Volume 51, Number 9

Inside This Issue

Picture of Joseph Chen, MD

Joseph Chen, MD

CANS President

Cause and Effect

President's Message

On September 8 and 9, a delegation from your California Association of Neurological Surgeons participated and testified at the Council of State Neurosurgical Societies.  The CSNS resolution agenda addressed multiple issues regarding prior authorization, physician unionization, equity, sustainability, and other topics.  As is perennially the case, your delegation plays an outsize role, given the size and energy of its delegation.  This was the last meeting where I was privileged to be our contingent’s head.  I’m grateful that our association has chosen as capable a successor as Dr. Ciara Harraher, who will be picking up the leadership of our delegation next year.

Economic models

As a socioeconomic organization, it is wonderful to see the lively diversity of points of view amongst our newsletter contributors and the very interesting letter from Dr. Bohmfalk last month.  I believe many of the factual points cited by various authors are not debatable. Yet, interpreting the data often will lead to wildly different conclusions depending upon the observer’s local conditions, contextual situation, and biases (the “point of view”).  This is compounded by the situation that economics is not really a “science” in the same way that many other aspects of the social sciences and other disciplines are not scientific in the most rigorous sense.

In my first editorial, I touched on the issues of confirmation bias and mentioned in passing the philosophers of science, Quine and Popper.  The key issues in social and economic studies are similar to the issues when dealing with a difficult clinical diagnosis:

1: Correlation does not imply causation

2: There are underlying phenomena and causal mechanisms that are outside our ability to observe.  That is, we often don’t know what we don’t know.

3: Depending on the circumstances, some similar observed phenomena may be generated by different mechanisms.

4: “Occam’s Razor” and its specific use, “Osler’s Rule” are invalid.  As one of my brilliant mentors likes to state: “Some dogs have both ticks and fleas – they both itch but are different, and just because you have one doesn’t mean you can’t have the other.”

5: Any single or multiple sets of observations may have infinite precise hypotheses as to causation, known as “underdetermination of the empiric data” attributed to W. V. Quine.

6: One can only prove that a hypothesis is false, attributed to Karl Popper.

Unfortunately, much of economic and social science research (along with most medical research) fails at point 1.  Beyond logical process errors, there are issues with agenda-driven or confirmation bias-driven research characterized by selective weeding of data (witness the unjustly maligned phrase “facts and alternative facts”) and unsupported hypotheses presented as settled science. Further, it is likely to be unethical to pursue large-scale scientific experimentation on human populations.  Yet, why is it that there are so many people who are quite sure that they can engineer simple solutions to complex socioeconomic problems for which we have insufficient knowledge of causation?

I should hazard engaging in my own hypothesizing: To ensure a continued intake of capital, the media-supported punditry amplifies a self-validating message to consumers through mass communications for the purpose of maximizing transactional value between advertisers and media outlets.  The more hysteria the message conveys, the more consumer demand there is for that message.  Hence, the simultaneous rise of MSNBC and MAGA.  The republic

has gone through this before, with Pritzkers, Hearsts, anarchists, assassinations of presidents,  W. J. Bryants, Fr. Coughlins, Huey Longs, and more.  We should take comfort that the republic has survived to this date despite apocalyptic predictions to the contrary.

And so thus, there is a dearth of meaningful debate, instead being replaced by sloganeering and ad hominem attacks.  And along with a poor debate, there are poor policy prescriptive.

To return to the debate over healthcare, we have, over a period of nearly 60 years, deep governmental involvement in healthcare with a large number of initiatives and “fixes” aimed at sustainable improvements in access, affordability, and quality in healthcare.  This has resulted in the Rube Goldberg system of institutional processes, controls, and methods of capital flow that describe the current healthcare system and its bureaucratic overseers.  And yet, despite the massive capital expansion of the healthcare ecosystem and legitimate revolutionary improvements in treating certain diseases, neither patients nor healthcare professionals feel that things have improved.  

Is this really a circumstance of the care itself? Could it be a manifestation of something else?  Is the current debate status merely a rehashing of certain set biases dependent upon commonly held assumptions masquerading as facts?  So, to return to the prescriptive outlined by our editorialist and letter writer:  Is “Medicare for All” going to be a solution any better than what has come before?  Will “Medicare for All” eventually become “VA for All”?  Or is it time to deregulate?

About 25 years ago, I was interested in surgical approaches to chronic “central pain.”  At the time, there was great interest in the work of Nguyen and Keravel, among others, regarding using motor cortex stimulation.  Initial reports were highly encouraging, with excellent improvements in pain.  Yet, long-term results were poor due to issues of plasticity.  Looking into the history of pain procedures, it seemed this was par for the course.  Whether it was peripheral rhizotomies, cordotomies, medial thalamotomies, cortical lesions/resections, or stimulation of any number of targets, initial results were followed by recurrences. In the long run, the typical ⅓ better, ⅓ the same, and ⅓ worse would inevitably re-establish itself, and patients would be as miserable as they were before on average.  One of my brilliant mentors always said, “The brain is a sneaky bastard.”

I think the same thing happens with the regulatory management of healthcare.  Humans are sneaky and will eventually find loopholes.  Such is the fundamental feature of human intelligence and behavior.  A treadmill of increasingly specific regulation is bound to create more loopholes and expand bureaucratic controls that consume precious healthcare dollars and negatively affect the quality of care and advancement of science and technology in medicine.

One may conclude that what is therefore required is a complete examination and rebuilding of the system.  Yet, while internally consistent, all systems conceived by humans cannot deal with the human element, the foibles of the Human Condition, and the diversity and noise that makes it special.

Aside from the debate on policy prescriptive, perhaps the one thing that we all can do is accept that our knowledge of cause and effect within the social and political realm is murky, contrary to the concrete certainty and moral absolutism of the punditry.  It is, therefore, time to stop picking sides per se to be able to have a greater appreciation of the Human Condition in all its power and frailty.

Quote of the Month

Difficulties strengthen the mind as labor does the body.
 – Seneca

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Corner

You may have noticed some changes in our newsletter format last month.

The changes were prompted by a direction from President Chen to update/modernize our newsletter – the newsletter has never been updated since CANS started publishing a monthly edition under the editorial direction of our late editor, Randy Smith. It may be of historical interest to you to know that the newsletter used to be mailed by US mail, but a few years ago, and for obvious reasons, CANS joined the modern world and started exclusively e-mailing a PDF version. We also publish a web version.

I want to point out three prominent changes in the PDF version that you receive in your email on the last day of every month:

  • The newsletter is printed in two columns for ease of reading longer articles.
  • The font is more modern and cleaner looking.
  • The color has changed from “power” red to an “optimistic and hopeful” green. Since neurosurgeons are eternal optimists, and since CANS is a strong and vibrant association, I felt that green reflects our optimism and hope for a great, successful, and innovative future for all neurosurgeons in the Golden State.

Some changes will be noted in the web version also. However, the one-column appearance will not change.

I hope you will enjoy the changes, but please let me know if you don’t. Be critical.

I also want to bring to your attention two essays that touch on who we are as neurosurgeons and humans. The first is by our Resident Consultant, John Hyunkuk Choi, and the second is by Ian Ross, who writes a bimonthly column, “From the Trenches.”

Included in this issue are all the regular columns.

As always, my editorial committee and I welcome all suggestions and criticism. Please e-mail me at or call me at 805-701-7007 if you prefer to discuss any issue directly with me.

I hope you will enjoy this issue.

Photo of the month

A trail at Harmon Canyon, Ventura, CA
The photo was taken by Moustapha AbouSamra, MD, on July 3, 2023, at 11: 40 AM. iPhone 13 Pro.

Picture of Anthony M DiGiorgio, DO

Anthony M DiGiorgio, DO


Academic Practice Corner

“When a metric becomes a target, it ceases to be a good metric.” – Goodhart’s Law
“Conflicting plans flatten the human being.” – Alexander Solzhenitsyn

For more of my thoughts on Quality Metrics, please see my latest piece in JAMA and my upcoming talk at the Western Neurosurgical Society Meeting.

Orwell’s 1984 depicts an omnipotent government exerting control over every facet of human life, from thoughts to words. Although healthcare isn’t a mirror of this dystopia, there are alarming resemblances. The drive to centralize and standardize healthcare through an assertive implementation of quality metrics resembles Orwell’s Big Brother. Suddenly, factors like readmission rates, chemical DVT prophylaxis, coding queries, and HCAHPS overshadow the once-sacred physician-patient relationship.

Good intentions paved our path here. Policymakers believed they could enhance healthcare quality by quantifying, standardizing, and controlling it through a centralized entity: CMS. Sadly, this implementation underscores the pitfalls of overzealous central planning.

While quality measurement is essential—every industry relies on internal metrics—the aggressive incentivization of arbitrary metrics from the top damages our healthcare sector. This top-down approach embodies central planning, dooming it to failure. As F.A. Hayek aptly stated, “The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.”

Consider the Hospital Readmission Reduction Program—central planners aiming to reduce hospital readmissions tethered millions of dollars to this metric’s achievement. Predictably, readmissions decreased. Yet, mortality rates spiked. Most patients are readmitted because they need further care, a fact overlooked by the planners.

Nevertheless, CMS continues to invest in the quality metrics behemoth. Taxpayers have funded $1.3 billion for metric development, culminating in a CMS catalog of over 2,200 metrics. As a friend insightfully noted during a testimony to the House of Representatives Committee on Small Business, CMS must adopt a “quality diet.” The Government Accountability Office concurs.

This bloated metric-focused system showcases regulatory capture at its finest. A select few receive government contracts, regulatory and industry personnel rotate roles regularly, and some form consultancy groups, navigating the complexities they once set. Hospital administration burgeons, diverting resources from patient care, all while complying with a sea of metrics, half of which bear no clinical relevance.

These administrative expenditures are tangible. Independent physician practices shell out billions annually for metric reporting. An average 160-bed community hospital hires nearly five full-time employees just for quality metric reporting. Larger hospitals need over 100,000 person-hours each year to report metrics. Given California’s new $25 hourly minimum wage for healthcare workers, the ballooning costs of quality metric reporting are evident.

When we forgo market forces in favor of central planning, the ensuing bureaucracy ironically devours the resources intended for the core industry. Hospitals strategically manipulate the system since enhancing metrics often offers a better return on investment than genuinely improving care. This environment suppresses innovation as institutions become ensnared within rigid frameworks, making metrics the end rather than a mere tool for enhancement.

In the drive for quality, the core essence of healthcare—the patient’s well-being—must remain paramount. Quality metrics, while crucial, should serve as guideposts, not as unyielding mandates. It’s time for a recalibrated approach that harmoniously integrates metrics with the genuine needs of patients and the expertise of healthcare professionals. As we tread this path, let’s be wary of central planning’s snares, ensuring that in our quest for numbers, we don’t lose sight of the human heartbeat at the center of it all.

From CMA President

Dear friends and colleagues,

I am pleased to let you know that the California Medical Association and the Coalition to Protect Access to Care, a broad and diverse group of health care organizations, filed a statewide ballot initiative today with the California Attorney General’s office to expand access to health care for millions of Californians. Our goal is to qualify the measure for the November 2024 ballot.

The initiative builds on the historic investment that the Governor and Legislature made earlier this year to dedicate additional funding to the Medi-Cal program. The Protect Access to Healthcare Initiative is critical to ensuring the accessibility and affordability of health care services for all Californians, as well as recognizing the critical role that physicians play in achieving this vision.

Now more than ever, it is important that the 15 million Californians who rely on Medi-Cal for health coverage have access to care. Equally as important is ensuring that emergency room wait times are reduced for ALL Californians, that there is more funding for mental health care across the state and that we help reduce the cost of important prescription drugs.

Specifically, the initiative will:

Make the Medi-Cal provider rate increases that were included in the 2023-24 state budget deal permanent for generations to come;

Expand access to health care for Medi-Cal patients, which will result in reduced emergency rooms usage, and shortening wait times for all Californians;

Increase funding for mental health programs that care for children and Medi-Cal patients; and

Enable California to manufacture its own insulin and other prescription drugs to increase affordability for Californians.

In the coming months, we will be working closely with the other members of the coalition to gather the hundreds of thousands of signatures needed for the initiative to be placed on the ballot.

Your support and engagement will be invaluable in driving this initiative forward. In the coming weeks and months, we will reach out to you with opportunities to assist in outreach and education efforts and keep you updated on the progress of this initiative.

In the meantime, please visit for more information.

As always, should you have any questions, suggestions, or ideas, please do not hesitate to reach out.

Best wishes for a healthy future,

Donaldo M. Hernandez, M.D., FACP
President, California Medical Association

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

Project Phoenix and Amazing Grace

Changing Times

Amazing grace how sweet the sound
That saved a wretch like me
I once was lost, but now I’m found
Was blind but now I see
-John Newton

Several years ago, after the loss of our home to the Thomas Fire, I wrote in these pages an essay titled “Amazing Grace.” In it, I described four people “who act in a Godly way: people who are kind, generous, empathetic, and loving. People who are simply “good.”

In this essay, I write about another person who fits perfectly in this category. Pamela Price Klebaum is an acquaintance and a neighbor; our sons played sports together long ago. She is an accomplished woman–a lawyer, an editor, a college professor, and now an artist whose preferred medium is glass. She likes glass because “It readily offers the means to artistically express the dualities of fragility and strength, clarity and opacity, movement, and stasis.”

Pam’s website is

Pam and her husband Noel did not lose their home in the Thomas Fire, but many neighbors did, including us. But they felt devastated.

To honor those who lost their homes, Pam created “Project Phoenix.” She made a small glass house for each neighbor who rebuilt. “Each glass house is unique; all are about the same size and can be held comfortably in the hands.”

Examples of Glass Houses

Details of a Glass House

Pam, who walks up and down the streets of our hilly neighborhood for exercise, completed her final Project Phoenix House in August 2023.  House number 112 is ours; it is much larger than the others, perhaps because it took us longer to rebuild! We received it on September 8 with a beautiful handwritten note indicating that she tried to “capture the pitch of your garage, and the horizontal lines suggest beams – of support.”

Our Glass House, Project Phoenix # 112

In describing this project on her website, Pam concludes that finishing this emotional project felt “like a celebration.” And then she added, “Amazing Grace.”

Amazing Grace, indeed!

From a religious perspective, “Grace” is given freely to humans; they don’t need to earn it. In fact, some believe that humans cannot be good enough to earn it. It is a veritable miracle.

What kind of miracle?

Long ago, during a visit to Ventura and in a private conversation with the late Rabbi Kushner, the author of “When Bad Things Happen to Good People,” I asked him if he believed in miracles. Of course, I do was his response. Then he quickly added: “Parting the Red Sea is not a miracle but a special effect. A marriage surviving the death of a child is a real miracle!”

Surviving the Thomas Fire was indeed a real miracle, and having people like Pam Klebaum in our lives is a true manifestation of the Grace of God!

FINAL – CSNS Resolutions 2023F


Title: Inclusion of Radiation Safety Training for New Neurosurgery Interns – Adopted as Amended (with AANS amendment)

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS develop a standardized module (eligible for CME) to teach principles of radiation safety in neurosurgery with the goal that the Society of Neurosurgeons include this module in Neurosurgery Intern Bootcamp.

Fiscal note: (zero)


Title: National MSSIC Initiative Promoted by Organized Neurosurgery

Action: Rejected

BE IT RESOLVED, that our National organizations (the AANS and CNS) work

with the Washington committee to seek federal and CMS support for a National

program mirroring that of MSSIC to reduce spine care cost and improve patient

outcomes; and

BE IT FURTHER RESOLVED, that this program promote physician incentive

payment for quality improvement.

Financial cost: 0


Title: A Call to Study the Neurosurgical Residency Application Arms Race

Action: Rejected

BE IT RESOLVED, that the CSNS studies and creates a white paper on the nature and effects of extracurricular achievement pressures on applicants to neurosurgical residencies.


Title: A Call for a New Position Statement From Organized Neurosurgery on Gun Violence

Action: Rejected

BE IT RESOLVED, that the CSNS urges the CNS and AANS to prepare a joint position statement, with policy recommendations, on the toll of gun violence and in support of gun control laws at least in keeping with and/or exceeding those of the ACS, the AMA, and the ATS.

Fiscal note: none


Title: A Call to Relocate Certain Neurosurgical Meetings and Courses

Action: Rejected

BE IT RESOLVED, that the CSNS calls on its parent bodies to consider

refraining from holding any meeting or course in states that are legislating policies

antithetical to accepted public health conduct and principles.


Title: Unions in Neurosurgery

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS surveys neurosurgeons to determine their understanding and interest in unionization at the attending level; and

BE IT FURTHER RESOLVED, that a white paper be written describing the reality of how unionization affects other industries (airline, railroad) and could affect neurosurgery practice in the future.



Title: Naming of CSNS Resident Fellowship in Memory of Dr. David Jimenez

Action: Adopted Amended Resolution

BE IT RESOLVED, the one of the CSNS Resident Fellowship for the Southwest Quadrant be called, “David Jimenez CSNS Resident Socioeconomic Fellowship” in his memory.


Title: Improving Communication on CSNS Resolutions

Action: Adopted

BE IT RESOLVED, that the CSNS changes the format of resolutions to include a separate section titled “Corresponding Author(s)” that must include at least one but not more than two of the authors so as to facilitate ease of communication; and

BE IT FURTHER RESOLVED, that the email address/addresses for the Corresponding Author(s) are listed immediately after their name(s) so that correspondence regarding any resolution can be easily and appropriately routed by all members/committees to facilitate future work on the resolutions.



Title: AANS and CNS should support the NERVES Society to increase and maintain membership productive to Neurosurgical success

Action: Adopt Amended Resolution

BE IT RESOLVED, the CSNS ask the boards of the AANS and CNS to participate in broadcasting the value of the NERVES Society; and

BE IT FURTHER RESOLVED, the CSNS assist the AANS and CNS membership to gain a better understanding in the value and encourage neurosurgical practices of all varieties to join and participate in NERVES.

Fiscal note: 0


Title: Best practices for ergonomic and continuity of neurosurgery practice for the peri- partum neurosurgeon

Action: Adopted

BE IT RESOLVED, the CSNS distribute a survey to assess what challenges are encountered by peri-partum neurosurgeons and institutionally-based steps that have been taken to ensure ergonomic and continued practice; and

BE IT FURTHER RESOLVED, the results of prior survey be presented to CSNS to inform the creation of a best practices resource; and

BE IT THEREFORE RESOLVED, the CSNS ask its parent bodies (AANS/CNS) to collaborate with the SNS and the ACGME to publish best practices regarding ergonomics and continuity of neurosurgical practice and for peri-partum neurosurgeons in training and clinical practice.

Fiscal Note: $100


Title: Adding an option on the CSNS website to post ideas and encourage collaboration

Action: Adopted Amended Resolution

BE IT RESOLVED, the CSNS allow members and resident fellows to post resolution ideas on the CSNS website with the goal of enhancing collaboration and decreasing duplication in the resolution composition process.

RESOLUTION XII-2023F – Adopted amended resolution

Title: Collective Bargaining Efforts of Resident Physicians and Effects on Neurosurgical Residency Training

Action: Adopted Amended Resolution

BE IT RESOLVED, the CSNS survey neurosurgical residents on their perspectives on the potential effects of collective bargaining efforts on resident education quality, wellbeing, and productivity to identify the benefits and drawbacks of such efforts.



Title: Understanding and Re-Evaluating the Urgency to Board Certification

Action: Adopted

BE IT RESOLVED the CSNS, alongside parental bodies, partner with the ABNS

to study number of neurosurgeons and the circumstances under which applying for

deferred board certification beyond 3 years has occurred.

Fiscal note: None


Title: Assessment of Regulatory Obstacles for Neurosurgical Training Programs in the United States

Action: Rejected

BE IT RESOLVED, the CSNS ask the ACGME de-identified results of ACGME evaluations for all neurosurgical residency programs that it accredits in the United States, including all citations, designated areas for improvement, available residency positions, and program closures for the last 20 years.

BE IT FURTHER RESOLVED, the results be presented to CSNS and offered for presentation to the SNS detailing commonalities amongst programs in challenges achieving accreditation and develop solutions and curriculum to address these challenges at a national level, in an effort to support workforce training maintenance and expansion.

Fiscal Note: $100


Title: Neurosurgery’s Commitment to Climate Change Mitigation

Action: Rejected

BE IT RESOLVED, the CSNS request that its parent bodies (AANS/CNS) adopt a formal position statement or endorse that of the AMA/ACS, recognizing the effect of climate change on neurosurgical care quality and access in the United States, recognizing climate change as a public health emergency, and further encouraging research and committing resources to the study of climate change’s effect on neurosurgical care, the economic impact of climate change on neurosurgical care, the provision of neurosurgical care through climate crises, and supporting the discussion, research, and publication of these topics; and

BE IT FURTHER RESOLVED, the CSNS develop and distribute a survey of currently practicing neurosurgeons and current neurosurgical trainees to assess their opinion on current efforts to minimize the impact of surgical services on

climate change and their overall opinions on the impact of medicine on climate change; and

BE IT FURTHER RESOLVED, the results of this survey be presented to the CSNS and compiled for publication to better define the priorities of our members in relation to climate change mitigation; and

BE IT FURTHER RESOLVED, CSNS ask its parent bodies, AANS and CNS, to instruct the Washington committee to include sustainable neurosurgery in its biennial pulse survey, including advocacy for the use of sustainable and reusable medical devices, and to consider its addition to the legislative agenda priority list for 2024.

Fiscal Note: $50


Title: Assessing the Value of Mid-Level Providers in Neurosurgery Care and Productivity

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS survey current practice environments regarding the utilization of APPs and impact on neurosurgical care and productivity, as well as, billing methods and salary models. Additionally, survey of relative impacts of APPs on team dynamics and physician burn out reduction should be assessed.

Fiscal note: None


Title: The Hoover Resolution: Evaluating and Addressing Physical Threats to Neurosurgeon Safety & Mortality

Action: Adopted Amended Resolution

bodies, update the recent review of neurosurgeons affected by workplace physical violence or homicide.


Title: Expansion of the CSNS Diversity Task Force, creation of an ad hoc committee, and formal evaluation of the relationship between diversity and patient safety

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS request an update from the CSNS Diversity Task-Force resolution authors as well as its five assigned committees with reports of specific ongoing DEI initiatives and upcoming efforts.

Fiscal note: None


Title: Assessing the impact on patient safety from delays and denials in prior authorization for surgical procedures

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS work to identify the volume and percentage of neurosurgical cases that are delayed or denied by prior authorization requirements, in order to evaluate the impact on patient outcomes; and

BE IT FURTHER RESOLVED that the CSNS release a white paper to publicize these findings and support collaborative efforts in influencing the conduct of payers in the context of prior authorization for neurosurgical procedures.

Fiscal Note: None


Title: Assessment of the social media utilization of neurosurgical practitioners

Action: Adopted

BE IT RESOLVED that the CSNS research neurosurgery-related content on social media platforms, via systematic review of the most popular neurosurgery content found on the top social media platforms in order to characterize current utilization, as well as research the relevant laws and ethical perspectives of sharing patient- and health-related information in such a forum; and

BE IT FURTHER RESOLVED that based on that research, the CSNS, along with the help of parent organizations and legal counsel, generate a white paper to help inform neurosurgeons regarding legal and ethical concerns related to use of patient information and neurosurgical practice on social media.

Fiscal note: review of white paper by parent organization legal counsel


Title: Observerships for Medical Students without a Home Program

Action: Rejected

BE IT RESOLVED, that the CSNS collaborates with the CNS Foundation to develop a funded clinical observership exclusive for medical students without a home program to prepare them for sub-internships.




Title: Current State of Ambulatory Spine Centers

Action: Adopted Amended Resolution

BE IT RESOLVED, that the CSNS circulates a survey of neurosurgery training programs to understand the involvement of residents in ambulatory surgery centers.



Title: Neurosurgical Medical Director Survey

Action: Adopted

BE IT RESOLVED, the CSNS survey the neurosurgical community for better understanding of : 1. the population of Neurosurgical Medical Directors in the US currently, 2. the differences in the responsibilities and job descriptions in various practice settings (e.g. employed, academic and private, physician groups and healthcare systems), 3. contracting and compensation, and 4. the educational needs of Neurosurgical Medical Directors, and

BE IT FURTHER RESOLVED, the survey results be distributed to the participants to provide information that can support their negotiations with hospitals and development of their programs, and

BE IT FURTHER RESOLVED, the results of this survey guide CSNS and the Medical Directors Representative Section to address the needs of the Neurosurgical Medical Directors community in terms of providing educational material and support.


Title: Ongoing Collaboration Between The Council of State Neurosurgical Societies and Respective State Societies to Understand and Improve Neurosurgeon Wellness Across All Professional Stages

Action: Rejected

BE IT RESOLVED, that the Council of State Neurosurgical Societies have an ongoing partnership with the many neurosurgical state societies to spearhead a collaborative initiative to examine, promote, and support the wellbeing of neurosurgeons at all stages of their careers

Picture of Ian Ross, MD

Ian Ross, MD

A Perfect Performance, Every Time

From the Trenches

A new anesthesiologist is in the room. He is some sort of genius with a Ph.D. and a lab. Either he wants to make a little more money or “keep his hand in it.” Good grief. The last guy we had like this had been part of a start-up and made a pile before going to medical school. I suppose that he, too, was smarter than me about money, at least. But slow as molasses.

We are not exactly off to the races with my Friday afternoon case. It has already been delayed … by a combination of this gas man and a newly minted orthopod who booked a case for two hours that took twice as long—just one of those days.

The patient is a successful singer/songwriter. You would think he would take care of his body, but he has been ignoring a rotten tooth for quite some time. He showed up in the ED after having had a seizure. He had been having headaches for weeks. Surprise. He has a brain abscess.

I am flattered when successful people let me drill holes in their heads. It is a form of approbation, for sure. But then again, this guy was stupid enough to ignore the tooth and the headaches for quite some time. So, should I have been impressed that he was allowing me to operate on him?

Finally, the operation starts. Nothing goes right. The guy from the company that supports the image guidance hardware/software does not know his stuff, and it takes a while to get a good registration. Luckily, I had done enough of these cases back in the day before we had any image guidance equipment, so I am not nervous. I know where to make the incision, and I am certain we will be OK, even if the image guidance is not. I cut a larger-than-normal craniotomy so that I could bring in an ultrasound device and confirm where the abscess was before I cut into the brain.

The brain is more swollen than I anticipated. Stupid me, I did not make sure that the patient was on steroids and antibiotics before the case. The brain starts to herniate out. To make my not-so-swell day even worse, I have Mr. FM-radio announcer/scrub tech in the background, muttering unctuous idiocies into my ear while I do all this. The neophyte anesthesiologist is too nervous to play music, at least not anything I can hear. Thank God for small mercies. Perhaps he heard, I do not like music in the OR.

Fast forward, I find the abscess, get a bunch of material out of the bloody/pus-filled mess, biopsy the adjacent brain, and run down to pathology with the specimen to confirm that it is not a tumor. I then wash out the cavity, force the brain back in, and tack together the dura as best I can. I push the bone flap into place, screw it down, close the wound and mutter a prayer. He ends up doing great, going home in a couple of days with a PIC line for IV antibiotics. One of my mentors once said that sometimes you walk through a field of shit and end up smelling like a rose.

Cathy and I have friends, Akiko and Nathan, who are professional musicians. They both play the violin at a very high level. Nathan recently was booked as the soloist for a concerto at the Hollywood Bowl. He was going to be performing in front of over 10,000 people, with the LA Phil backing him up. We were in the audience (I do like music, just not in the OR). At the intermission of the show, before the concerto began, I bumped into Akiko. She was very nervous. And I guess so was her husband, Nathan. Things do not always go perfectly for professional musicians, either.

The performers at the Bowl are projected onto big screens; you can see them up close, like rock stars at a concert. Nathan is a pro, and it showed. His sound seemed flawless, and he was able to project an appropriate balance of satisfaction and nonchalance. After the show, he suggested it had just been another day at the office. Right. He had been up there for over 40 minutes, playing a very complicated and fast baroque piece of music without a note in front of him.

Where I come from, the operating room is referred to as the operating theatre. It is where surgery is performed. But I think that the analogy should stop there. How the performance goes for us surgeons does not really matter so long as the result is good. I have heard horror stories of soloists freezing up with stage fright before a performance or of not being able to get through the show completely. Can you imagine that happening in the OR? I guess that Nathan was just doing his job. But he did not mess up, and I was impressed.

Sure, a musical performance disappears into the ether once over. Good or bad, it will be largely forgotten soon enough. We own the outcome of our labors for much longer periods of time.

We never get to enjoy ecstatic applause. We perform for very small audiences. Few people understand exactly what we do. But I like it that way.

Picture of Brian Gantwerker, MD

Brian Gantwerker, MD

Art Imitates Life Imitates Art

Private Practice Corner

Life imitates Art far more than Art imitates Life.

Oscar Wilde, “The Decay of Lying: A Protest,” 1889

The popular YouTuber Dr. Will Flanary, aka Dr. Glaucomflocken (, has been a medical social media sphere staple for several years.  He has been at the AANS and, most recently, the CNS.  I met him briefly while he was in Los Angeles and had a sufficiently awkward interaction, so I am certain he will never come to CANS.  Sorry.  He parodies most of our medical situations:  the awkward interaction with the new hospital administrator, the jock from ortho, the bookish neurologist, and my favorite – the pathological neurosurgeon.  He loves picking on us.  With a much-needed snicker, I have watched a LOT of his videos.  His most recent video series was “30 Days of Healthcare.”  It is a litany of familiar bureaucratic atrocities committed on a daily basis in healthcare. 

The most recent can be found here:

It speaks of “UnitedHealthcare For All.”  United Healthcare.  The “Sarlacc” of the current healthcare landscape.  Sarlacc was the desert-dwelling living mouth in ‘Return of the Jedi’, where the villain of the movie’s first half, Jabba the Hut, tossed his enemies to “be slowly digested over 1,000 years.”  A gaping, toothed maw that drew in and consumed everything.  United Healthcare.  From the United Healthcare Group’s own site: “Full year 2022 earnings from operations were $28.4 billion, an increase of 19%, with strong contributions from Optum and UnitedHealthcare. Earnings per share grew 17% compared to last year. The medical care ratio at 82.0% for the full year 2022 and 82.8% for the fourth quarter was consistent with the company’s recent Investor Conference outlook.” And from this year – courtesy of Forbes:  UnitedHealth Group Reports $4.7 Billion Profit As Optum And Health Plans Maintain Momentum (

No healthcare entity – physician group or hospital system- can report $28.4B in earnings.  Over the past five years, UHG has consumed physician practices, now employing over 70,0000 physicians.  It is the largest single employer of physicians under their shell company of Optum.  They also own home healthcare companies now, coding sources, revenue recoupment entities that audit physician and hospital claims, surgery centers, pharmacies, Medicare Advantage plans, and more.  A shocking number of people also float back and forth between CMS/HHS and the UHG sphere.  I myself filed a FOIA request to discern who in HHS or CMS worked for UHG.  I have been stonewalled, with HHS saying they don’t understand my request.  The query is ongoing, and I plan on bringing this up with my congressman, whose office I visit this coming Friday. 

Judging from the posture HHS has taken on the No Surprises Act (NSA), applying the law as they see fit by setting the qualified payment amount (QPA) to benefit the insurers unilaterally.  The Texas Medical Board (TMB) has filed lawsuits against HHS for unfair and inappropriate enforcement of the law.  TMB has prevailed in each of the three suits.  The portal where physicians submit their disputed claims has been summarily shut down.  Prior to this, HHS raised the fee to enter arbitration from around $50 to over $300 per instance.  When asked about their behavior by a congressional oversight committee, California’s own Xavier Becerra, now head of HHS, said, without evidence, most of the THOUSANDS of physician claims “were frivolous.”  To date, he has taken a very divisive and dismissive stance, even telling NPR that physicians need to “stop gouging patients.”

When asked directly, Dr. Ami Berra (D-CA, 6th district) on a Zoom call why HHS seems to be intent on not applying the bipartisan law as written (which he was instrumental in crafting), shrugged and responded he had no idea why Secretary Becerra seems to be intent on rewriting the law in a way he sees fit.  Regardless of one’s political affiliation, it is not hard to see where the chips lie.  The most recent hearing on the NSA on the Hill this week was NOT attended by Secretary Becerra, who is hobnobbing at the UN instead. 

So, if UHG is the intended recipient of the healthcare keys, we will have a new level of danger to the practice of medicine and our patients.  This week, over 300 of our colleagues from AAOS lobbied on the hill in a very strong show of support.  Both private practice and employed/academic physicians attended.  Certainly, this is an exemplar of giving a damn.

The perception of accountability always seems to fall flat when you finally “follow the money” to the decidedly biased decision created in the bureaucratic silo of HSS and CMS, as just when we

figure out the connections, we get shut down.  This can manifest in FOIA requests that go unanswered, poor or no follow-up from your congressperson, and tweets calling out these medical vampires that go unnoticed and unshared.  While the singularity approaching a single-payer system (most likely owned and administered by UHG) is an existential threat and will further destabilize our medical system, all is not lost.  There are possible things that we can do. 

Despite a small number of medical influencers whose following exceeds most small countries, they do not want to stir the pot to advocate for patients or their colleagues. In fact, many of them assume a persona for fear of retribution from their institutions or employers.  They are actually uniquely positioned by their anonymity to do something about it.  Cutting through the din and interference from insurers and the hospital lobby is crucial.  Taking back the narrative stating physician fees drive cost is salient to change.  If so, why are costs still rising AFTER cutting reimbursements by over 20% over the past ten years? Being such a huge cost driver, why do we keep losing those savings?  Andrew Witty, CEO of UHG, took home 23.8 million last year.  (

No matter how busy, I don’t know any neurosurgeon still working clinically who made anywhere near this amount. 

We need to manifest caring in the most popular medical influencers.  Sadly, Dr. Flanary is in the minority of medical influencers.  Most of the social media clout-chasing landscape is rife with those who really are in it for themselves.  Far be it from me or anyone to rag on these folks for getting clicks and likes, but wouldn’t it be smarter to tweet about important issues that affect our specialty occasionally? 

If one has a platform, use it.  The bully pulpit is no pulpit if all you do is bully people into following you by rage farming.  There is no grand intervener to save us.  At the end of the day, we have to work our individual niches and give a little time to draw attention to the Great Hypocrisy threatening the independence of all physicians.  Because if we don’t give a crap, laypeople certainly will not. 


Updates for the 2023 CMA House of Delegates

Dear Colleagues:

The 152nd Annual Session of the California Medical Association (CMA) House of Delegates (HOD) will convene October 21-22, 2023, at the JW Marriott Los Angeles L.A. LIVE in downtown Los Angeles. As you plan your participation in the meeting, your Speaker requests that you carefully review the following information.


Please take note of these important upcoming deadlines! Details for each are included below.

Sept. 12: If you would like to honor a CMA member who passed away since last HOD, please submit an “in memoriam” resolution and photo to Navdeep Dhaliwal.

Sept. 27: Reserve a room through CMA’s room block at the JW Marriott Los Angeles L.A. LIVE in downtown Los Angeles.

ASAP: Reservations for childcare are required for planning purposes, as spaces are limited.

ASAP: Tickets for the Presidential Gala are almost sold out! To purchase tickets, please contact Jennifer Moller.


The draft schedule of the weekend’s major events and activities is posted on the HOD website and will be continuously updated until we get to House. Please check with your delegation coordinator for information about your own delegation’s caucus meetings and meal functions.

New Delegate Orientation

New delegates and alternates should plan on attending the New Delegate Orientation, which will be held virtually on Tuesday, Oct. 17, from 6:30 to 7:30 p.m. Click here to register now.

HOD in-person registration will be open starting Friday afternoon, Oct. 20, for any attendee who arrives early. We highly suggest checking in at Registration in advance of the inevitable rush on Saturday morning.

Sessions of this year’s House of Delegates are tentatively scheduled as follows:

Saturday, Oct. 21: 8 to 11:30 a.m. (Session 1)
Saturday, Oct. 21: 1 to 5 p.m. (Session 2)
Sunday, Oct. 22: 8 to 11:30 a.m. (Session 3)
Sunday, Oct. 22: 1 to 4 p.m. (Session 4)

In addition to conducting various elections, hearing from leaders in organized medicine, honoring members with awards and other business, the weekend will consist of education and debate on major issues, spread across the four general sessions of the

House. We hope to adjourn no later than 4 p.m. on Sunday, Oct. 22.


CMA has secured a block of guest rooms reserved at the JW Marriott Los Angeles L.A. LIVE at a special rate. Reservations may be made by clicking here. Delegates are strongly advised to book early, since the room block is limited and the discounted rate may no longer be offered after the block has filled. The deadline for the discounted rate is Sept. 27. If you are unable to reserve a room through our room block, please continue to check the website as rooms become available.

For housing questions, contact Marriott Hotel Reservations at (213) 765-8600 or toll free at (877) 622-3056. Please note that all housing questions are handled through the JW Marriott, not through CMA staff. For questions about whether your hotel expenses are eligible for reimbursement, please confirm with your delegation coordinator, as expense policies vary from delegation to delegation.


CMA has partnered with ACCENT on Children’s Arrangements, Inc., to offer half- and full-day services on Saturday and Sunday, October 21-22, as well as an evening slot for parents who would like to have childcare during the Gala. Parents are responsible for breakfast and lunch; however, snacks will be provided. In addition to childcare, there are numerous activities around the Los Angeles area to enjoy.

Childcare Schedule
Saturday, October 21: 7:30 a.m. to 5:30 p.m.
Saturday, October 21: 5:30-10:30 p.m.
Sunday, October 22: 7:30 a.m. to 4 p.m.

All ACCENT staff members have full background checks and are CPR and first aid certified. All children ages 6 months to 12 years are welcome to participate, with age-specific activities planned for them. There is no costs to sign up, but reservations are required for planning purposes as spaces are limited. Thanks to The Doctors Company for sponsoring this service!


All delegates and alternate delegates will be pre-registered for the meeting based on delegation rosters submitted to CMA. Delegates and alternates should be duly elected or appointed per the method or manner prescribed to each delegation in the CMA Bylaws. If you have questions about if you are recorded as a delegate or alternate for 2023, please contact Dya Carranza.

CMA PRESIDENTIAL GALA (Almost sold out!)

Tickets for CMA’s Presidential Gala are selling quickly! The Gala will take place the evening of Saturday, Oct. 21, and will include dinner, entertainment and dancing, in celebration of incoming CMA President Tanya Spirtos, M.D. To purchase tickets, please contact Jennifer Moller.


Each year during HOD, 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 last HOD, please submit an “in memoriam” resolution and photo to Navdeep Dhaliwal by Sept. 12. A sample template is available if needed. Thank you for your assistance in honoring our dedicated CMA member physicians.

We look forward to a productive 152nd Annual Session – and we hope you also take time to enjoy your stay in Los Angeles. We also wish to encourage any and all of you to contact us, through your delegation chairs or directly, with questions, concerns or recommendations regarding this year’s House!

Jack Chou, M.D.
Speaker of the House
Tel: (626) 851-6345
Fax: (626) 851-5661

Picture of John Hyunkuk Choi CANS Resident Consultant PGY5 – Stanford

John Hyunkuk Choi CANS Resident Consultant PGY5 – Stanford

From Classrooms to Craniotomies

Residents Corner

Two years ago, I had a meal with an attending who was about to retire from a busy neurosurgical practice. A mentor and role model, he had been seminal in my decision to pursue neurosurgery. There came a point in our meal when the discussion of what he would do after retirement came up, and he described how he had plans to start a business, explore some local tenens jobs, and focus on mentorship roles; he then said something I could not quite understand at the time—once a neurosurgeon, always a neurosurgeon. Though he was moving away from practicing clinical neurosurgery, the job had become integral to his identity.

I had a similar mindset when I first entered residency—I came in as a former high school teacher. The lessons and memories from teaching at an underprivileged high school in south Los Angeles had been so formative in developing my sense of self that my

medical school experiences seemed bland in comparison. On my first day teaching, I stood alone in front of six classes, each with about 36 students; in some of my classes, I was barely three years older than the oldest students. By the end of the day, my laptop was stolen, my car was keyed as part of a gang initiation, and one of my co-teachers, who had also started that day, cried and hid in my room during our lunch break. On my first day in medical school, we reviewed a course syllabus.

And then, I entered residency. From that very first hour that I navigated through the EMR and started reading about my patients, a similar apprehensive feeling came about me as I suddenly felt a new weight of responsibility. Just as I had felt about my students when I was a teacher, these were now my patients as a doctor. In a way, I relished it—the potential for meaningful impact re-ignited a passion that had been buried under institutional safeguards and curricular formalities in medical school.

In those first few weeks of residency, I was reminded of a student I had during my second year as a teacher. His name was Juan. With his height barely at 5 feet, he puffed up his chest and forced his voice an octave lower to demonstrate how tough he was. I would find out later that he had come from a middle school where he had been mercilessly bullied and, as a product, tried to make a strong showing to keep people at a distance. His biology class with me was right before lunch, and he would always put his head down when the bell rang and pretend to sleep instead of going to get food. When I asked him if he was okay, he muttered expletives and said he was tired and not hungry despite his stomach growling. Knowing when to give someone space, I let him stay in my classroom and just put a sandwich or some other food on his desk. It was always eaten by the start of the next period.

Mr. James was two days out from a ruptured MCA aneurysm when he was transferred to our hospital. He was remarkably intact, and we planned a craniotomy to clip his aneurysm the following day. Just three days in as a fresh intern, I sat down next to him at eye level as I tried to consent him for a surgery I had only experienced secondhand about ten months ago in my sub-internship. Interestingly, while he hesitatingly accepted the idea of a craniotomy for surgical obliteration of the aneurysm, he became confrontational when I mentioned how he might need a bedside EVD in the ICU if he started to develop hydrocephalus from his condition. The idea of having a drain inserted through his scalp and into his brain without general anesthesia seemed terrifying to him. I tried to draw him a picture to explain how the apparatus would work—a terrible idea. One look at the one-horned demon in my scraggly ink, and he told me to leave the room and give him some time. Knowing there was a lot he had to process, I told him I would be back to chat more and that I was sorry he had to be in this position in the first place. Before I left the room, I grabbed a box of tissues and left it on his table. Not knowing what to say, I struggled to find some parting words before I settled on a pedestrian reassurance. “None of this is fair, isn’t it? But I promise we’re here for you.” And then I left the room.


Juan would continue to keep his head down during lunch in my room until one day, I sat at my desk grading papers, and he suddenly called out to me. “Ugh, mister, what is this?” He hadn’t ever been the first to engage me in conversation before. I looked over my computer to see him staring at the kimbab—a traditional Korean meal akin to a California roll—I had left on his desk.

“That’s kimbab. It’s sort of like sushi, but nothing’s raw. I grew up eating that stuff.”
“Is this Chinese or something?”

“Korean,” I muttered as I shuffled through a seemingly endless stack of papers. “Just try it—if you don’t eat it, I will take it back.” 

I saw him take a bite out of the corner of my eye. And then another bite. And he went through the rest of the rolls, and I could tell he wanted more as he eyed my lunch beside me.

“Good, isn’t it? It’s healthy, too. I’m pretty swamped and not that hungry, do you want some more?” I motioned to the food next to me without looking at it. He slowly got up from his seat at the back of the room and approached my desk.

“Is that our lab report?” He made small talk as he took another roll from my Tupperware.

“Yeah, I haven’t gotten to yours yet.”

“Don’t bother, I didn’t know anything.”

Feigning an overly dramatic and incredulous look, I snapped my head over to him. “You didn’t know anything? But you answered my questions perfectly when I checked in on you during the lab.”

Sheepishly, his voice rose in tone as he stopped making eye contact. “I mean, I didn’t try to write anything down. Sorry, I’ll do it right next time.” As he made his way for another roll, I pulled them back and handed him his report instead. “Not later, now. And you can eat while you work.”

At that moment, my stomach growled loudly, and we both laughed. 


I blinked twice as I looked at my phone. JAMES L422, sleepier, can you come by the bedside to assess? I ran over without a second thought and cursed myself for not returning to his room

sooner. I had meant to go back and consent him for the EVD again but had gotten held up by several other tasks to the point where it was almost 6 hours later. Thankfully, I had told the bedside nurse to watch out for sleepiness as one of the indicators that he would be developing hydrocephalus. Knocking on ceremony, I opened the door before hearing a response and walked in to find him eating dinner and watching America’s Got Idol on the television.

“Oh.” I looked around for the nurse, who was nowhere to be seen. My sudden panic turned to reassurance and started to give way to awkwardness as I looked over at his food. “Nice sandwich.”

                    “It tastes like horse shit.” He smiled at me, though, as he held up his juice. “This cranberry juice is okay though.”

Collapsing into the chair next to his bed, I tiredly sighed. “I haven’t eaten yet, so that sandwich looks great—even if it tastes like sandpaper. But you’re okay? The nurse said you were a little sleepy.”

He looked at me incredulously. “It’s almost 7; what are you doing not eating? You already look like one of those twigs. Here, take my sandwich.”  I laughed and put my hands up “I think I’d get fired if I stole food from a patient.”

“I’m not asking, son, take this sandwich. It’s going to the trash either way. I won’t let you take my cranberry juice, though.” He said with a chuckle. We had a companionable silence before he slowly spoke again. “Didn’t you say you were going to talk to me more about a drain you’d stick into my head or something?”

With that, the mood in the room suddenly shifted, and I straightened my posture. “Actually, that’s why I rushed over here so quickly when the nurse told me you were sleepy.”

Rapping his fingers against the table, he took another swig of cranberry juice before holding the sandwich towards me. “Well, how about you tell me why I might need this thing while you take this sandwich.”


Juan went to UC Berkeley on a full-ride scholarship studying biological sciences. We had many more lunches before I eventually transitioned from teaching to medicine, but we continued to keep in touch. When he had his first biology class at Berkeley, he sent me an email highlighting the syllabus and whimsically remarked that he already knew all its topics since 9th grade. I printed out that email and framed it in my lab during my medical school years.

Mr. James was my first EVD three days into my intern year, and I will never forget how sleepy he looked when I walked in later that night. He went for a craniotomy the next day, and I also joined that with my chief. He recovered well, and about two weeks later, he was discharged from the hospital completely intact. Before he left, he asked if he could take a picture with me and gave me another sandwich as a parting gift. 

At this point in my career, I have been in a neurosurgery residency for about as long as I had taught high school. While neurosurgery has become a vocation of sorts, and I feel privileged to be a part of this special field, my identity as a teacher has found a way to blend seamlessly with my current occupation. As a more concrete example, I created an undergraduate class to teach neuroscience to Stanford students, planned didactic sessions for the junior residents, APPs, and nurses, and tried to teach whenever I could during rounds or at the bedside. In a more nuanced manner, the interpersonal soft skills I developed in talking with students and building trust with them have since played a role in every patient encounter I have had. All this to say in perhaps the same manner as my mentor—once a teacher, always a teacher.

From CMA

CMA and AMA urge court to protect patient safety and uphold long-standing prohibition against non-physicians’ use of “doctor”

The California Medical Association (CMA) and the American Medical Association (AMA) have filed a joint amicus curiae brief defending California’s long-standing law that prohibits the use of the term “doctor” or the prefix “Dr.” by anyone other than California-licensed allopathic and osteopathic physicians. In this case, Palmer v. Bonta, et. al., three nurse practitioners with Doctorate of Nursing degrees are suing state officials to block California Business and Professions Code section 2054, so the nurses can call themselves doctors.

Judge invalidates federal regs that allow insurers to artificially deflate payments in surprise-billing disputes

 On August 24, 2023, the U.S. District Court for the Eastern District of Texas invalidated regulations that establish the methodology insurers use to calculate the qualifying payment amount in surprise-billing disputes – part of a series of federal rules being challenged in court by the Texas Medical Association because they skew the arbitration process in insurers’ favor. As a result of this decision, federal agencies have temporarily suspended all federal independent dispute resolution process operations.

Court lifts injunction on retroactive enforcement of CMA-sponsored law requiring reimbursement for COVID-19 services

A Los Angeles County Superior Court lifted a preliminary injunction on the retroactive enforcement of Senate Bill 510’s requirement that health plans and insurers reimburse health care providers for certain COVID-19 claims that predated the effective date of the law. This action removes any legal grounds for plans not to comply with all provisions of the law, including its retroactive application to pre-2022 claims.

DHCS implements system fix to allow claims for Pfizer bivalent COVID-19 vaccine for small children

Last month, the California Department of Health Care Services (DHCS) informed providers that its system was not yet able to appropriately process claims for the bivalent booster dose for children six months to 4 years, and urged Medi-Cal providers to hold such claims. CMA has learned that the DHCS system fix is being implemented this week.

Medi-Cal Rx to reimplement prior auth for some therapeutic classes, including enteral nutrition products

DHCS recently initiated Phase IV, Lift 2 (P4/L2) of the Medi-Cal Rx transition, which will reinstate prior authorization requirements for new start therapies for standard therapeutic classes 68, 86, and 87, which includes enteral nutrition products, effective September 22, 2023.

Expert panel to discuss approaches to advocating for equitable health policy at PHC Health Equity Leadership Summit

 To help you learn how to become an effective advocate for health equity both in and out of health care settings, East Palo Alto Mayor Lisa Gauthier will be a featured speaker at Physicians for a Healthy California’s Health Equity Leadership Summit, held September 14-15 in San Jose. Gauthier will join a panel of policy and community leaders for a session titled Developing and Advocating for Equitable Health Policy.

Women in Neurosurgery

Louise Eisenhardt, MD

First Female President of the Harvey Cushing Society
First Editor of the Journal of Neurosurgery

Editor’s Note: This month’s column is being republished with permission from the WINS Webpage. As an update, the AANS has now had two additional female presidents, Shelly Timmons and Ann Stroink.

As a right hand to Harvey Cushing, MD, Louise Eisenhardt, MD was the first neuropathologist and kept records on all of his surgical pathology specimens. She was a Charter Member of the Harvey Cushing Society which she served as President, long-term Secretary-Treasurer, and Historian. She also was the first (and only so far) female president of the Cushing Society which is now known as the American Association of Neurological Surgeons, (AANS). The Congress of Neurosurgeons (CNS) was at one time considered a “rebel” offshoot of the Cushing society but now is another well respected professional organization where Louise Eisenhardt, MD gave lectures and continuing education courses on neuropathology. She was also the first editor of the Journal of Neurosurgery, leaving that role only as she retired from professional life.

“As the first editor of the Journal of Neurosurgery, Louise Eisenhardt, acting with the advice of the editorial board, was responsible for making decisions on the acceptance or rejection of submitted manuscripts. Her log, covering the first 14 years of editorial decisions, is a record of Neurosurgical progress and of the forces — scientific, technical and other — that shaped the field of neurosurgery. Any peer-review process is subject to pitfalls that become evident in retrospect, but an effective peer-review process is one of the basic ingredients of scientific progress. The decisions to accept or reject manuscripts submitted to the Journal of Neurosurgery during Eisenhardt’s tenure are highlighted in the historical vignette presented in an issue of the Journal of Neurosurgery.” (J Neurosurg 1997 Dec;87(6):972-6.)

Louise Eisenhardt, M.D., associate of Harvey Cushing, scholar, investigator, editor, teacher, and curator of the Brain Tumor Registry at Yale. She achieved many “firsts” for women in medicine. A figure in the Homeric tradition of observing accurately and reporting honestly, Dr. Eisenhardt set high standards for both colleagues and students as well as for aspiring medical authors. She left a tradition worthy of emulation.

From the Medical Board of California

Important Reminder: Physician Duty to Notify Patients About the Open Payments Database

The Medical Board of California (Board) wants to remind physicians of their responsibility to notify patients about the Open Payments database which went into law January 1, 2023.

The Open Payments database is a national transparency program that collects and publishes information about financial relationships between drug and medical device companies and

certain healthcare providers.

Specifically, the law requires physicians to do the following:

  1. Provide patients with either a written or electronic notice of the database at their initial office visit that includes the following text:

“The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at

If the physician uses an electronic records system, a patient signature is not required, however, they must include a record of this notice in the patient’s records. If the physician uses a paper-based records system, then the written notice to the patient must include a signature from the patient (or their representative) and a date of signature. Further, a copy of the written notice must be provided to the patient (or their representative) and included in the patient’s records.

2.                Post a visible notice regarding the database at each location where the physician practices. The notice must include a web link to the database and the following text:

“For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.”

If a physician is employed by a health care employer, that employer is responsible for meeting this requirement.

3.                Beginning January 1, 2024, physicians who use a website in their medical practice must conspicuously post the notice described in number 2 on their website. If a physician is employed by a health care employer, that employer is responsible for meeting this requirement.

Resources to Help You Comply with This Law

The Board has posted on its website a sample notice that may be used to comply with requirements No. 2 and No. 3 described above. If you print this sample notice and place it in an area likely to be seen by all persons who enter the office (e.g., a patient waiting room), you will be compliant with requirement No. 2. If you copy the wording on the notice and place it conspicuously on a physician’s website (e.g., on the homepage), you will be compliant with requirement No. 3. A violation of these requirements constitutes unprofessional conduct and may result in Board discipline.

More information can be found on the Board’s FAQ webpage and the California Legislative Information webpage.

Historical Vignette

Julian R. Youmans
Founding Chairman of the Neurosurgery Department at UC Davis
Author of the Reference Textbook “Neurological Surgery”

Editor’s Note: This historical vignette is a republication of the obituary of an important California Neurosurgeon, a veritable giant whom I had the honor of meeting.

Dr. Julian Ray Youmans, 91, died in El Macero, California on November 12th, 2019 following an extended illness. Julian was greatly loved by his family and friends, and will be deeply missed. Julian was born in Appling County, Georgia on January 2, 1928 to John Edward Youmans, Jr. and Jennie Lou Milton Youmans. He grew up in the Ten Mile community, outside of Baxley, Georgia. Julian entered the US Navy after high school graduation, where he served from 1944 to 1946. In 1952, he earned his Doctor of Medicine from Emory University Medical School in Atlanta, Georgia. He completed his Neurological Surgery Residency at the University of Michigan in 1958. While at the University of Michigan, Julian also obtained his Doctor of Philosophy in neuroanatomy and neurophysiology in 1957. Julian’s field of work, both in private practice and University affiliations, took him to many locations early in his career. He settled permanently with the University of California, at Davis in 1967. Julian served as Professor and Founding Chairman of the Department of Neurosurgery, where he actively practiced until 1991. In addition to receiving numerous awards for innovative contributions to his field, Julian continues to be credited for creating and editing the enduring text “NEUROLOGICAL SUGERY, A Comprehensive Reference Guide to the Diagnosis and Management of Neurosurgical Problems.” He had a passionate interest in continual learning, as well as a community minded conscience.

Julian was instrumental in the expansion of housing for UCD students and applied his penchant for hospitality into local businesses. He continued to be active in managing a family business with his three sons. He was also on the Board of Directors of a private, social club, The Bohemian Club, in San Francisco. Through this club he met many national and international leaders in education, government, industry and society in general. Julian met and married Nancy Nesbit in 1954. Together they had three sons. He is survived by their three children, Reed Nesbit (Susan), John Edward (Rose) and Julian M. (Julie). He is also survived by longtime companion, Georgene Pucci. Julian leaves a legacy of love and affection for his grandchildren, great grandchildren, great-great grandchild, as well as numerous nieces, nephews, and dear friends.

Frank Mayfield

The Mayfield Headrest

Innovators in Neurosurgery

Editor’s Note: This article is republished with permission from Elsevier

World Neurosurgery
Volume 153, September 2021, Pages 26-35


Eponyms of Cranial Neurosurgical Instruments: An International Collaboration to Optimize the Field of Neurosurgery

Lukasz Strulak 1Ferda Gronki 2Kaveh Shariat 1, Daniel Schöni 1Alex Alfieri 1 3

Cranial positioning and fixation are of critical importance for a craniotomy.6,28,29 One of the most commonly used devices for this purpose is the horseshoe and general-purpose headrest (1967) and skull clamp (1972) (Figure 5B). These were developed by Frank Mayfield (Figure 5A) together with George Kees (Figure 5A), who both also designed the Mayfield arterial clip in 1972.6,30,31

With the emerging field of microneurosurgery and subsequent smaller craniotomies, the need for secure head stabilization became increasingly important, resulting in the significant advancement of headrests and clamps.6 The aim of the Mayfield horseshoe and the general-purpose headrest is to primarily support the head and enable the surgeon optimal surgical access as well as intraoperative mobilization of the head.6,28,29 Mayfield head clamps, in contrast, firmly stabilize the head during operations by attaching the skull through the clamp to the operating table, thereby reducing any potential head movement to the minimum.6,28, 29, 30

Frank Mayfield was born in South Carolina on June 23, 1908, and spent his childhood on a farm.30,31 He obtained his undergraduate degree from the University of North Carolina and attended Virginia Medical College, where he graduated in 1931.31 Upon completion of his residency in 1935, he served as a graduate fellow and instructor at the University of Louisville under Roy Glenwood Spurling until 1937 when he established a community practice specializing in neurosurgery in Cincinnati, Ohio.31 During World War II between 1942 and 1945, Mayfield served as Chief of Neurosurgery at the Percy Jones General Army Hospital in Battle Creek, Michigan.30,31 He officially joined the University of Cincinnati as an assistant professor of clinical surgery in 1945 and was later promoted as clinical professor in 1967. Concomitantly Mayfield directed the graduate neurosurgical training programs at The Christ Hospital and Good Samaritan Hospital between 1946 and 1977.30

He was elected as the president of the Ohio State Neurosurgical Society in 1947, the Academy of Medicine of Cincinnati in 1950, and the Ohio State Medical Association in 1959. In 1958 he was appointed to the American Board of Neurological Surgery and eventually became its chairman in 1962.30,31 Two years later, he was named President of the Harvey Cushing Society between 1964 and 1965, and in this short period transformed it into the American Association of Neurological Surgeons, in the so-called “Mayfield Proclamation.” Unsurprisingly, Mayfield became the first recipient of the prestigious Harvey Cushing Medal awarded by the American Association of Neurological Surgeons.31,32 He practiced neurosurgery in Cincinnati, Ohio for nearly 50 years, before his death at the age of 82 on January 2, 1991.30,31


September is Childhood Cancer Awareness Month

September 1 – Idalia remains a tropical storm moving into the Atlantic after bringing heavy rain and wind to northwestern Florida, southern Georgia, and the Carolinas. Three are known dead. Preliminary estimates suggest the storm caused up to $20 billion in damage. 

Structures damaged by Hurricane Idalia in Horseshoe Beach, Florida.

September 2 – Jimmy Buffett died at the age of 76. In a tribute, Paul McCartney said, “Jimmy Buffett had a most amazing lust of life and a beautiful sense of humor.” If you attend one of his concerts, do you become a “Parrot Head?”

September 4 – On this day in 1781, Spanish settlers founded Los Angeles. The Governor was Felipe de Neve.

September 4 – Labor Day. In the late 1800s, Americans worked 12 hours a day, seven days a week, often in low-paying jobs and unsafe conditions. Farms, factories, and mines employed children. In this context, American workers held the first Labor Day parade, marching from New York’s City Hall to a giant picnic at an uptown park on Sept. 5, 1882. The American labor movement was among the strongest in the world, and in the years that followed, municipalities and states adopted legislation to recognize Labor Day. New York recognized it in 1887. 

Labor Day parade in Union Square, New York in 1887. Credit…New York Public Library

President Grover Cleveland signed a bill into law on June 28, 1894, declaring Labor Day a National Holiday. There was no particular significance for the “first Monday in September,” except that it fell halfway between the 4th of July and Thanksgiving. Now, Labor Day is more a celebration of the end of Summer, with barbecues and sales, rather than labor protests. 

September 4 – It is the 25th anniversary of the founding of “Backrub” better known as Google, by Larry Page and Sergey Brin while they were students at Stanford University. You may Google this.

August 6 -As he canceled the seven remaining oil and gas leases in Alaska’s Arctic National Wildlife Refuge, President Biden said, “Alaska is home to many of America’s most breathtaking natural wonders and culturally significant areas. As the climate crisis warms the Arctic more than twice as fast as the rest of the world, we have a responsibility to protect this treasured region for all ages.”

September 8 – International Literacy Day. The intent is to remind everyone worldwide of the importance of literacy as a matter of dignity and human rights.

September 8 – According to the United States Geological Survey, a powerful earthquake struck in the High Atlas Mountains of Morocco shortly after 11 PM with a magnitude of 6.8 and a depth of about 11 miles. The quake was caused by the collision of the

African and Eurasian tectonic plates, and it occurred at a relatively shallow depth, which makes more dangerous. It was the strongest to hit the area in more than 120 years. The epicenter was 50 miles from Marrakesh, a historic UNESCO World Heritage City. The quake was felt as far away as Portugal. The death toll has exceeded 2900.

A damaged mosque in Marrakesh. Nariman El-Mofty for The New York Times

September 9 – Coco Gauff, a 19-year-old, captured her first Grand Slam title, winning the U.S. Open singles final, 2-6, 6-3, 6-2, over Aryna Sabalenka of Belarus, and became the first American teenager to win the U.S Open since Serena Williams won the tournament in 1999 at 17. Last year, Serena Williams retired at the U.S. Open. This year, Coco Gauff wins.

Michelle V. Agins/The New York Times

September 11 – In 2001, we were attacked by terrorists. America and the World changed since!


September 11 – Hurricane Daniel in the Mediterranean Sea has been causing excessive rain in several countries. Now, it caused the collapse of two dams in the northeastern Libyan city of Derna. Several cities were swept away. More than 10,000 people are missing, and more than 11,300 are feared dead.

The city of Derna, Libya.Jamal Alkomaty/Associated Press

September 12 – The Food and Drug Administration and the CDC approved a new round of COVID-19 vaccines, effective against EG.5 — currently the dominant strain. They will arrive alongside the seasonal flu vaccine and shots to protect infants and older adults from R.S.V. by the end of this week. Federal officials have been retreating from labeling the new formulation as boosters to previous shots, preferring to recast them as an annual immunization effort akin to the flu vaccine. The Biden administration plans to urge the public to get their Covid and flu shots simultaneously, a practice that some experts consider safe. The CDC said in a news release, “If you have not received a COVID-19 vaccine in the past 2 months, get an updated COVID-19 vaccine to protect yourself this fall and winter.”

September 12 – The Census Bureau indicated that the poverty rate rose to 12.4 percent in 2022 from 7.8 percent in 2021, the largest one-year jump on record. Poverty among children more than doubled. The increases followed two years of large decline driven primarily by safety net programs created or expanded during the pandemic. Median household income, adjusted for inflation, fell 2.3 percent in 2022, to $74,580, as the fastest inflation since 1981 overwhelmed the impact of increased employment and rising wages.

September 14 – California State lawmakers approved SB 525, which would raise the hourly minimum wage at large health facilities and dialysis clinics-more than fifty employees – to $23 next year, $24 in 2025, and $25 in 2026. It would boost hourly wages at community clinics to at least $21 in 2024, $22 in 2026, and $25 in 2027. Other health facilities would go to at least $21 an hour in 2024, $23 in 2026, and $25 by 2028. California would become a national leader in this, as usual.

Healthcare workers protest in favor of higher wages and better working conditions as they march down West Sunset Boulevard near Los Angeles Medical Center on Sept. 4. (DANIA MAXWELL/LOS ANGELES TIMES VIA GETTY IMAGES)

September 15 – About 13,000 United Auto Workers members go on strike against a General Motors plant in Missouri, a Ford factory in Detroit, and a Stellantis – parent company of Chrysler – Jeep plant in Ohio. This is the first time in UAW’s 88-year history that its members simultaneously walked out on all three companies.

September 15 – at sundown. Rosh Hashanah marks the world’s creation, meaning “head of the year,” the Jewish New Year. It also marks the beginning of the Jewish High Holy Days leading up to Yom Kippur, the Jewish day of atonement. 

September 16- The LA Dodgers clinched the National League West Division Title for the 10th time in eleven years. Go Dodgers!

September 17 – Constitution and Citizenship Day. The US Constitution was signed on this day in Philadelphia in 1787.

September 18 – The US Senate will no longer enforce a dress code in its chambers, according to majority leader Chuck Schumer. Ouch!

September 19 – National Voter Registration Day.

September 19 – The U.S. Fish and Wildlife Service announced that Southern Sea Otters, who often make their home off the Central California Coast – from Ventura in the south to Monterey in the north –  will keep their status as “threatened” under the Endangered Species Act.

Photo from the Monterey Bay Aquarium

September 20 – Four months after announcing that the hot dog-shaped Wienermobile was changing its name to the Frankmobile, Oscar Meyer said that the one-of-a-kind Wiener on wheels is reverting to the original name

The Oscar Mayer Wienermobile sits outside the Oscar Meyer headquarters, in Madison, Wis.

September 22 – On this day in 1862, U.S. President Abraham Lincoln issued the preliminary Emancipation Proclamation, declaring all slaves free as of Jan. 1, 1863.

This document, believed to be one of two or three similar copies in existence, was presented by an anonymous donor to Lincoln’s home state of Illinois. 

September 23-24 – Yom Kippur is the holiest day on the Jewish calendar. Jews fast, pray, seek forgiveness from God and each other, and come closer to God. It is the Day of Atonement—“For on this day He will forgive you, to purify you, that you be cleansed from all your sins before God (Leviticus 16:30.)

September 25 – Covid-19 tests are now available to be ordered for free from the US government. People can order four tests per US household through 

September 26 – A new National Center for Health Statistics survey says that long Covid-19 may have affected as many as 962,000 – 1% 0f children and 17.9 million – 7% of adults in the U.S.

September 27 – The Unions and Hollywood studios reached a tentative agreement to end the strike, allowing writers and actors to return to work after 148 long days.

September 27 – The Senate has unanimously passed a formal dress code for the first time, including coat, tie, and slacks for men. The bipartisan bill from Democratic Sen. Joe Manchin of West Virginia and Utah Republican Sen. Mitt Romney requires that members abide by a real dress code – rather than an unwritten custom – when on the Senate floor, including coat, tie, and slacks for men. The resolution doesn’t specify what is deemed business attire for women on the Senate floor.

September 27 – A NASA astronaut safely returned to Earth on Wednesday after spending 371 days in space, a record in spaceflight for American astronauts.

Frank Rubio, a NASA astronaut, being helped off the Soyuz MS-23 spacecraft on Wednesday minutes after he and Roscosmos cosmonauts landed near Dzhezkazgan, Kazakhstan. The trio returned to Earth after logging 371 days in space. Credit…NASA/Getty Images

September 28 – On this day in 1928, Scottish researcher Sir Alexander Fleming discovered Penicillin.

September 28 – Senator Dianne Feinstein Senior Senator from California dies at 90. She was the longest serving senator, who had a distinguished career, but her last few months were marred by illness including encephalitis resulting in intermittent confusion, raising questions about mandatory retirement age.

September 29 – On this day in 1907, construction began on the Washington National Cathedral.

September 30 – On this day in 1846, Ether was used for the 1st time by American dentist Dr. William Morton to extract a tooth.


WNS Meeting Portola Hotel & Spa, Monterey,                        Sept. 29-Oct. 2, 2023
WFNS Cape Town,                                                                   December 6-11, 2023
CANS, Annual Meeting, Intercont Mark Hopkins, San Francisco, CA January 12-14, 2024
CSNS Spring Meeting, Chicago                                                 May 2-3, 2024
AANS Annual Meeting, Chicago                                               May 3-6, 2024 
NSA Annual Meeting Penha Longa Resort, Portugal              June 16-019, 2024

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

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

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CANS Board of Directors

CANS Board of Directors

CANS Board of Directors

President             Joseph Chen , MD            Bakersfield
President-Elect   Ciara Harraher, MD          Santa Cruz
Vice-Pres            Samer Ghostine, MD        Los Angeles
Secretary            Brian Gantwerker, MD     SantaMonica
             Sanjay Dhall, MD               Los Angeles
Imed Past Pres    Javed Siddiqi, MD            Beverly Hills
Past President     Mark Linskey, MD              Irvine
Northern CA
Anthony DiGiorgio, DO                                  San Francisco
Marco Lee, MD                                               Stanford
Odette Harris, MD                                           Stanford
Harminder Singh, MD                                     Stanford

Southern CA
Omid Hariri, DO                                               Orange Co
Namath Hussain, MD                                     Loma Linda
Ian Ross, MD                                                    Pasadena
N. Nicole Moayeri, MD                    Santa Barbara

Resident Board Consultants
John Choi, MD                                                Stanford
Yagmur Muftuoglu, MD, PhD                        UCLA
Paras Savla, DO                                              Arrowhead
John Yue, MD                                                  UCSF

Past President Kenneth Blumenfeld, MD    San Jose Past President Deborah C. Henry, MD Newport Beach Past President Theodore Kaczmar, Jr, MD  Salinas
Past President     Phillip Kissel, MD  San Luis Obispo
Past President     Praveen Mummaneni      San Francisco
Past President Langston Holly                       Los Angeles
Past President John K. Ratliff, MD Stanford               Past President     Patrick Wade                     Glendale

Newsletter           Moustapha AbouSamra, MD Ventura                     
              Austin Colohan, MD         Temecula
Website Chair     Anthony DiGiorgio, DO    San Francisco

Executive Secretary         Emily Schile          Sacramento