency Neurosurgery Committee Medico-Legal Committee Communication and Education Committee Medical Practices Committee Workforce Committee
“This content represents the business of the CSNS meeting and does not represent CSNS, AANS, or CNS policy unless adopted by this body and approved by the parent organizations”
TITLE: Increasing administrative support for CSNS resident and medical student fellows
Submitted by: Cara Sedney, Joe Cheng, Bharat Guthikonda
WHEREAS, the “critical mission” of the Council of State Neurosurgical Societies (CSNS) is socioeconomic education exemplified by our fellowships; and
WHEREAS, the growth and complexity of coordinating the CSNS fellowship has changed significantly over the years given changes and competing interests within the leadership infrastructure; and
WHEREAS, the appropriate administration of the fellowship is a key driver of fellow satisfaction and experience; and
BE IT RESOLVED, that the CSNS create 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. Fiscal note: $15,000 dollars/year
Assigned Committee(s): Communication and Education Committee Young Neurosurgeons Rep Section
“This content represents the business of the CSNS meeting and does not represent CSNS, AANS, or CNS policy unless adopted by this body and approved by the parent organizations”
TITLE: Neurosurgical residency non-service time: Evaluation of program opportunities for research, enfolded fellowships, away rotations
Submitted by: Tim Gooldy MD, Tyler Cole MD, Luis M. Tumialán MD
WHEREAS, neurosurgical residency is periodically re-evaluated and re-structured by ABNS, RRC, SNS to address the dynamic needs of the profession and training environment; and
WHEREAS, neurosurgical training programs do not have uniform or consistent options available for non-service time activities or elective rotations; and
WHEREAS, neurosurgical training programs do not have clear descriptions of opportunities or support available for non-service time activities or rotations; therefore
BE IT RESOLVED, that the CSNS create a survey 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, option to undergo their chief year during PGY-6.
Fiscal Note: None
Prior Resolutions: None
1. American Board of Neurological Surgery – Training Requirements https://abns.org/training-requirements
Assigned Committee(s): Communication and Education Committee Young Neurosurgeons Rep Section
“This content represents the business of the CSNS meeting and does not represent CSNS, AANS, or CNS policy unless adopted by this body and approved by the parent organizations”
TITLE: The processes and framework of a lawsuit: A guide for the neurosurgical trainee
Submitted by: George Koutsouras, Jason Stacy MD
WHEREAS, both neurosurgical residents and fellows are subject to liability in their practice; and
WHEREAS, if named in lawsuit, a neurosurgery resident or fellow member may be unaware of the processes henceforth that will occur; and
WHEREAS, the CSNS in 2021 described the malpractice litigation process and provided guidance for the neurosurgeon if they were to be named in a malpractice lawsuit.1 , but a resident resource is not clearly available for neurosurgery trainee; and
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 do-not’s if named in a malpractice claim, and recommendations for how to avoid being named in a claim.
Lefever D, Esfahani DR, Kandregula S, Trosclair K, Demand A, Vega A, Stacy J, Hussein N, Dossani R, Pendharkar A, Menger R, Kosty J, Mazzola C, Agarwal N, Kimmell K, Rosenow J, Cozzens J, Schirmer C, Guthikonda B; Council of State Neurosurgical Societies (CSNS). The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges. World Neurosurg. 2021 Jul;151:370-374. doi: 10.1016/j.wneu.2021.03.039. PMID: 34243671.
FISCAL NOTE: None CONFLICTS OF INTEREST: None
Assigned Committee(s): Medico-Legal Committee
Communication and Education Committee Young Neurosurgeons Rep Section Neurotrauma and Emergency Neurosurgery Committee Workforce Neurosurgeons as Medical Directors Rep Section
Title: Assess the current neurosurgery graduate medical education compensation variability, while adjusting for regional differences
Submitted by: George Koutsouras, Laura McGuire MD
WHEREAS, most graduate medical education trainee salaries are funded by the Center for Medicare and Medicaid Services; and
WHEREAS, each sponsored academic institution independently determines established post-graduate year annual benefit package and salary1; and
WHEREAS, there is no established guidelines for institutions to determine resident wage, leave, insurance and other compensation features and it is unknown if resident benefit packages meet the rise of inflation, cost of living, and other needs of a resident; and
WHEREAS, other specialties, beside neurosurgery, have assessed resident salary as it correlates with cost of living indices2,3; and
WHEREAS, identifying differences in resident salary and compensation based on geographical location may identify the need to provide greater financial compensation to trainees as is adjusted by geography; therefore
BE IT RESOLVED, that the CSNS identify resident salary across the United State through either publicly available inquiry or by communication with individual program coordinators throughout neurosurgery GME to determine resident benefit package variability.
FISCAL NOTE: $87 for Cost of Living Index sponsored by The Council for Community and Economic Research (https://www.coli.org/products/)
CONFLICTS OF INTEREST: None
Assigned Committee(s): Communication and Education Committee Young Neurosurgeons Rep Section
TITLE: Implementation of The Melany Thomas Senior CSNS Fellow Position
Submitted by: Bharat Guthikonda, MD, Jason Stacy, MD, Richard Menger MD, Devon Lefever, MD, John Ratliff, MD, Joseph Cheng, MD
WHEREAS, the CSNS is an excellent introduction to organized neurosurgery and socioeconomic education for CSNS resident fellows and
WHEREAS, the CSNS resident fellows are a group that has immense long-term organized neurosurgical leadership potential and
WHEREAS, many CSNS resident fellows do outstanding work during their fellowship year and have an interest in remaining involved in CSNS and in organized neurosurgery and
WHEREAS, the importance of Ms. Melany Thomas to CSNS is long-standing and valuable; therefore
BE IT RESOLVED, the CSNS leadership will choose one outstanding interested CSNS resident fellow each year to be recognized as the Melody Thomas Senior CSNS Fellow. This awardee would then serve as the Senior CSNS 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 those CSNS resident fellows who express interest and apply for the Melody Thomas Chief Fellow Award.
Fiscal Note: $2500, to be awarded as a stipend to the Melody Thomas Senior CSNS Fellow
Assigned Committee(s): All Committees and Representational Sections
TITLE: Evaluation and analysis of non-spine surgeons performing endoscopic spine surgery
Submitted by: Richard Menger MD MPA, Devon LeFever MD, Bharat Guthikonda MD
WHEREAS, there has been a formal position statement from the AANS and CNS regarding arthrodesis of the spine by non-spine surgeons, further investigation is warranted regarding the prevalence and training of non-spine surgeons performing endoscopic spine decompression surgery; and
WHEREAS, neurosurgeons and fellowship-trained orthopedic surgeons undergo specialized indexed board certification training those in other specialties are not specifically trained in surgery of the spine; and
WHEREAS, this can create a misconception among the public as well as devaluation of spine surgery intended CPT codes; and
WHEREAS, there has been recent legislation (HB941) introduced into the State Legislature in Louisiana limiting spine surgery CPT codes to spine surgeons; therefore
BE IT RESOLVED, the CSNS study the public perception, clinical incidence of, and training pipeline for endoscopic spine decompression surgery.
FISCAL NOTE: $100
PRIOR RESOLUTIONS: RESOLUTION IV-2012F Spine Surgery and Scope of Practice
TITLE: Creation of a Publication Advisory for Predatory Journals
Submitted by: Raj S. Lavadi, M.B.B.S., Joseph Raynor Linzey, M.D., M.S., Avi A. Gajjar, Miguel RuizCardozo, M.D., M.P.H., Saad Javeed, M.B.B.S., Sangami Pugazenthi, B.S., Galal A. Elsayed, M.D., John I. Ogunlade, D.O., Brenton Pennicooke, M.D., M.S., Nitin Agarwal, M.D.
WHEREAS, contributing to the literature is of known value even early on in an academic career; and
WHEREAS, aspiring surgeon-scientists may unknowingly engage the services of predatory journals1; therefore
BE IT FURTHER 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
PRIOR RESOLUTIONS: None
Deora H, Tripathi M, Chaurasia B, Grotenhuis JA. Avoiding predatory publishing for early career neurosurgeons: what should you know before you submit? Acta Neurochir (Wien). Jan 2021;163(1):1-8.doi:10.1007/s00701-020-04546-9
TITLE: From Student to Intern: Flattening the Residency Learning Curve
Submitted by: Raj Swaroop Lavadi, M.B.B.S., Joseph Raynor Linzey, M.D., M.S., Avi A. Gajjar, Miguel Ruiz-Cardozo, M.D., M.P.H., Saad Javeed, M.B.B.S., Sangami Pugazenthi, B.S., Jacob K.
Greenberg, M.D., M.S.C.I., Galal A. Elsayed, M.D., Daniel M. Hafez, M.D., Ph.D., Nitin Agarwal, M.D.
WHEREAS, exposure to neurosurgery clinical service, while growing, remains limited during medical school training; and
WHEREAS, the clinical learning curve grows at an exponential rate between medical student rotations and the start of internship1; therefore
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
PRIOR RESOLUTIONS: None
Radwanski RE, Winston G, Younus I, ElJalby M, Yuan M, Oh Y, Gucer SB, Hoffman CE, Stieg PE, Greenfield JP, Pannullo SC. Neurosurgery Training Camp for Sub-Internship Preparation:
Lessons From the Inaugural Course. World Neurosurg. 2019 Jul;127:e707-e716. doi:
I will always remember the moment as if it were yesterday.
It was 7 o’clock in the morning on the fourth day of my neurosurgery rotation. Just hours before, I had the opportunity to participate in the removal of a 10cmx8cm meningioma from a patient’s brain. I was filled with adrenaline and excitement, but also immense fatigue. The day prior, an 85-year-old man with dementia had been transferred to our facility with a chronic subdural hematoma. His hematoma had grown over the last several months and he was now showing evidence of neurological deficits. Soon after his transfer, the decision was made to proceed with surgery.
The chief resident and I scrubbed in, prepped, draped the patient, and prepared to place a burr hole over the patient’s right frontal lobe to drain his blood accumulation. As I stood there with a suction in one hand and gauze in the other, I suddenly heard the attending surgeon whisper into the chief resident’s ear “I think this is a good one for him” as he glanced over at me. Almost immediately the chief resident handed me a scalpel and said, “are you ready for this?”
Maybe it was the fact I had not slept in 30 hours, or perhaps it was the fear that if I said no, I would never be able to operate again, but something came over me in that moment and I immediately answered “yes.” He quickly walked me through the steps of the operation, how to make a proper incision, how to drill a burr hole, and, of course, reminded me not to drill into the patient’s brain. I proceeded through each step methodically, until I picked up the drill with an acorn bit attached. I remember thinking in that moment that this could not be real and what could I have done to earn such a responsibility? Never in a million years did I expect to be doing such a procedure as a third-year medical student. Yet, there I was, holding a drill to a patient’s head, ready to penetrate his skull. It was truly a surreal moment, and many emotions were going through my head. Fortunately, I was able to quickly push aside any self-doubt as I mustered the confidence to carry out the task at hand and before I knew it, I had drilled a burr hole, incised the dura, and inserted a subdural drain.
Though the experience may have lasted less than 15 minutes, it was one I will never forget. Not only did the patient do well and leave the hospital within a few days, but it left a profound, lasting, and humbling effect on me. It reminded me just how critical neurosurgery can be and why it takes many years of painstaking training to become a proficient surgeon. One who is competent in all domains and capable of saving lives without causing undue harm. This remarkable experience only heightened my respect for the specialty of neurosurgery and for the first time ever truly exposed me to the responsibilities that come with being a surgeon. Nonetheless, it simply added fuel to the fire that burns inside of me, pushing me to pursue my dream of one day becoming a neurosurgeon.
September 1 – NY Times – The director of the CDC recommended that the vast majority of Americans receive an updated coronavirus booster shot that perfectly matches the circulating strain of the virus, adding a critical new tool to the country’s arsenal as it tries to blunt an expected wintertime surge of the virus. The decision cleared the way for health workers to give people the redesigned shots within days. Not only will this bivalent booster decrease the likelihood of infection and severe illness and help reduce transmission of the virus it could also decrease the likelihood of developing long Covid. I can’t wait to receive it!
September 5 – Labor Day and end of summer. You wouldn’t know it, given the heat wave.
September 6 – Temperature reached 116 degrees in Sacramento, a new record high. With wildfires burning on both sides of the state, California succeeded in avoiding rolling blackouts for now. Not a small accomplishment.
September 7 – A skeleton, discovered in a cave in Borneo, Indonesia, appears to be evidence of the oldest known surgical amputation that occurred 31000 years ago. The patient, a child, evidently survived the amputation of his left lower leg and eventually died at age 19 or 20. An analysis of the Bornean bones led the team of researchers from Australia to rule out causes like a traumatic accident or animal attack and to conclude it was a “deliberate surgical amputation.” Until now, it was thought that the earlier surgical amputation took place in France 7000 years ago. In the age of hunters and gatherers, these were talented surgeons with some knowledge of anatomy and technical skills.
September 8 – International Literacy Day. At least 771 million young people and adults currently lack basic literacy skills, according to UNESCO.
September 8 – Queen Elizabeth II dies. She was 96 and the longest reigning monarch in Britain. She reigned for seven decades. This is how she looked two days before she died as she prepared to ask Liz Truss to form a new government, replacing Boris Johnson.
September 9 – Governor Kathy Hochul of New York declared a state of emergency because of the growing polio outbreak to better equip health care providers with tools to curb the spread of the sometimes disabling virus before it takes further hold in the state. The Polio vaccine is known to be safe; it makes no sense that some people are not vaccinated.
September 10 – World Suicide Prevention Day.
September 11 – 21 years ago, America’s homeland was attacked by terrorists. It was horrible. 9/11 changed the way we look at the world. This anniversary reminds us of the loss of innocent lives and sacrifice. And it also reminds us of how we came together as a nation.
September 13 – The Los Angeles County Department of Public Health said the first known death from the monkeypox virus in the US occurred in Los Angeles. The US Centers for Disease Control and Prevention said the person had a severely weakened immune system. Not time to panic … yet.
September 14 – CNN – Taking a daily multivitamin might be associated with improved brain function in older adults, a new study says, and the benefit appears to be greater for those with a history of cardiovascular disease. The findings did not surprise the researchers – rather, they were shocked, said Laura Baker, an author of the study and professor of gerontology and geriatric medicine at Wake Forest University North Carolina. The researchers – from the Wake Forest University School of Medicine, in collaboration with Brigham and Women’s Hospital in Boston – analyzed cognitive function in older adults who were assigned to take either a cocoa extract supplement containing flavonoids, a multivitamin, or a placebo every day for three years. I’m buying my multivitamins today.
September 14 – Yvon Chouinard, founder of Patagonia, a private company headquartered in Ventura, CA, transferred ownership of the company to two entities that will ensure that future profits will be used to combat climate change and safeguard some of our planet’s wild places. Mr. and Mrs. Chouinard did not reap any tax benefits at all; in fact, they had to pay 17.5 million dollars in taxes to complete this transaction. Nothing of this nature was ever done before. Patagonia, valued at three billion dollars and whose annual profits are 100 million dollars, may now say: “Earth is our only shareholder.” Great news for the environment and a great example for all capitalists.
September 17 – is Constitution Day, which commemorates the day in 1787 that 39 of the delegates to the Constitutional Convention signed the document in Philadelphia.
“We the People of the United States, in order to form a more perfect Union….”
September 18 – President Biden declared, “We still have a problem with Covid,” but the Covid-19 pandemic is “over.”
September 19 – A study co-authored by the AMA and published in Mayo Clinic Proceedings, the study titled “Changes in Burnout and Satisfaction With Work-Life Integration in Physicians Over the First 2 Years of the COVID-19 Pandemic,” shows that the pandemic magnified long-standing issues that have accelerated the burnout rate. At the end of 2021, nearly 63% of physicians reported symptoms of burnout, up from 38% in 2020. It also found that satisfaction with work-life integration dropped from 46.1% in 2020 to 30.2% in 2021. Meanwhile, average depression scores rose from 49.5% in 2020 to 52.5% in 2021. This modest rise in depression suggests that the burnout increase is primarily due to work-related distress. Physician heal thyself.
September 20 – An advisory group called the U.S. Preventive Services Task Force, comprised of a panel of medical experts appointed by the Department of Health and Human Services, recommended for the first time that doctors screen all adult patients under 65 for anxiety. This highlights the extraordinary stress levels that have plagued the United States since the start of the pandemic.
September 20 – National Voter Registration Day.
The states in which it is easiest to vote: first, Oregon, then Washington, then Vermont, Hawaii, then Colorado, and sixth … California.
September 21 – 73 years ago today, Mao Zedong declared, “We announce the establishment of the People’s Republic of China.”
September 21 – International Day of Peace. “Imagine” that!
September 22 – First day of Autumn. You wouldn’t know it with heat waves affecting most of our Country!
September 23 – CNN- According to a study published in the journal Psychological Science, fetuses create more of a “laughter-face” in the womb when exposed to the flavor of carrots consumed by their mother and create more of a “cry-face” response when exposed to kale. “We decided to do this study to understand more about fetal abilities to taste and smell in the womb,” indicated the lead researcher Beyza Ustun, a postgraduate researcher in the Fetal and Neonatal Research Lab at Durham University in the UK. Does this apply to all green vegetables?
September 26 – Rosh Hashanah, a two-day Jewish celebration of the New Year. It is observed on the first and second days of the Jewish month of Tishrei. This year, it begins on September 26 and ends at sundown on September 27. It is always nice to celebrate joyful new beginnings.
September 26 – On time and perfectly on target, NASA’s Double Asteroid Redirection Test spacecraft slammed into a small asteroid at more than 14,000 miles per hour. NASA’s DART was testing a method to protect the earth from large space rocks in the future. Cheers to another great accomplishment of our space program.
September 27 – Hurricane Ian landed in western Cuba this morning as a category three storm. It is expected to barrel toward the west coast of Florida. Tampa Bay may get its first direct hit from a hurricane since 1921. The results could be devastating. This year’s hurricane season is in full force.
September 28 – Hurricane Ian made landfall along the southwestern coast of Florida as a powerful Category 4. It is one of the strongest hurricanes to make landfall on the west coast of the Florida peninsula and unleashed catastrophic floods and life-threatening storm surges. The storm flooded roads and homes, uprooted trees, sent cars floating in the streets, and left nearly 2.5 million homes and businesses without power.
September 28 – Aaron Judge tied Roger Maris’ single-season American League home run record set in 1961. The Yankees slugger crushed the record-tying 61st home run in the 7th inning against the Toronto Blue Jays.
CSNS Fall Meeting October 7-9, 2022 San Francisco, CA
CNS Annual Meeting October, 9-15, 2022 San Francisco
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 (firstname.lastname@example.org) or fax (916-457-8202).
The assistance of Emily Schile and Dr. Javed Siddiqi in the preparation of this newsletter is acknowledged and appreciated.
• To place a newsletter ad, contact the executive office for complete price list and details.
• Comments can be sent to the editor, Moustapha AbouSamra, M.D., at email@example.com
or to the CANS office firstname.lastname@example.org.
• Past newsletter issues are available on the CANS website at www.cans1.org.
• If you do not wish to receive this newsletter in the future, please E-mail, phone or fax Emily Schile (email@example.com, 916-457-2267 t, 916-457-8202 f) with the word “unsubscribe” in the subject line