Volume 50, Number 8

Inside This Issue

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

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

CANS President

President's Message

The 14th Amendment to our constitution was ratified in 1868 and includes language that no state can “deny to any person within its jurisdiction the equal protection of the laws.” Perhaps the most important manifestations of how the 14th Amendment has been interpreted over time has been reflected in Title IX of the Civil Rights Act, which was signed into law 50 years ago, and reads: “No person in the United States shall, on the basis of sex, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance.”

In our divided nation, Title IX is an example of bipartisan consensus and how the Executive, Judicial and Legislative branches of our government have worked synergistically.  Three years after its passage in 1972, the US Department of Health, Education and Welfare (renamed the Department of Education subsequently) issued an advisory requiring every educational institution that receives federal financial assistance to provide written proof of compliance with Title IX.  The US Supreme Court ruled in 1984 that Title IX’s non-discrimination and compliance requirements applied to any educational institution that received federal financial assistance and not simply to student financial aid.  In 1988, while a highly popular Republican President, Ronald Reagan, was in office, the  Senate and House of Representatives responded to the 1984 Supreme Court ruling by passing legislation that clarified that Title IX applied to “all operations” of any institution which received federal financial assistance.  This “Civil Rights Restoration Act of 1987” was vetoed by President Reagan in March 1988, and within one week, Congress (with Republican and  Democratic collaboration) overrode the President’s veto by again passing the legislation with a two-thirds majority in the House and Senate.  The Civil Rights Restoration Act became law.

Before Title IX, approximately 10% of US medical students were women.  The graph below shows the decreasing gender disparity in US medical schools from 1980 through 2015;  by 2022, the 50th anniversary of Title IX, over 50% of medical school applicants are women, and a similar number of women matriculate into medical school. 

*Graph Reference:

Within Neurosurgery, gender disparity exists, but there is consistent growth of women in residency programs and among ABNS and/or AOA-certified neurosurgeons.  Currently, there are eleven California neurosurgery residency programs with a total of 165 neurosurgery residents, 43 (or 26%) of whom are women.

The 50th anniversary of the passage of Title IX offers us a chance to reflect on how far we have come and what journey remains.  California appears to lead the country in this evolution, and the 50th-anniversary annual CANS meeting in January 2023 will be a great opportunity to celebrate our past accomplishments as we commit to a brighter future. 

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

CANS Newsletter Editor

Editor's Report

Our President, along with the annual meeting committee, is hard at work planning an exciting agenda for our fiftieth annual meeting. It will be at the historic Mission Inn in Riverside from January 13-15. Among the topics that will be discussed are the following three:

  • Title IX and neurosurgery – please see the president’s message.
  • Entrepreneurship in neurosurgery: how to develop your brilliant ideas, how to seek funding, how to monetize them, etc.
  • Evolution of the neurosurgery career: from early career planning to retirement.

At CANS, we strongly feel that residents in training are an integral component of our society, the largest state neurosurgical society in the USA.   Participating in our annual meeting is a wonderful opportunity for you to meet established neurosurgeons of California, learn about and offer input into socioeconomic discussions, and network with our profession’s leaders. Neurosurgical residents in California are already CANS members unless they individually opted out. Registration for the meeting is free. The Society will pay for one night’s accommodations at the Mission Inn in Riverside. Residents from all California neurosurgical residency programs are encouraged to submit an abstract – 200 words or less – There will be three awards of varying amounts for the top three abstracts on socioeconomic/health care or basic science topics. The deadline for submission is December 16.


This month’s Women in Neurosurgery column was written by Julie Pilitsis, the first female neurosurgeon to become dean of a medical school, it is a great accomplishment, and we are so very proud of Julie. Our female colleagues are making tremendous strides in gaining equity, but much still needs to be done. We have come a long way from the 1970s when I started my training. Then, it was uncommon to see female neurosurgeons in leadership positions and it was uncommon to see women in board rooms, etc.

Please see this iconic photo of Katharine Graham when she joined the Board of Directors of the Washington Post.

Katharine Graham, the lone woman in the room in 1975

Things are different now, and hopefully, they will continue to improve.

In this issue, there are two important communications from the Washington office of the AANS/CNS, specifically its director Katie Orrico. The first is about the unanimous passing by the U.S. House of Representatives of H.R. 3173, the Improving Seniors’ Timely Access to Care Act. The legislation would streamline and standardize prior authorization in the Medicare Advantage (MA) program. The second is a request to contact your representative and request support for Medicare Providers Act (H.R. 8800) authored by two physicians, congressmen Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.) Please take a minute to reach out to your US congressperson.

Also included are the CSNS resolutions that will be discussed and voted on at the CSNS Fall Meeting in San Francisco that precedes the CNS meeting on October 7 and 8. The CANS board will discuss them and take a position on each resolution during its upcoming zoom meeting on October 2. We will keep you informed of the outcome in our next newsletter.

The residents’ Corner is written by Lauren Stone, a fourth-year resident and one of our new residents’ board consultants. Her essay titled “zoom in, zoom out” deals with the constant need to reorient one’s view both professionally and personally.

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

Julie G. Pilitsis, MD, PhD, MBA, FAANS

First Female Neurosurgeon to become Dean of Medical School

Women in Neurosurgery

Excerpts printed with permission- Article published in AANS neurosurgeon on August 1, 2022. Please see link below

Ten years ago, I set a career goal to become a dean for a college of medicine. To that end, I worked toward gaining experience in the clinical, education and research aspects of medicine under the guidance of Dean Vince Verdile at Albany Medical College. The next step was gaining the position of chair of The Department of Neuroscience and Experimental Therapeutics after a national search. Subsequently, I obtained additional leadership training through the Harvard course for chairs, Executive Leadership in Academic Medicine and my MBA. To help me garner institutional budget experience, I joined the system’s finance committee. To gain philanthropy experience, I obtained formal training and worked closely with our institutional foundation, specifically in securing gifts from our Parkinson’s Disease community and for our institutional faculty development program, which I co-directed. On February 14, 2022, I joined the students, staff, and faculty in the Schmidt College of Medicine at Florida Atlantic University (FAU) as dean and vice president of Medical Affairs. Instantaneously, I felt the humbling responsibility of becoming the first female neurosurgeon to become a dean.

I have begun working with FAU’s president, John Kelly and chair of FAU’s Board of Trustees, Brad Levine, to build FAU Health Network, a coalition of collaboration among FAU’s nine colleges on six campuses, enabling us to play a pivotal role in a new phase of responsive and innovative healthcare delivery in South Florida. Our overarching goal is to improve the care of the 3.2 million patients in Palm Beach, Broward and Martin Counties, by transcending the competitive landscape through joint educational and research endeavors. We will work with our community partners to offer outstanding opportunities for dynamic faculty and learner experiences, provide connectivity to the local healthcare community and ensure recruitment and retention of our skilled health care professionals.

A community is essential for all of us to get to where we are going. The central tenet of my time at FAU will echo that spirit of developing a health care workforce “of the community, for the community.” I am proud to be a part of the neurosurgical community.

Picture of Moustapha AbouSamra, MD

Moustapha AbouSamra, MD

To err is human. To forgive divine
Alexander Pope - An Essay on Criticism

Changing Times - Losing Trust and Regaining it Making Mistakes and Admitting Them

Last Month, Rochelle Walensky, an infectious disease specialist and the Director of the Centers for Disease Control and Prevention, said that the agency “did not reliably meet expectations” and must “do better.” This came after an external review, which she commissioned last April, found shortcomings in the COVID-19 response. She said, “To be frank, we are responsible for some pretty dramatic, public mistakes, from testing to data to communications.”

No wonder the public lost trust in the agency’s ability to handle a pandemic that killed more than one million Americans. And when the public loses trust in an otherwise reputable government agency such as the CDC, we all suffer.

To be sure, and with the help of our government, we developed vaccines against COVID-19 in record time and made them available to the public for free, also in record time. But because of mixed messages, delayed and sometimes false information, the public became confused. As a result, a substantial percentage of our population did not agree to receive the vaccine …

Dr. Richard E. Besser, who served as acting director of the CDC during the Obama administration, said, “For a long time, CDC has undervalued the importance of direct communication to the public with information the public can use. And Dr. David Dowdy, an epidemiologist at Johns Hopkins Bloomberg School of Public Health, said messages to the general public need to be “very clear, very simple, very straightforward, not framed for scientists.”

A recent example of how the lack of trust translates into the inability to carry out a simple and essential ingredient for the success of a public health campaign is vaccinating our young ones. I was really excited when vaccines against COVID-19 became available for children over 12, then 5, then 2. This meant that my ten grandchildren could be vaccinated, and we could all feel safer and return to more normal behavior when interacting with extended family and friends.

I was and continue to be surprised, as I am sure many of you are, that as of early August, around 5% of eligible children under five received the first dose of the vaccine series. Worse, the number of children under five being immunized has been decreasing. As to those aged 5 to 11, only 30% are fully vaccinated; consider that vaccines for this group have been authorized since the fall of 2021 and ‌‌are available anywhere shots are given.

Are there any other factors that contributed to the loss of trust? Yes, there are many, but I will name the following here:

  • The spread of false information online: according to a  survey released by the Pew Research Center, nearly three-quarters of people across 19 countries believe that the spread of false information online is a “major threat.” I totally agree. Social media and internet sources quote information that is often clearly false or taken out of context. Educating our public and our children on how to evaluate the information they read must be part of our educational approach.


  • The spread of false information by licensed physicians: I admit that they are in the minority, but it is hard to believe that any physicians, who by definition are individuals who believe in science and are scientists, could do that. Allow me to name a few.
  1. Lee Merritt, an orthopedic spine surgeon from Nebraska, claims that the SARS-CoV2 virus is a genetically engineered bioweapon and that vaccination dramatically increases the risk of death from COVID. She also claims that the entire pandemic is a vast global conspiracy to exert social control.

Dr. Simone Gold is a board-certified emergency medicine physician from California. She tells people to avoid vaccination against the coronavirus. As an alternative, she pushes drugs that

  1. have not been proven effective at treating COVID-19 — drugs that she also offers to prescribe to the audience in exchange for $90 telehealth appointments. She recently gave a talk in my own County of Ventura.
  2. Joseph Ladapo, MD, Ph.D., previously a physician at UCLA, now Florida’s Surgeon General and head of the Florida Department of Health, discourages vaccination and the use of masks. He was not necessarily truthful about his credentials, when he applied for his position in Florida.

This led the California Legislature to pass a bill allowing regulators to punish doctors for spreading false information about Covid-19 vaccinations and treatments. Governor Newsome has not signed the bill yet. Physicians are and should be held to a higher standard. I agree with this approach.

  • The politicization of healthcare and specifically the COVID-19 pandemic: is it not puzzling that there were differences between Republicans and Democrats in the rate of wearing masks, getting vaccinated, etc.? One example that makes me sad is the disrespect with which Dr. Anthony Fauci was treated of late. I like Dr. Fauci, and I trust him. Has he made mistakes? Yes, several. One, in particular, had to do with wearing masks early in the pandemic … But I did not envy his position. He was at the head of an agency that was amid a fast-moving pandemic, with information that was rapidly changing, and he had to face the media daily and come up with decisions that affected millions, decisions that proved, in retrospect, wrong. But to err is human.

Were his intentions honorable? Absolutely. Did he admit his mistakes? Yes, he did, although sometimes not right away. Why do I feel sad? Consider that in 2019, Anthony Fauci was cited as a hero by President George H. W. Bush and awarded the nation’s highest civilian honor by President George W. Bush, both Republicans; he was seen as a charming but no-nonsense doctor/scientist who had served the public for five decades‌. But our former President, also a Republican, vilified him. So, now in 2022, Dr. Fauci became, to so many, a villain.

I strongly believe that politics should not play a role in our approach to public health.

As to Dr. Fauci, I wish him the very best in his retirement, which he announced recently. He served us with distinction.

Yes, to err is human. We all make mistakes. But when we do, we must learn from them, admit them, and apologize for them. It is the only way physicians and everyone else involved in our Health Care can regain the public trust.

Photo of the Month

Photo taken by Moustapha AbouSamra, MD. On July 18, 2022, at 4:48 PM iPhone 13 Pro

Golden Shower Tree
Cassia fistula

The golden shower tree (Cassia fistula) is a plant found in tropical and subtropical regions. It’s at its peak during the middle of the summer. The golden shower tree is both the national flower and tree of Thailand. The Latin name of “cassia” comes from “Kassia,” which means “fragrant plant.” It holds a sacred place in scriptures like the Ramayana and Mahabharata.

Picture of Katie O. Orrico, Senior Vice President

Katie O. Orrico, Senior Vice President

Health Policy and Advocacy
American Association of Neurological Surgeons/
Congress of Neurological Surgeons

Improving Seniors’ Timely Access to Care Act

On Sept. 14, the U.S. House of Representatives unanimously passed by voice vote H.R. 3173, the Improving Seniors’ Timely Access to Care Act. The legislation would streamline and standardize prior authorization in the Medicare Advantage (MA) program. Among other things, the legislation:

  • Establishes an electronic prior authorization process;
  • Requires the U.S. Department of Health & Human Services to establish a process for real-time decisions for items and services that are routinely approved;
  • Improves transparency by requiring MA plans to report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals or denials; and
  • Encourages plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

Immediately preceding the vote, the House Energy and Commerce Health Subcommittee unanimously approved the bill, clearing the way for its consideration by the full House.

The AANS/CNS Washington Committee issued a press release – please see below – applauding the passage of this legislation. Attention now turns to the Senate, where Sen. Roger Marshall, MD, (R-Kan.), hopes to fast-track the bill’s passage in the upper chamber.

This action represents a significant legislative victory on our top legislative priority, following five years of sustained advocacy.

The AANS/CNS Washington Committee – PRESS RELEASE – September 14, 2022

Neurosurgeons Applaud Congress for Passing Legislation to Streamline Prior Authorization  House action is a critical step in advancing legislation to ensure timely access to care in Medicare Advantage.  Washington, DC—Today, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) applauded the U.S. House of Representatives for passing the Improving Seniors’ Timely Access to Care Act (H.R 3173). This legislation would streamline prior authorization in the Medicare Advantage (MA) program.  Led by Reps. Suzan DelBene (D-Wash.), Mike Kelly (R-Pa.), Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD (R-IN) in the House, this legislation would ensure that seniors get timely decisions about the care provided by MA by:   Establishing an electronic prior authorization program;  Standardizing and streamlining the prior authorization process for routinely approved services, including establishing a list of services eligible for real-time prior authorization decisions;  Ensuring prior authorization requests are reviewed by qualified medical personnel; and  Increasing transparency around MA prior authorization requirements and their use.  “The use of prior authorization has increased significantly over the last several years — causing unacceptable delays and denials of medically necessary care. Our patients cannot afford to wait or jump through unnecessary hoops to get care for painful and life-threatening neurologic conditions such as brain tumors, debilitating degenerative spine disorders, stroke and Parkinson’s Disease. This progress is a vital step towards preserving patients’ timely access to care,” said John K. Ratliff, MD, FAANS, FACS, a neurosurgeon at Stanford University and chair of the AANS/CNS Washington Committee.   Dr. Ratliff concluded, “America’s neurosurgeons want to thank House leaders for bringing this bill forward for a vote. Now it’s time for the Senate to finish the job and pass this bill before the end of the year.”   To bring improved transparency and oversight to the Medicare Advantage program, the AANS and the CNS have joined forces with the Regulatory Relief Coalition — a group of national physician specialty organizations advocating for a reduction in Medicare program regulatory burdens to protect patients’ timely access to care. The RRC has been an important ally in the efforts to advance the Improving Seniors’ Timely Access to Care Act.

Picture of Katie O. Orrico, Senior Vice President

Katie O. Orrico, Senior Vice President

Health Policy and Advocacy
American Association of Neurological Surgeons/
Congress of Neurological Surgeons

Medicare Providers Act (H.R. 8800)

As you know, on Jan. 1, 2023, neurosurgeons face a minimum 8.42% Medicare payment cut, including a:

  • 42% cut for all Medicare Physician Fee Schedule (MPFS) services in 2023 to comply with Medicare’s budget-neutrality requirements; and
  • 4% Statutory Pay-As-You-Go (PAYGO) Act cut, triggered due to new federal spending.

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:

  • Ensure financial stability and predictability in the Medicare physician payment system;
  • Promote and reward value-based care innovation; and
  • Safeguard timely access to high-quality care by advancing health equity and reducing disparities.

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!

Picture of Marshall Grode MD

Marshall Grode MD

Professor Emeritus, Department of Neurosurgery

Picture of Ray Chu MD

Ray Chu MD

Associate Professor, Department of Neurosurgery

Historical Vignette

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.

Picture of Anthony Di Giorgio, DO

Anthony Di Giorgio, DO

Patient Choice within Medicaid

Academic Corner

“Our fear of death is like our fear that summer will be short, but when we have had our swing of pleasure, our fill of fruit, and our swelter of heat, we say we have had our day.”
-Ralph Waldo Emerson

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?

From the CMA

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.

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

Brian R. Gantwerker, MD, FAANS, FACS

Access, Equity, and the Crisis in Medicine
Amid every crisis lies great opportunity.
Albert Einstein

Private Practice Corner

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. 

From CMA

Medi-Cal announces new commercial managed care plan contracts for 2024 and beyond

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.

Alarming Medicare survey results underscore need to reform physician payment system

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.

CMA bill to provide more eRx flexibility for low volume prescribers passes state legislature

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.

Bill to install trauma kits in buildings for emergency response goes to governor’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 statement on appointment of Diana Ramos, M.D., as CA Surgeon General

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.”

On-demand Webinar: Medi-Cal Rx phased implementation plan

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.

Help us honor CMA members who have passed

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.

CMA updates COVID vaccine billing resources to include new bivalent boosters

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 publishes FAQ on health care worker retention bonuses

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.

Bill introduced in Congress to stabilize Medicare for physicians and patients

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.

Picture of Lauren Stone, MD

Lauren Stone, MD

Zooming In, Zooming Out

Residents Corner

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.

Just try. 

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.

Just try. 


Admittedly, the process becomes smoother and – having tried it before – more familiar the next time. 

Aren’t you glad you zoomed out

CSNS 2022 Fall Resolutions

       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, a singlepayer system offers the best prospects for those and other desiderata listed in the statements; and

WHEREAS, neurosurgeons’ incomes would likely not be reduced under 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 PAHCF is fundamentally an insurance industry front group; 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, the AMA and American College of Radiology (ACR) withdrew their PAHCF memberships, leaving AANS, CNS, and the Virginia Orthopaedic Society as the sole remaining physician organizations; 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. 


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

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.  


  1. 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.


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

“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: 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.


  1. He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: A narrative review. Am J Surg. 2021 Jan;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007. Epub 2020 Jun 23. PMID: 32680622; PMCID: PMC7308777.
  2. Pasha AS, Al Shabeeb R. Do Differences in Internal Medicine Resident Salaries Correlate with Variation in Regional Cost of Living? J Gen Intern Med. 2020 Aug;35(8):2508-2509. doi:10.1007/s11606-019-05471-z. Epub 2019 Oct 25. PMID: 31654348; PMCID: PMC7403360.
  3. Morello SL, Shiu KB, Thurston J. Comparison of resident and intern salaries with the current living wage as a quantitative estimate of financial strain among postgraduate veterinary trainees. J Am Vet Med Assoc. 2021 Nov 12;260(1):124-132. doi: 10.2460/javma.21-07-0336. PMID: 34780353.

FISCAL NOTE: $87 for Cost of Living Index sponsored by The Council for Community and Economic Research (

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: 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


“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: 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. 


PRIOR RESOLUTIONS:   RESOLUTION IV-2012F Spine Surgery and Scope of Practice ne_FINAL-APPROVED_082121.ashx

Assigned Committee(s): 

  • Medico-Legal Committee
  • Medical Practices Committee
  • Coding & Reimbursement Committee Safety 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: 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.




  1. 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


Assigned Committee(s):

  • Medico-Legal Committee
  • 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: 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.       




  1. 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:



Assigned Committee(s):

  • Communication and Education Committee
  • Safety 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”

Picture of Shivum Desai, MS IV

Shivum Desai, MS IV

AZCOM, Midwestern University
Drilling My First Burr Hole

Medical Student Essay

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. 

Tidbits September

Tidbits September

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 ( 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