C Ontentsontents O G Ic a L T He American Association of Neurological Surgeons

N A ICA SSO R C E I M A T A I E O

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S F N N O E U E R G O R L S U CC ONTENTSONTENTS O G IC A L T HE AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS

AANS BULLETIN The quarterly publication of The American FEATURES Association of Neurological Surgeons Is Subcertification Good for Neurosurgery? As neurosurgery A. John Popp, MD, Editor 6 James R. Bean, MD, Associate Editor evolves, more physicians are considering the pros and Barbara Peck, Staff Editor cons of subspecialty practice. Deia Lofendo, Staff Writer Outcomes Initiatives Outcomes reporting instruments are OFFICERS AND DIRECTORS (1999-2000) 14 now available on N://OC®. Martin H. Weiss, MD, President Stewart B. Dunsker, MD, President-Elect Meet Your President AANS President Martin H. Weiss, A. John Popp, MD, Vice President 23 MD, sets the organizational agenda for his term in office. Stan Pelofsky, MD, Secretary Roberto C. Heros, MD, Treasurer New Orleans Highlights from the 67th Annual Meeting. Russell L. Travis, MD, Past President 24 Consolidation CSNS passes resolution requesting consolidation of AANS and CNS. Directors-At-Large: William F. Chandler, MD • Robert A. 25 Ratcheson, MD • Jon H. Robertson, MD • Volker K.H. Sonntag, MD • Fremont P. Wirth, MD • Jeffrey A. Brown, MD, NW Regional Director • Gary Vander Ark, MD, SW DEPARTMENTS Regional Director • Robert B. Page, MD, NE Regional Director • William E. Mayher III, MD, SE Regional Director 3 Newsline Reports on news, members, trends and legislation, including “From the Lyal G. Leibrock, MD, CSNS Liaison Hill” and “Neuro News.” David F. Jimenez, MD, Young Neurosurgeons Liaison 32 News.Org Reports on professional organization news, including AANS/CNS AANS NATIONAL OFFICE Sections and committees. 22 S. Washington St., Park Ridge, IL 60068 Phone (847) 692-9500; Fax (847) 692-2589 E-mail: [email protected] Web site: www.neurosurgery.org COLUMNS Laurie L. Behncke, CMP, Associate Executive President’s Message Martin H. Weiss, MD, discusses the future of organized Director — Programs 2 neurosurgery. Robert R. Cowan, CPA, Associate Executive Director — Administration 11 Guest Column: How One Specialty Experienced Subspecialization and Certification Raymond J. Jaskot, Director of Information Services Interview with the President of the American Board of Facial Plastic and Recon- Jacquelyn Lloyd, Director of Marketing structive Surgery, Peter A. Adamson, MD. Tony Loster, CGCM, Director of Print Production and 13 Neurosurgical Fellowships David F. Jimenez, MD, addresses the need for improved Fulfillment Services post-residency training programs. Susan A. Nowicki, APR, Director of Communications 16 Managed Care: Changes in the Marketplace John A. Kusske, MD, discusses the John R. O’Connell, Director of Development managed care organization of the future. Lisa Sykes, CMP, Director of Meetings Practice Management: Neurosurgery – The Cost of Doing Business June Wasser, Director of Professional Development 17 James R. Bean, MD, discusses two strategies to reduce costs in neurosurgical practice. CHANGE OF ADDRESS: AANS, 22 S. Washington St., 18 Coding Corner Greg Przybylski, MD, answers complex reimbursement questions. Park Ridge, IL 60068-4287 26 Research Foundation Foundation sets all-time record in 1998 fundraising campaign. © 1999 by The American Association of Continuing Medical Education AANS offers comprehensive pain management course. Neurological Surgeons, all rights reserved. 28 Contents may not be reproduced, stored in a 29 Membership AANS welcomes new Candidate members. retrieval system, or transmitted in any form by any means without prior written 30 Secretary’s Report Stan Pelofsky, MD, discusses the accomplishments of our permission of the publisher. organization over the past year. The AANS Bulletin is published quarterly by 37 Advocacy and the Standard of Care Chairman of the Professional Conduct The American Association of Neurological Committee, W. Ben Blackett, MD, JD, discusses the AANS guidelines for Surgeons, 22 S. Washington St., Park Ridge, IL 60068-4287, and distributed without charge to the providing expert medical testimony. neurosurgical community. Unless specifically stated Practice Profile Richard N. Wohns, MD, highlights his innovative practice- otherwise, the opinions expressed and statements 38 made in this publication are the authors’ and do building techniques. not imply endorsement by the official policy of the AANS. 40 Personal Perspective Editor A. John Popp, MD, examines the issues surrounding neurosurgical subcertification. Spring 1999 • AANS Bulletin 1 PP RESIDENTRESIDENT’’ SS MMESSAGEESSAGE MM ARTINARTIN H.H. WWEISSEISS,, MDMD

led to the development of Sections that represent the “focused” interests of our membership. United We Stand The leadership of the Sections will now Working Together to Secure the Future of Neurosurgery. participate in the deliberations of the AANS Board in order to enhance communication and understanding between the Sections and the AANS.

hank you for the honor that you have Research and Education Young Neurosurgeons bestowed upon me in allowing me to Medicine is facing an extraordinary chal- Since Active membership in the AANS T serve as President of the AANS. Dur- lenge from both the private health insurance requires certification by the American ing my tenure as President-Elect, I have industry, as well as governmental sources. Your Board of Neurological Surgery, the Royal gained a deep appreciation of the dedica- Association is actively involved at all levels to College of Surgeons (Canada) or the Mexi- tion of our leadership to the Association and ensure that neurosurgery is fully represented can Council of Neurological Surgery, A.C., to neurosurgery; it is my sincere hope to carry in such negotiations. Our ongoing focus on there may be a perception among young these efforts forward in the coming year. growth and development of the discipline is neurosurgeons that they are not included essential if we are to ensure the position of neu- in the programmatic efforts of the AANS. Speaking up for Neurosurgery rosurgery in the hierarchy of medical practice. Nothing could be further from the truth! The AANS has been the spokesorganization This growth can only come from contin- Young neurosurgeons tracking for their for North American neurosurgery since ued investment in R&D by the Association and Boards are eligible for Active (Provisional) 1965, serving as the neurosurgical voice on all of the agencies and organizations that it rep- membership and residents in training may such topics as managed care reimburse- resents and supports. The Research Founda- participate in the AANS as Candidate mem- ment, FDA regulations and socioeconomic tion of the AANS actively supports neurosur- bers. All members at every level are encour- affairs. The Association has broadened its gical research efforts at every level, and its aged to participate in the activities of the membership base by welcoming into its recent decision to combine translational Association. The Chairman of the Young ranks certified neurosurgeons from Canada Neurosurgeons Committee now partici- and the Republic of Mexico. We also have Martin H. Weiss, MD, pates in the Board deliberations so that the invited representatives of their leadership is President of the AANS specific issues confronting our younger to attend our Board of Directors’ meetings and Professor and membership can be brought to the atten- as a way to enhance the relationship with Chairman of the Depart- tion of the Board in a very direct way. our North American colleagues. ment of Neurological Surgery at the School of Broader Representation Communications Medicine of the University During the past year, the AANS leadership The Bulletin constitutes one of numerous of Southern California has made a deliberate effort to reach out to communication efforts of the Association. our constituency. We recognize that this is a It is our major vehicle for the dissemina- research efforts (including clinical research) two way street - the leadership must have tion of Association-related material and so- with the strong basic science program presently input from our members to develop the pro- cioeconomic news. Including information in place bodes well for the development of new grams best designed to meet their needs. on CPT coding, legislation, managed care fundamental precepts for neurosurgical care. In the past, we have broadened participa- markets, and outcomes studies. It is your In terms of continuing medical education on the Board of Directors by developing forum for comment to the membership tion, the Association’s Professional Devel- the quadrant representative positions, thereby about such issues, and I would strongly en- opment Program offers the premier vehicle assuring input to the Board from each State courage you to bring your resources to the for dissemination of technical, cognitive Neurosurgical Society. With the addition of membership through this vehicle. and socioeconomic information relevant to Board participation by Section leadership and Our major scientific publication is the our practices. It continues to enjoy great the Young Neurosurgeons Committee, your Journal of Neurosurgery. Combined with its success in service to the membership. organization embraces every aspect and need online edition, Neurosurgical Focus, the of the entire community of neurosurgeons. Journal provides sophisticated peer re- Subspecialization I look forward to working with and for viewed neuroscience pertinent to our Although the AANS remains officially opposed you in the coming year in the firm convic- present practice, as well as the potential to “certified subspecialization” in neurosurgery, tion that our united efforts will assure that growth of neurosurgery. we clearly recognize the evolution of special- the stature of neurosurgery in the medical ized areas of interest. This understanding has community is sustained. ■

2 Spring 1999 • AANS Bulletin NN EWSLINEEWSLINE NewsMembersTrendsLegislation

FROM THE HILL

n AANS and CNS Endorse “Quality Health Care Coalition Act.” On March 25, 1999, the AANS and CNS participated in a press conference held by Representatives Tom Campbell (R-CA) and John Conyers (D-MI) announcing the introduction of H.R. 1304, the “Quality Health Care Coalition Act of 1999.” This bipartisan legislation would allow physicians to collectively negotiate the terms and conditions of their contracts (including fees) with health plans, without violating the antitrust laws and without joining a labor union. Under the bill, a group of health care professionals engaged in negotiations with a health plan would be entitled to the same treatment under the antitrust laws as bargaining units, which are recognized under the National Labor Relations Act. The AANS and CNS believe that this bill will help level the playing field between health plans and physicians so doctors can negotiate terms that are beneficial to both them and their patients. Gary C. Dennis, MD, a neurosurgeon from Washington, DC, who represented the AANS and CNS at the press conference, said, “This legislation is an important step in shifting medical decision making power away from health plans and back to physicians and patients, where it belongs.”

n National Bipartisan Commission on the Future of Medicare Fails to Agree on Reform Proposal. The National Bipartisan Commission on the Future of Medicare failed to approve Commission Co-Chair Senator John Breaux’s (D-LA) proposal for Medicare reform. The 17-member commission was required by the Balanced Budget Act of 1997 to make recommendations to the Congress on how Medicare could be restructured to modernize the program and extend the life of the Medicare Trust Fund. The Breaux proposal would have used the Federal Employees’ Health Benefit Program as a model for Medicare. Under this plan, Medicare beneficiaries would be given a defined contribution from which they could choose health insurance coverage from a number different health plans. Senator Breaux expects to offer legislation based on the recommendations he presented to the Commission. Senate Finance Committee Chair William Roth (R-DE) plans to mark-up this legislation later this spring.

n Debate on Managed Care Reform Heats Up. On March 18, 1999, the Senate Health, Education, Labor and Pensions (HELP) Committee passed along party lines the Senate Republican Leadership “Patients Bill of Rights” (S. 326). Through participation in the Patient Access to Specialty Care Coalition, the AANS and CNS supported a number of democratic amendments aimed at strengthening the bill’s provisions related to choice of physician and access to specialty care. On March 24, 1999, the House Commerce Health Subcommittee held a hearing on patient protection legislation. This committee tentatively plans to mark- up a bill later this spring. Other committees working on managed care reform legislation include the Senate Finance Committee and House Ways and Means and Education and Workforce Committees.

■ AMA Decides Against Union. Despite complaints from its members regarding managed health care and the loss of physician autonomy, the American Medical Association (AMA) has decided not to form a union. In a recent statement, D. Ted Levers, MD, Vice Chair of the AMA Board of Trustees, said, “The AMA has decided that it will not form a national labor organization representing physicians at this time. We have considered the matter in depth, and we realize that forming a collective bargaining unit has profound implications for the AMA, the medical profession and our patients. The issue is so complex, and of such far-reaching impact on the practice of medicine and patient care, that the matter requires careful and thorough consideration by the House of Delegates before it selects a course of action.”

Spring 1999 • AANS Bulletin 3 NN EWSLINEEWSLINE NewsMembersTrendsLegislation

AANS APPOINTS NEURO NEWS NEW EXECUTIVE DIRECTOR David Fellers, CAE, currently Executive AANS/CNS Support the use of Placebo Surgery in Clinical Trials Director of the American There are currently two National Institutes of Health sponsored studies being conducted on Parkinson’s Society of Plastic and Disease patients that use placebo control groups and several other similar studies under consideration. The Reconstructive Surgeons AANS and CNS have issued a position statement in support of such placebo surgery research studies. in Arlington Heights, Illinois, has been named AANS/CNS Position Statement on Placebo Surgery the new Executive Director 1. The AANS and CNS support the conduct of rigorous validation trials to insure that new operative of The American Associa- procedures are safe and effective. tion of Neurological 2. In certain specific neurological conditions, the use of “placebo surgery” may reduce investigator and Surgeons. The announce- patient bias in analyzing treatment outcome and, therefore, increase the likelihood that results of a trial ment of his appointment was made during the will be interpreted correctly. AANS Annual Business Rationale Meeting April 26, 1999, in New Orleans. Mr. Fellers’ Major scientific and technological advances in recent years have resulted in new opportunities to apply appointment will become innovative medical and surgical therapies to the treatment of complex neurological diseases. In the interest of effective in July. public health, it is critical to insure that these new treatment alternatives are safe and effective before they are put into widespread usage. In most situations, trials in human subjects are necessary to determine the effec- tiveness or safety of a new drug or procedure. The most reliable trials are those conducted prospectively and TRIBUTE TO LESTER A. in which the treatment in question is compared with either no treatment or an alternative treatment. For new MOUNT, MD Lester A. Mount, MD, drug therapies, the benchmark clinical investigation involves a placebo or control group, which is blinded to President of the AANS the patient and physician investigators. For trials involving surgical procedures, this type of study is compli- from 1976-77, died on cated by the fact that the patients and physician both know whether the patient underwent the procedure. In March 27, 1999. Dr. certain types of trials, this knowledge may introduce bias into the analysis of results, particularly when the Mount, a 51-year member endpoints are somewhat subjective in nature. The use of a placebo surgical control group, may in certain of the AANS, was situations, reduce this bias. It is clear that increased objectivity in results analysis is desirable and could feasi- Professor Emeritus of bly protect the public welfare by insuring that an invalid or dangerous procedure not achieve widespread Clinical Neurological usage following incorrect interpretation of initial results. Surgery at Columbia Therefore, the AANS and CNS support the use of placebo surgery in clinical trials, but under limited and University’s College of carefully selected guidelines: Physicians and Surgeons. a) each prospective study should be evaluated individually by appropriate federal and/or local institu- Dr. Mount was the tional oversight committees to determine if a placebo surgery group is necessary to determine accurate recipient of the 1989 AANS Cushing Medal. results b) the placebo procedure should be as safe as possible and designed so as to properly blind the study and insure accurate analysis of the results c) patients must be fully informed as to the nature of the study, necessity for the placebo control group, risks of placebo procedure and treatment alternatives

4 Spring 1999 • AANS Bulletin Is subcertification good for neurosurgery?

By Barbara Peck

ubspecialization is a controversial topic that organized neurosurgery, and other medical specialties, has been debating for the greater part of the past decade. Should fellowship-trained neurosurgeons qualify to sit for Cer- Stificates of Added Qualifications under the American Board of Neurological Surgery? Should subspecialties that cross more than one currently recognized specialty, like Pain Medi- cine, be allowed to form their own boards, or issue joint specialty subcertificates? Or, should every neurosurgeon, equally trained in residency, receive the same specialty qualifications, regardless of whether an individual chooses to focus on a specific area of the field, therefore representing a single, united definition of “neurosurgeon” to patients, third-party payers and referring physicians?

The American Board of Medical Specialties The American Board of Medical Specialties (ABMS) is made up of representatives from its 24 approved medical specialty boards, including the American Board of Neurological Surgery. The ABMS charges itself with the mission of maintaining and approving the quality of medical care by assisting member boards in their efforts to develop and utilize professional and educational standards for the evaluation and certification of physician specialists. Member boards must adhere to the standards set by the ABMS in relation to how certificates are awarded, and cannot change certification requirements without the consent of the ABMS. Each member board Currently, the 24 member boards issue certificates in 37 areas of must have strict, written criteria for issuing board certification in- general specialization and certificates of special or added qualifica- cluding residency requirements, case load requirements, written tions in 75 areas. and oral exams and more. One of the reasons the ABMS was initially created in 1933, was to standardize the definition, training The American Board of Neurological Surgery and certification of medical specialists. The American Board of Neurological Surgery (ABNS) is the rec- The ABMS also establishes standards for the approval of new ognized ABMS board for neurosurgery. There are 14 directors specialties and subspecialties. In order for a new board to join the in the ABNS that represent the following organizations: The ABMS, it must receive approval by both the ABMS and the Ameri- American Association of Neurological Surgeons (4); Society of can Medical Association’s Council on Medical Education (AMA/ Neurological Surgeons (3); American Medical Association (2); CME). The process begins with an official application to the Liai- Congress of Neurological Surgeons (2); American Academy of son Committee for Specialty Boards, an organization sponsored Neurological Surgeons (1); American College of Surgeons (1); by the ABMS and the AMA/CME. Six of the 24 members have been and Neurosurgical Society of America (1). Upon successful approved since 1949, and the last medical specialty board approved completion of both the written and oral board exams, appli- was the American Board of Medical Genetics in 1991. cants are rewarded with specialty certification in neurological Once a board is approved as a member of the ABMS, it can issue surgery. The ABNS does not currently recognize or issue any both primary certification certificates and subspecialty certificates. subspecialty certificates.

6 Spring 1999 • AANS Bulletin Non-ABMS Recognized Boards boards, including Internal Occasionally, a group of physicians create a separate board that is Medicine, offer up to 10 not officially recognized by the ABMS. These types of boards in- different subcertificates. clude the American Board of Pediatric Neurosurgery, American Different boards may Board of Pain Medicine and American Board of Spine Surgery. also issue joint These boards set their own standards and criteria for certification, subcertificates with other and are completely independent, self-designated boards. Certifica- boards. In this case, appli- tion from these boards is usually not recognized by third-party pay- cants would first pass their ers, hospital review committees or the medical community. respective board’s general “Although some of these boards incorporate testing measures exam and then meet the and review of training, they have not demonstrated the program additional criteria to sit for review and quality control integral to the process of the ABMS,” certification. For example, said Sidney L. Tolchin, MD, 1995-96 AANS President, in Neurosur- the American Board of Orthopaedic Surgery, American Board gical Focus. “Self-designation can be accomplished, therefore, by of Plastic and Reconstructive Surgery, and the American Board listing oneself as such on a name plate, placard or by advertising in of Surgery jointly sponsor a subspecialty certificate in hand sur- a medium such as the Yellow Pages.” gery. Likewise, the sports medicine subcertificate is jointly spon- However, the concept of only recognizing ABMS boards has re- sored by the boards of Family Medicine, Internal Medicine, cently been challenged as self-designated boards upgrade and es- Emergency Medicine and Pediatrics. tablish strict criteria for certification. The American Board of Pain Most Certificates of Added Qualifications are granted after for- Medicine recently achieved “ABMS equivalent” status in the state mal post residency training in the form of an Accreditation Coun- of California. cil for Graduate Medical Education (ACGME) approved fellow- “I consider myself double-boarded – both by the American ship. The ACGME is made up of the American Medical Associa- Board of Neurological Surgery and the American Board of Pain tion, Association of American Medical Colleges, American Hospi- Medicine,” said Kim Burchiel, MD, former President of the Ameri- tal Association, Council of Medical Specialty Societies, and the can Board of Pain Medicine. ABMS. The ACGME works with each ABMS approved board to set The American Board of Pain Medicine is made up of pain spe- up Residency Review Committees (RRC) in each specialty area. cialists from neurosurgery, neurology, anesthesiology, and other RRCs set and monitor the criteria and quality of both residency specialties. The group has officially applied to the ABMS for offi- programs and approved fellowship programs. cial recognition, but has not yet received a response. “Currently in neurosurgery, there are no ACGME approved fellowships,” said Julian Hoff, MD, Chairman of the AANS/CNS Fel- Levels of Subspecialization lowship Task Force. “There is a lot of inconsistency in the duration Official recognition of subspecialization can be accomplished at and quality of neurosurgery fellowships right now. One of the rec- various levels. The highest level is the creation of a separate board ommendations of the Task Force is to change this and formalize for the specialty. A board may offer different primary certificates as the fellowship process in neurosurgery.” a way of distinguishing members with varying backgrounds and The AANS/CNS Sections have been charged with developing interests. These candidates take different initial written and oral fellowship criteria for their respective areas. Pediatric neurosurgery board examinations. For example, the American Board of Radiol- fellowships are currently accredited through the Accrediation Coun- ogy allows its applicants to choose between four different general cil for Pediatric Neurosurgery Fellowships (ACPNF). certificates: Diagnostic Radiology, Radiation Oncology, Radiologi- “Pediatric neurosurgeons were concerned with the lack of qual- cal Physics or Radiology. ity in their educational experience and, therefore, created a mecha- A board also may offer subcertificates in a specific area. In nism to inspect and establish fellowship guidelines and monitor order to obtain a subcertificate, the applicant must first pass the programs for content and quality,” said Marion L. Walker, MD, primary exam in that specialty. There are additional criteria an Chairman of the AANS/CNS Section on Pediatric Neurological applicant must meet in order to sit for a subcertificate exam, Surgery. which in most cases involves additional, officially approved train- “The ACPNF accreditation process is rigorous and mirrors the ing. For example, radiology offers four subcertificate areas in parameters set forth by the RRC. It is our hope that one day, coun- addition to the nine primary certificates; the American Board of cils like the ACPNF will cease to exist and that accredited subspe- Anesthesiology offers subspecialty certificates in critical care cialty training will fall under the auspices of the ABNS.” medicine and pain management; and the American Board of Otolaryngology offers subspecialty certificates in otology/ neurotology and pediatric otolaryngology. Some of the larger continued on next page

Spring 1999 • AANS Bulletin 7 continued from page 7

Subspecialization Within Neurosurgery control,” Martin H. Weiss, MD, President of the AANS, said. As medicine evolves and technology progresses, the question of If the ABNS decides to issue subcertificates, then they must go subspecialization within neurosurgery is coming to a head. Should through the ABMS subcertificate process, which includes comment subcertificates be offered, or should the integrity of the general from other organizations. For example, when the American Board neurosurgeon be supported? of Otolaryngology proposed its neurotology subcertificate, the “Subspecialization within neurosurgery is nothing new. It is ABNS had considerable comment and was successful in altering about time we recognized these doctors for their additional train- what procedures would be included for this subcertificate. ing,” Dr. Walker said. “Subcertification is a simple way to provide Over the past decade, there have been several debates between neurosurgeons with the appropriate recognition for their current specialties that have led to joint subcertificates or the denial of and focused expertise, support continuing medical education and subcertificates, including battles between plastic surgery and oto- provide the quality of care our patients deserve and demand.” laryngology for reconstructive facial surgery (see page 11 for the Presently, the ABNS is discussing four possible options for ad- highlights of this struggle). dressing subspecialization “Our experience in plastic surgery has been, whether you like it within neurosurgery: 1) Make or not, in areas where there is direct competition from other spe- no changes; 2) maintain ac- cialties. You have to offer a subcertificate or be prepared to lose that “Subspecialization creditation/credentialing as is, area completely,” said Kenna Givens, MD, Chairman of the Ameri- within neurosurgery but formalize the various can Board of Plastic Surgery. “We did not necessarily want to offer subspecialties’ role in the subcertificates, but felt it was in the best interest of our specialty.” is nothing new. It is ABNS (ie: examiners, guest examiners, exam questions, Is Subspecialization the Trend? about time we etc.); 3) accredit neurosurgery Is subspecialization the answer to protecting the public against recognized these fellowships through the unqualified practitioners, improving patient care, enhancing trans- ACGME, but do not offer lational research and advancing the specialty of neurosurgery? Many doctors for their subcertificates; or 4) accredit would say, “Yes,” arguing that healthcare trends toward centers of and offer subcertificates. excellence, reduced length of stay and overall hospital cost empha- additional training.” Accrediting neurosurgical size the need for subspecialization. fellowships through the Others, however, including some managed care organizations ○○○○○○○○○○○○○ ACGME is not an easy task. that operate with one neurosurgeon for every 50,000 enrollees, be- —MARION L. WALKER, MD ACGME requires that there be lieve that the future of medicine rests in the hands of the generalist. at least 25 potential programs They caution against the fragmentation of medical services that in the area and the board must results from overspecialization, and argue that the all-purpose, do- issue statements on the impact the fellowship will have on the core everything generalist is more marketable to third-party payers. curriculum in the specialty, among other criteria. According to With all that is happening in today’s fast-changing healthcare ACGME, fellows involved in an approved program cannot be paid environment, the debate surrounding subspecialization will con- for their work. This, combined with the fact that the grace period tinue to be a source of controversy for years to come. ■ for federally issued student loans does not extend into fellowships, puts great financial strain on both the program and the fellow. There We Want to Hear From You are several categories in other specialties where ACGME approval has been awarded, but no fellowship program has applied. The American Association of Neurological Surgeons is “Fellowship material is not supposed to be a significant part of the interested in hearing your thoughts on subspecialization. core curriculum for that specialty,” Don Quest, MD, ABNS Secretary, Direct your comments, questions, or concerns to the attention said. “If we grant spine fellowships, we are saying that spine is not a of A. John Popp, MD, Editior of the Bulletin, and send them via significant part of the core curriculum for neurosurgical residents. The fax to (847) 692-2589, via e-mail at [email protected] or post your proposal also must be reviewed and approved by the entire ABMS, feedback on NEUROSURGERY://ON-CALL®. including our competition. We want to help neurosurgeons, not open ourselves up to infringement by orthopedic surgeons.” To access the N://OC® site, go to www.neurosurgery.org and Another proposal being considered is to accredit neurosurgical click on “Professional Pages.” There, you will find a link for the fellowship programs through the Society of Neurological Surgeons, AANS Bulletin Board, select the link and share with us your which is comprised of program directors. views on subspecialization. “This concept may allow us to recognize neurosurgeons who did additional training, but keep it in house where we have better

8 Spring 1999 • AANS Bulletin The Pros and Cons of Subspecialization

aspects of intracranial surgery, but is most specialized in spinal Subspecialization: The Inevitable Road We Must Travel surgery. Unfortunately, this degree of specialization has come at the cost of other disciplines previously occupied by neurosurgery, such as KIM J. BURCHIEL, MD peripheral nerve surgery, peripheral vascular surgery (i.e. carotid endarterectomy), and pain surgery. We need to broaden our “special- We are neurosurgeons because our predecessors ized” practices to re-incorporate these areas into the practice of chose to develop neurological surgery as a YES! neurological surgery. specialty of general surgery. The question before us now is whether further specialization in our field will promote progress Broadening the Neurosurgical Horizon and development in neurological surgery, or simply fragment an already In my opinion, any perception of an “oversupply” of neurosurgeons is small discipline into a series of segmented, “special interest” groups. based on an unnecessarily limited definition of neurological surgery. I am of the opinion that advancement in our specialty can only be Expanding the horizons of neurological surgery will expand the fostered by a concentration of intellectual and creative effort in each number of neurosurgeons needed. Competition within neurosurgery is of the discrete subspecialties that compromise our field. The trick will largely based on overlapping, and in some cases, identical clinical be to advance the interests and practice of these subspecialties, experience of the competing practices. Specialization of practices while at the same time maintaining the fundamental integrity of may well promote collegial cooperation and cross-practice referral. neurosurgery as a whole. Furthermore, as a training program director, I am confident that Neurosurgery is already very specialized. The average neurosur- neurological surgery is simply too broad a discipline for every trainee geon has a broad range of competencies, including many, if not most, to become competent in every aspect of our specialty. There is simply not enough training time The Evolution of Vascular Surgery available to comprehensively BY BARBARA PECK train every resident in every subdiscipline. To that end, As medicine has evolved, almost every specialty In 1996, a group of vascular surgeons broke off subspecialization may provide has been faced with the question of subspecialization. from general surgery and applied to become their own our future neurosurgical The American Board of Surgery (ABS), which currently American Board of Medical Specialties recognized leaders with an opportunity to offers subcertificates in pediatric surgery, vascular board. The group argued that 1) Vascular surgery was expand their clinical and surgery, hand surgery and surgical critical care no longer a pillar within general surgery; 2) only academic skills, as well as medicine, has recently struggled with its vascular vascular surgeons should do vascular surgery; 3) only surgeon members on the role of subcertificates. vascular surgeons should teach vascular surgery; and provide them with a mechanism “The American Board of Surgery began awarding 4) vascular surgery is an intellectually and technically to promote scientific advance- the vascular subcertificate in 1983, as a way to unique specialty. The ABS responded with concerns ment within the field of develop the teachers of the future,” said Wallace about access to care, considering the uneven distribu- neurosurgery. Richie, MD, Executive Director of the American Board of tion of vascular surgeons and the belief that all general Surgery. “However, that is not what ended up happen- surgeons are trained with enough broad knowledge to Establishing Formal Training ing. We initially allowed surgeons to be grandfathered adequately care for many vascular patients. Guidelines in to the certificate and it began to be used as an “This was a huge crisis within surgery,” Dr. Richie Neurosurgery, as a core exclusive franchising license.” said. “We worked continuously for over a year directly discipline, can survive and By 1989, the situation had become so intense with the vascular surgeons to solve this issue.” thrive by emphasizing a core within the ABS that the Board developed an official In the end, the ABS was restructured to delegate policy against any other subcertificates. more of the responsibilities to the subspecializations curriculum during training, “It evolved so far that no one could perform within the structure of the Board. Sub-boards and such that fundamental vascular surgery unless they had the subcertificate,” advisory councils were created, and more vascular knowledge and skills are Dr. Richie said. “That was not the intent and the Board surgeons were added to both the surgery Resident imparted in every training fully believes that every general surgeon is adequately Review Committee (RRC) and as examiners. program. This core curriculum trained to perform these procedures. We wanted there “We had to change, evolve and develop as our is already under development to be a partnership between general surgeons and subspecialties continued to mature,” Dr. Richie said. by the Society for Neurological vascular subspecialists, not create vascular czars. The “My advice for other specialties going through these Surgeons and by The American decision to subspecialize created a potential tool tough times is to develop a core curriculum that is Association of Neurological toward pooling the surgical work force by establishing strong, don’t allow grandfathering, and keep communi- Surgeons and Congress of who can do what procedures.” cation at an all-time high.” Neurological Surgeons through Continued on next page

Spring 1999 • AANS Bulletin 9 The Pros and Cons of Subspecialization

Continued from page 9 their Sections. By necessity, the curriculum will be constrained by the five-year training period now accredited by the Resident’s Review Subspecialization — At What Cost? Committee. Subspecialty training should be reserved for fellowships, broadly defined as a period of postgraduate training of EDWARD R. LAWS JR., MD several months to years devoted to one of the component subspecialties of neurological surgery. The first disadvantage of subspecialization is the threat of fragmentation within our specialty. Neurosur- NO! geons really do need to stand together, because there Benefits of Subspecialization We can anticipate both immediate and future benefits to neurological are so few of us, and there are so many people who would like to move into the area of neurosurgery without having received the surgery, and to society at large, by further subspecialization in our necessary training to do so. The fewer voices that we have to combat practices: these threats, the more vulnerable we are to attack. Excessive subspecialization also may lead to a loss of perspective, ● Concentration of experience and expertise, particularly in less meaning that individuals who are devoted to a narrow window of the field common disorders; may lose interest and their ability to contribute to organized neurosurgery ● Promotion of excellence in the subspecialty by subspecialized as a whole. This, of course, is an intellectual disadvantage that we cannot societies and journals, didactic and hands-on special courses, and afford. And, one would hope that neurosurgeons who decide early in their research awards; careers to concentrate on a particular aspect of the field might remain ● Promotion of research in the specialized subdisciplines of vitally interested in neurosurgery and clinical neuroscience in general. neurosurgery; This loss of perspective can be translated into a loss of versatility, ● Maintenance of our leadership in areas where we are currently if individuals completely abandon segments of neurosurgical practice. “sole source” providers (i.e.: surgical neuro-onclogy, In such cases, a superspecialized neurosurgeon may not function neurotraumatology, and functional neurosurgery); and very well in a group when it comes to taking a call or handling an ● Enhanced competition with other disciplines for overlap areas (i.e.: emergency. Once again, a certain amount of expertise and a broad spine, pain, peripheral nerves, vascular/endovascular surgery, knowledge base need to be maintained by us all. radiosurgery, and craniofacial surgery). Impact of Subspecialization There is no doubt in my mind that if we allow neurosurgery to fragment There certainly is an impact from subspecialization on the training of into separate component disciplines, we will lose our identity in organized neurosurgical residents and fellows, and on the shaping of the medicine, and cease to be recognized by a public to whom neurosurgery is neurosurgeon’s career. Because we see a perceived need to become an synonymous with superlative clinical medicine. The problem is that without expert in a certain area and to obtain additional credentials, both for subspecialization, neurosurgery as a specialty will certainly stagnate both career building and in some instances to find a job, pressures exist that clinically and scientifically. The prospect is surely too dismal to contem- have led to an increased training period. There is a growing desire on the plate, particularly as we enter a new millennium that will see a continued part of trainees for fellowship experiences following ordinary neurosurgical acceleration in the growth of our understanding of basic neuroscience and training, and for early decisions on the part of our residents, which may in the function of the human nervous system. some cases preclude a broad-based education and residency experience. Further subspecialization will continue to occur in neurosurgery, One aspect of subspecialization that is apparent in some of our with or without the various regulatory bodies of our discipline. The colleagues who do coronary bypass surgery is the phenomenon of challenge to us is not how to limit subspecialization, but how to boredom and burnout. Although everything we do involving the maintain the connections nervous system is exciting, if one works in too narrow of a field the that tie us together as a risks of becoming humdrum and commonplace do exist. In individuals specialty. who are working extraordinarily hard in a very narrow area, the phenomenon of burnout can readily occur.

Kim Burchiel, MD, is Chairman of Neurosurgery is a great profession and it should be for all of us. the Department of Neurological Part of the fun is the daily challenge of confronting difficult disorders Surgery at Oregon Health affecting the nervous system. If subspecialization limits the experi- Sciences University. A 14-year ences that produce so much in the way of professional rewards, then member of the AANS, Dr. Burchiel is the Secretary/Treasurer of the we need to look at the costs that we pay for a subspecialty career. AANS/CNS Section on Pain and a former President of the American Edward R. Laws Jr., MD, is Professor of Neurological Surgery and Medicine at the Board of Pain Medicine. University of Virginia. A 24-year member of the AANS, Dr. Laws served as the 1997- 98 President of the AANS and is the current Chair of the AANS Nominating Committee.

10 Spring 1999 • AANS Bulletin GG UESTUEST CCOLUMNOLUMN KR ATIEUSSELL ORRICO L. TRAVIS, MD

readily the subspecialists who frequently perform the procedures patients want and How One Specialty need, with good result. For example, otolaryngologists, whose residencies include as much or more train- Experienced Subpecialization ing than do plastic surgery residencies in facial plastic surgery, for years had diffi- culty explaining to patients and colleagues and Certification the true nature of that training. Language often compounded the problem, since Interview with the President of the American Board of older certifying boards have Greek names Facial Plastic and Reconstructive Surgery. and younger boards have English names. Surveys have shown that patients have no idea what a certificant of the American Board of Otolaryngology actually does, hile the debate continues over ample of a medical specialty that reluc- and the ABMS has prevented the certifi- whether it is in the best interest tantly, but for compelling reasons, chose to cation board from adding “Head-and- of medicine for specialties to establish its own specialty certifying board Neck Surgery” to its name. Wdevelop their own self-ap- to provide its colleagues and the public with Emerging specialties typically take pointed boards, recent developments in- a recognizable landmark for identifying some years to become ABMS members. dicate that a growing number of them surgeons with particular training and ex- They grow up, meanwhile, outside the are nevertheless choosing to do so, hop- perience in facial plastic surgery. ABMS. They may be perfectly legitimate ing to gain recognition for their highly boards, but for a variety of reasons, they specialized skills and enhance their Peter A. Adamson, are not initially welcome under the specialty’s ability to meet the growing MD, President of the ABMS umbrella. They may not fit the needs of the medical consumer. American Board of ABMS technical definition of a subspe- Supporters of this trend argue that cer- Facial Plastic and cialty. They may be opposed by some in tifying subspecialty boards are integral to Reconstructive Surgery. the parent specialty board who fear the their particular, dynamic subspecialty splintering of the medical specialty. Or, and that they are the inevitable result of an incumbent ABMS board may feel its an expanding knowledge base, techno- “turf” is threatened. logical advancements and biomedical All of these factors, at one time or developments. They firmly believe that What do you view as the driving another, stalled the development of an such boards provide them with a mecha- Q:force behind subspecialty boards? ABMS pathway for subcertification of nism for recognition, as well as give third- otolaryngology-trained facial plastic party payers a means to identify those Subspecialty boards are a natural surgeons. In response, these surgeons physicians with reimbursable expertise. A:outgrowth of rapidly expanding established their own subspecialty Those opposed to subspecialty boards medical technology and knowledge. To de- board, the American Board of Facial disagree. They argue that such boards will liver the benefits of new medical technol- Plastic and Reconstructive Surgery. result in the fragmentation of too many ogy and knowledge to patients, doctors of- Since the ABFPRS’s establishment in medical disciplines and may actually limit ten find they must focus their practices in 1986, the board has earned universal rec- a patient’s access to care. They fear that cer- narrower, deeper areas of their primary ognition as a board equivalent to the tified subspecialty boards will negate the training. Although their primary training ABMS primary boards. Although this ac- role of the generalist and, in turn, place is certified by member boards of the tion has prompted the ABMS into trying those who choose not to subspecialize at an American Board of Medical Specialties to develop an alternative subcertification unfair market advantage. (ABMS), doctors who further focus their pathway, the ABFPRS continues to be the Following are some highlights from a re- training and practice often desire to un- only board that certifies surgeons exclu- cent interview conducted with Peter A. dergo examinations to verify their addi- sively in facial plastic and reconstructive Adamson, MD, President of the American tional training and experience. They un- surgery. Although outside the ABMS fold, Board of Facial Plastic and Reconstructive derstandably reason that subcertification the ABFPRS has become, de facto, the con- Surgery (ABFPRS). The ABFPRS is an ex- will enable patients to identify more continued on next page

Spring 1999 • AANS Bulletin 11 GG UESTUEST CCOLUMNOLUMN CONTINUED R USSELL L. TRAVIS, MD

continued from page 11 the plastic surgery board (which was every state that has reviewed it for such formed in 1937, but did not earn approval equivalence. joint board for the two primary ABMS spe- until 1941). Hospitals, like many other medical cialties that have long competed for the In the case of otolaryngology, all the spe- institutions, will also have to recognize same “medical turf” — plastic surgery and cialty societies have actively supported those specialties. If the ABMS lags be- otolaryngology. subspecialization for the reasons I have hind or is held back by the politics of its stated above. Fragmentation has not been incumbent boards, hospitals will have to Who wants subspecialty boards a real problem. make their decisions without ABMS Q: and why? definition. Science will move on with or What do you see as the competi- without the ABMS. This question might better be Q: tive effects of subspecialty boards Legitimate boards, whether in or out A: phrased, “Who doesn’t want subspe- in the medical community? of the ABMS, are easily recognizable. All cialty boards and why?” After all, what could require accredited residencies and a rig- possibly be objectionable about subspe- If science develops the technology orous psychometrically validated exami- cialty boards, if they give patients an easier A: for a new specialty or subspecialty, nation. Hospital staffs should have no way to identify doctors who perform pro- it will happen and any “competitive effects” problem recognizing legitimate boards. ■ cedures they need, and give third-party pay- will be inevitable. We ought to be about ers a means of more readily recognizing providing useful, truthful information to reimbursable expertise? patients about such specialties in terms they Those who don’t want subspecialty can understand. If consumers gain such in- For more information on the boards include some within the ABMS. Al- formation about subspecialization, they though the ABMS has carried out its task will cast their economic ballots in the mar- ABFPRS’s journey toward of defining specialties, facial plastic ketplace more efficiently. Who could legiti- subspecialization, please surgery’s experience has suggested that mately be opposed to that? ABMS’s policies may not have kept up with contact:

Peter A. Adamson, MD “What could possibly be objectionable about subspecialty President, American Board of Facial Plastic and Reconstructive Surgery boards, if they give patients an easier way to identify One Prince Street, Suite 310 Alexandria, Virginia 22314 doctors who perform procedures they need, and give Phone: (703) 549-3223 Fax: (703) 549-3357 third-party payers a means of more readily recognizing reimbursable expertise?” the rapid growth of emerging specialties. What does the growth of “self-des- The AANS Bulletin provides Because the strong forces driving Q: ignated” boards mean at the state subspecialization continue whether the level and on hospital credentialing? this column as a forum for ABMS chooses to recognize them or not, opinions. Ideas expressed many physicians practicing non-ABMS Because the ABMS has not dealt ef- within are not an endorsement subspecialties, like facial plastic surgeons, A: fectively with legitimate new of ABMS-independent board have been forced to establish their own boards in some emerging specialties like fa- certification, and do not reflect boards. The ABMS disapproves of these cial plastic surgery and pain medicine, state official policy of The American competing boards, but we should remem- medical regulators have been forced to adopt ber that many ABMS boards began their regulations to determine which are “legiti- Association of Neurological life as “self-designated” boards, including mate” or “equivalent” to ABMS boards. Surgeons. the otolaryngology board (which was The ABFPRS has been found equiva- formed before there was an ABMS) and lent to primary boards of the ABMS in

12 Spring 1999 • AANS Bulletin N EUROSURGICAL FELLOWSHIPS D AVAVID I D F.F. JJIMENEZIMENEZ,, MD,MD, FACSFACS

CNS Task Force to address the issue of fellow- Neurosurgical Fellowships ships in the United States. The recommendations of the Task Force were presented in a re- Recognizing the Need for Improved Post-Residency cent Bulletin article (Spring 1998, pages 10-11). Among the Task Force recommendations, was Training Programs. a request for the development of standards for fellowships by the individual Sections. This process is currently taking place. Whether one agrees with fellowship train- pecialization of labor and skills has to 24 months, with the majority being ap- ing in neurosurgery or not, the reality is that been part of human culture through- proximately 12 months in length, thereby post-residency training programs exist and out history. Acquisition of new ideas demonstrating the wide variance between S significantly impact our specialty. We have and concepts has led to an ever expanding programs. much more to gain by recognizing them, knowledge base which, in turn, leads to the This lack of standardization also is evi- standardizing their curricula and providing compartmentalization of much of that denced by the significant variance in the appropriate quality assurance for this very knowledge. An example of that process oc- total number of cases performed per year important aspect of neurosurgical training. curred in general surgery in the early 20th by the fellows in the different subspecialties. Fortunately, this process has begun. ■ century, when neurological surgery estab- Respondents indicated that the total num- TABLE 1 lished itself as a unique and separate entity. ber of cases done per year by specialty Number of Fellowships Currently Available in The very process that created neurosurgery ranged between 150 for oncology, to as the U.S. and Canada continues to affect our surgical specialty much as 10,371 for pediatrics and 9,585 for U.S. Canada today. As research and clinical investigations spine. More importantly, the median num- Cerebrovascular 16 1 continue to evolve, so too has the need to ber of yearly cases performed by each fel- Epilepsy 3 0 subspecialize. low also varies significantly, with as little as Endovascular 16 1 This evolutionary concept has been cor- 18 cases for peripheral nerve fellows to as Neuro-oncology 21 2 roborated by a recent survey of 141 neu- high as 550 for spine, and from 313 cases Trauma/Critical Care 13 2 rosurgeons who have finished residency for endovascular fellows to 300 cases for pe- Pediatrics 13 2 training during the last five years. Survey diatric fellows. Peripheral Nerve 1 0 results (84.3 percent response rate) indi- Spine 27 2 cated that, during the past five years, be- Impact of Fellowships Skull Base 5 1 tween 24 and 28 percent of respondents In order to ascertain the impact of doing a Stereotactic Functional 11 1 had pursued post residency training in the fellowship on the current practice of the form of a formal fellowship. surveyed neurosurgeons, they were asked Totals 126 12 Currently, there are 126 U.S. and 12 what percentage of their practice comprised Canadian programs offering fellowships their area of post residency training. Inter- TABLE 2 in 10 different areas (Table 1). Spinal sur- estingly, spine and pediatrics are the two ar- Percent of Current Neurosurgical Practice gery is the most common fellowship of- eas that made up the majority of the neu- Which Involves Area of Fellowship fered with 27 established programs in the rosurgeons’ practices. Pediatrics 82.6 U.S. Others include cerebrovascular, pediat- This appears to indicate that, currently, Spine 82.1 rics, trauma/critical care, and most recently, there is room for continued growth in these Stereotactic 49.0 endovascular neurosurgery. fields. In contrast, epilepsy and peripheral Endovascular 46.0 nerve accounted for the least percentage of Cerebrovascular 42.7 Variance in Neurosurgical Fellowship Programs their practices (Table 2). Another finding Skull Base 32.5 Although the first formal fellowships were was that, of the fellows surveyed, 74.8 per- Epilepsy 32.4 established in the late 1960s and early 1970s, cent were not in favor of subspecialty board Peripheral Nerve 10.5 there has not been any formal mechanism certification, but 73 percent did favor the established by organized neurosurgery to concept of establishing a subspecialty cer- David F. Jimenez, MD, FACS, is Associate Professor of standardize length of training, quality of train- tificate of added qualifications (CAQ). Neurosurgery at the University of Missouri School of ing or the ultimate goals of these fellowships. A resolution was passed at a recent meet- Medicine. An eight-year AANS member, Dr. Jimenez is Chairman of the AANS Young Neurosurgeons According to the survey, neurosurgical ing of the Council of State Neurosurgical Soci- Committee and a member of the AANS/CNS Task fellowships vary in length from two months eties, which called for the creation of an AANS/ Force on Fellowships.

Spring 1999 • AANS Bulletin 13 Outcomes Initiatives Outcomes Studies Now Available on N://OC®.

BY ROBERT E. HARBAUGH, MD

hether we like it or not, we are living in the era of Outcomes Committee Projects outcomes studies. Numerous agencies are involved Starting in 1998, our pilot study on the treatment of patients with in measuring the outcomes of neurosurgical care intracranial aneurysms got underway. The study evaluated patients and neurosurgeons are increasingly required to de- being treated for ruptured or unruptured intracranial aneurysms WWWfine and document the success of their interventions. by microsurgical or endovascular approaches. Disease-specific data WOften,W those evaluating the value of neurosurgical care have little reporting instruments were developed by Issam Awad, MD, and insight into the issues that arise in the care of our patients and, members of the Cerebrovascular Section Outcomes Committee. unfortunately, data from these studies will be used to determine Pilot centers for the study included academic medical centers and government policy, patient referral and reimbursement. The private practice groups. Patient accrual ended on January 31, 1999; leadership of the AANS and CNS has recognized both the threat however, follow-up on these patients and data analysis will con- and the opportunity that reliable outcomes studies posed for tinue through 1999. The aneurysm study will be placed online in organized neurosurgery and, in 1997, I was asked to develop an effort to expand the number of neurosurgeons participating in this initiative. the program. The first step was to create a strategic plan for developing a neurosurgical outcomes initiative. The strategic plan included: 1) Organizing an Outcomes Committee with expertise in clinical neurosurgery, outcomes methodology and information technol- OUTCOMES INSTRUMENTS AVAILABLE ON N://OC® ogy; 2) initiating educational activities; 3) developing and performing a pilot outcomes study; 4) developing an online outcomes reporting system linked to the official Web site of the AANS and To access the Outcomes Section of NEUROSURGERY://ON-CALL®, ® ® CNS — NEUROSURGERY://ON-CALL (N://OC ); and 5) visit www.neurosurgery.org and click on “Professional Pages.” On the wel- performing online studies using this system. come page, select the “Outcomes” text link and type in your user name Over the past two years, we have met these goals. The Outcomes and password. In this section of N://OC®, you can browse through the Committee has representatives appointed by the Executive Com- latest Outcomes Sciences Newsletter, scan the outcomes reference library; mittees of each of the clinical neurosurgical Sections. The Com- view the outcomes studies in cerebrovascular surgery slideshow; access mittee also has members with particular expertise in outcomes teaching materials including methodology and information technology. Consultants from Out- “Principles of Guideline De- comes Sciences and the AANS Information Services Department velopment” and “Process of also contribute to the overall success of the Committee. Guideline Development and Committee members have developed educational materials for Dissemination”; and register ® the N://OC Outcomes page and have published articles in the for the Outcomes Sciences AANS Bulletin and in Neurosurgery. Outcomes-related topics have POINT System. been presented at the AANS and CNS Annual Meetings, Section Annual Meetings, and at Professional Development Program (PDP) courses. In fact, a PDP course in Outcomes Methodology is currently being developed, and we plan to continue our educational efforts as the rest of the plan unfolds.

14 Spring 1999 • AANS Bulletin The Committee has worked hard to develop a secure, reliable, Meeting AANS Members Needs online outcomes reporting system linked to the N://OC® Web site. The members of the Outcomes Committee are committed to We have reached this goal, and are working closely with Outcomes developing the necessary tools for neurosurgeons to participate in Sciences and the AANS Information Services Department to keep outcomes research in the most cost-effective manner. We are excited the submission of data safe and confidential. A full discussion of about the potential that exists for generating national and interna- the security systems developed for this outcomes project can be tional databases, determining the best practices and gaining insight found on the N://OC® outcomes page. into the value of our neurosurgical interventions. We hope that our neurosurgical colleagues will be as excited as we are and become in- Online Studies Available volved in this venture. If anyone has questions that are not addressed At present, there are two online studies available to all members on the N://OC® outcomes page, please contact me via e-mail at of the AANS and CNS. The first is a simple, one-page outcomes [email protected]. ■ reporting instrument that can be used for any neurosurgical diagnosis or procedure — the neurosurgical report card. The report card allows neurosurgeons to track basic outcomes measures, such Robert E. Harbaugh, MD, is a neurosurgeon at Dartmouth-Hitchcock Medical Center, nine-year AANS member, and Chairman of the AANS/CNS Outcomes Initiative — a as length of hospital stay, mortality, postoperative infection and team convened to provide tools to AANS/CNS members for use within their practice unplanned readmission or return to the operating room by CPT to measure, monitor and manage selected outcomes. and ICD-9 codes. Once the database is established, the individual neurosurgeon can compare his or her data to the overall database. HOW TO USE THE OUTCOMES SCIENCES POINT SYSTEM A more in-depth study on the treatment of patients with carotid artery stenosis also is online. The study, which began in January STEP ONE: Contact the AANS Information Services Department and request a registration form. 1999, evaluates the clinical, functional and The form will outline the terms of participation, including your agreement to submit all patient lesional outcomes of patients with carotid ar- information to the selected study that fits the inclusion criteria. tery stenosis treated by carotid endarterectomy or angioplasty and stenting. The out- STEP TWO: Fax back the signed form. Once the form is processed, you will receive your user name comes reporting system allows any member and password, which will give you access to the Outcomes Sciences POINT System Web site. of the AANS or CNS to enter all relevant data online. It is essential that every neurosurgeon STEP THREE: Access the Outcomes Sciences POINT System Web site, by visiting submitting data to the study report on all of www.outcomesciences.com/research and typing in your user name and password. Select the the patients they treat. There is no cost in- study in which you wish to submit patients. volved for AANS or CNS members and there are no patient or surgeon identifiers on the STEP FOUR: To enter a new patient, click on “Enter New Patient,” and type in the patient’s ID database. The identification code is kept at the number, history, comorbidities and pre-treatment results. When you are finished entering the AANS National Office and can be accessed information, click “Submit Form.” through the Internet, making submission of data via this system safe and confidential. STEP FIVE: To enter a form for an existing patient, click the appropriate “Next” link on the study The next study to go online will evaluate the grid and a new screen will appear for data entry. Select the text link that best corresponds to treatment of patients with lumbar disc disease. the appropriate answer listed on the physician or patient form. Select “Submit Form” when you Paul McCormick, MD, and other members of are finished entering the information. the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves have developed the STEP SIX: To receive a summary and analysis of data from your site and comparisons with other reporting instruments for this study, which sites, select the “Review Data” text link. should be online this spring. Once again, participation by all AANS and CNS members is STEP SEVEN: To exit the site, select “Exit” on the file menu of your Web browser. strongly encouraged.

For questions concerning this system or to receive a registration form, contact the AANS Information Services Department at (847) 692-9500.

Spring 1999 • AANS Bulletin 15 M ANAGED CARE JJ OHN A.A. KKUSSKEUDDKE,, MDMD

Diversification into multiple benefit products and distribution channels is key Changes in the Marketplace to the pursuit of these scale economies, The Managed Care Organization of the Future. since they bring in new volume without adding significantly to the costs of managing care. Robinson states that true network diversification will be an increasingly important comparative advantage in coming years, given the irreducible variation in con- he flood of defections from dawn of direct contracting and the squeezing sumers’ and purchasers’ preferences. the ravaged managed-care business out of the insurance middleman. Yet health T took a significant turn in late Decem- plans everywhere are in rapid expansion, di- The Fundamental Feature of Health Care ber 1998, as Prudential Insurance Co. agreed versifying into new networks, benefit designs, The main feature of health care is the het- to sell its ailing health care operations to Aetna distribution channels and geographic markets. erogeneity of consumers’ preferences and Inc. for $1 billion. The Aetna/Prudential deal In the March/April 1999 issue of Health providers’ capabilities. The continual flux in will affect about 6.6 million people nation- Affairs James C. Robinson explains that neu- supply and demand creates an enduring role wide and Aetna will become the nation’s larg- rosurgeons should be aware that although for the multi-product health plan as the est provider of managed care, with about 18.4 health care might be a local business, manag- nexus of contracts that links, coordinates and million members in HMOs according to a Los ing that care is a national enterprise. Many gives incentives to the many buyers and sell- Angeles Times article (December 11, 1998). health plans are eliminating their ownership ers of health care. Robinson states, “Health The proposed sale has alarmed doctors and plans have little to fear from the rhetoric of consumer groups, who fear the new company John A. Kusske, cutting out the middleman. Neither the in- will force patients to accept fewer services and MD, is Chairman of dividual consumer armed with a Medical doctors to accept smaller fees. The significance the AANS Managed Savings Account, nor the corporate pur- of this merger is related to a sea of change in Care Advisory chaser armed with a self-insured benefit pro- the health care insurance marketplace, and Committee. gram, can achieve provider rates and utili- represents the maturation of the current as- zation efficiencies comparable to those of- cending model of managed care; the multi- fered by large health plans.” product, multi-market health plan. The heterogeneity among providers also creates an enduring role for health plan net- Simultaneous Eclipse and Expansion linkages with provider systems, and almost works that cover every ZIP code and are It seems we are observing the simultaneous all of the national plans that plunged into ver- uniformly credentialized, contracted and eclipse and expansion of the managed care tical integration during the highmark of man- accredited. Health plans do not need to fear organization. HMOs are yielding one func- aged competition have since divested their that medical groups and hospital systems tion after another to purchasers and provid- staff models. will integrate into insurance and market- ers, thereby evoking questions about their At the same time, they are expanding rap- ing, once the regulatory demands for finan- future role and share of the premium dollar. idly in both scale and scope. According to cial solvency and the marketplace demands In addition, managed care plans appear to Robinson, organizational enrollments are up for network access are understood. be denying little care, notwithstanding all the and revenues are pyramiding as leading health Joint ventures between plans and pro- well-published horror stories and growing plans merge with and acquire their rivals, vider organizations are to be expected, as are complaints as HMOs become commonplace thereby demonstrating horizontal integration. long-term relationships between specific in America. As a result, the cost savings that plans and purchasers, but the diversified HMOs have achieved are in jeopardy. The Economics of Organization health plan will always participate in more In the 1990s, many markets have multiple Health plans must spread product develop- networks, products and markets than even managed care plans and multiple provider ment and pricing, utilization and quality the largest provider or purchaser. organizations, and vertical ownership rela- management, and computer information sys- As stated, health care is a local business. tionships are disintegrating. Large employers tems over large numbers of enrollees to hold But managed care—the development, pric- and purchasing alliances are retaining insur- down the administrative cost per enrollee. ing, and marketing of multiple provider ance risk and specifying benefit packages, and High patient volumes also are important for networks and benefit designs through mul- large provider organizations are accepting glo- obtaining discounts or attractive capitation tiple distribution channels in multiple geo- bal capitation. Pundits daily announce the rates from providers and suppliers. graphic regions—is a national business. ■

16 Spring 1999 • AANS Bulletin P RACTICE MANAGEMENT JJ AMES R.R. BBEAN,, MDMD

costs that some practices attain, serving as an achievable target toward which to aspire. Neurosurgery: The Cost of The problem with the idea is how to trans- late comparative cost data into management planning. For instance, Practice A may spend Doing Business $30,000/physician/year on medical records, while Practice B spends only $15,000. Clearly Cost Containment in Neurosurgical Practice. Practice B is better off. Or is it? The unan- swered questions are: 1) What does Practice n the not-too-distant, but receding past, those who continue to practice, and cannot B do differently that makes it more efficient, the establishment of a neurosurgical flee to friendlier economic climates, a change and 2) are all the costs accurately accounted? Ipractice in virtually any urban area prac- in the way a practice is managed is often the tically guaranteed a stable and substantial only alternative. Fee reductions are difficult to Responding to the Challenge practice income. Competition was limited, control; they are externally imposed. But, the The AANS is considering several ideas for payment was generous and growing, health other half of the revenue/expense equation is programs that will help our members re- plans were passive payment conduits, fees not. Expenses of practice are internal and spond to these challenges. Two strategies could be raised with impunity, and most within the control of the practice manager. come to mind. First, is to offer, or sponsor, a practice income was leveraged off global There is more reason than ever before to find unique quantitative practice analysis that surgical payments. ways to reduce costs of neurosurgical practice. itemizes internal office processes and assigns In the 1990s, however, the unthinkable oc- Recognizing the importance of expense an accurate cost to each. When costs exceed curred: neurosurgeons saw incomes fall, some levels to the success of neurosurgical prac- expectations, or benchmark goals, the pro- alarmingly, and managed care struck with re- tice, Edward R. Laws, Jr., MD, 1997-98 AANS cesses can be analyzed in detail, the reasons morseless “take it or leave it” indifference. Ar- President, appointed a Cost Containment for cost excess explained, and the process eas of high managed care concentration saw Task Force to examine ways of reducing costs modified. One such method is Activity- neurosurgeons pack up and leave. Some de- in neurosurgical practice. The Task Force, Based Cost Management, which uses a com- cided to retire to escape the hassle of practice, with John Kusske, MD, as Chair, met on sev- puter program to diagram office processes, liability threats and diminishing returns. Newly eral occasions to examine cost containment assign costs, and model alternative designs. trained neurosurgeons faced the disturbing strategies from three perspectives: 1) Reduc- The second strategy is to create compre- prospect of a financially insecure future. ing office expenses by making processes hensive practice management educational No practice anywhere, whether private or more efficient, 2) developing cost-effective programs for neurosurgeons. This includes academic, urban or rural, general or subspe- clinical pathways to make treatment effec- basic business theory and practical skills. It cialty, solo or group, can escape the financial tive and package pricing profitable, and 3) encompasses accounting and financial vise of falling reimbursements and rising initiating new clinical and business ventures statements, tax issues, integrated opera- practice costs. Medicare rates, rather than to expand competitive market share. tional and financial analysis, human being lower-end outlier fees, have become Most of the discussion focused on new resource management, marketing, contracting, the benchmark toward which commercial Medicare resource-based practice expense val- and strategic business planning. payers aim. Business expenses, for schedul- ues and the collection of practice data using The future success of neurosurgical ing battles, billing resubmissions, pre-autho- Activity-Based Cost Analysis or using an practice depends upon efficient manage- rizations, paper processing, and case man- American Medical Association Socioeco- ment and detailed business acumen. These agement communications, among others, nomic Monitoring Survey model to challenge two strategies, if implemented, should help have grown exponentially. low Health Care Financing Administration provide the missing link in neurosurgical Like most doctors, neurosurgeons are Medicare Fee Schedule values. training and practice. Further, it should do working harder for less. And, most find they Theoretically, the parallel benefit of this for neurosurgical business management are now interested in their HMO/PPO con- collective practice expense database is a bench- what plenary sessions and practical courses tracts, billing and business expenses, where mark against which participating practices do for professional practice. ■ they didn’t want to be bothered before. can compare themselves, looking for ways to cut costs. The data includes the range and Cost Reduction Imperative average costs for standard processes in the James R. Bean, MD, is a neurosurgeon in private There is often a feeling of resignation and pool of surveyed practices, such as billing and practice in Lexington, Kentucky. Dr. Bean is a 10-year AANS member, Associate Editor of the Bulletin, and fatality that follows the resentment, fear collections, record keeping, management, and Chairman of the Council of State Neurosurgical or anger of seeing income declines. But for so forth. It also would include the minimum Societies (CSNS).

Spring 1999 • AANS Bulletin 17 C ODING C ORNER G REGORY PPRZYBYLSKIRYZYBYLSKI, ,MD MD

modifier would help identify that the decompression was performed at a different Reimbursement Dilemmas location. Use of different ICD-9 codes, pair- The AANS/CNS Task Force on CPT Coding Responds to ing lumbar stenosis with 63047 and lumbar spondylolisthesis with 22630, should Challenging Coding Questions. further clarify the separate work performed.

When a procedure is done for lumbar Q:spinal stenosis, such as lumbar lami- Q:Is the microscope charge CPT 69990 20660, application of frame, is not appro- nectomy L2-5, and it is a bilateral proce- now an acceptable charge with CPT priate to code with 61751 for CT-guided dure, how would you code this operation 35301 for carotid endarterectomy? biopsy, as it is considered an integral part for Medicare? of that procedure. Code 69990 can be used with code The operations described by CPT A: 35301 as long as microdissection is Both codes 61751 and 61793 include A: codes 63047 and 63048 are consid- performed using a surgical microscope (not A: application of the stereotactic frame ered to be bilateral procedures. Therefore, just magnifying optical loupes). You should (20660). If you put the frame on somewhere neither can be used with a -50 modifier. If dictate in your operative note the reason for else in the hospital at a different time, then the operation includes only a laminectomy microdissection. However, it should be you could potentially code for the frame as of L2, L3, and L4 without any significant noted that carriers may still not reimburse 20660-59. Coding in conjunction with the foraminotomy or facet joint removal, then for this combination since it is somewhat radiation therapist depends on the work the appropriate code would be 63017. If unusual. Alternatively, this combination done by each. Some people do the whole significant foraminotomy and facet joint might trigger a manual review of the opera- procedure themselves and the radiation resection is performed at each level, then tive note by the payer’s medical director. therapist accounts for the radiation therapy the coding would be 63047 for the first using different codes. If the radiation thera- interspace and 63048 for each additional I periodically perform bone and wire pist does some of the work involved in interspace decompressed. Q:fusions, but cannot find an RVU for 61793, then both physicians should decide 22841. Should this code be used with a dol- how to split the work (i.e. one codes as an What is the proper code for placing lar amount or only for informational pur- assistant using the -80 modifier, or both code Q:an anterior cervical odontoid screw? poses? as co-surgeons using the -62 modifier). Currently, there is no code that ap- The code 22841 was developed when Medicare and Blue Cross are refusing A: propriately describes the use of od- A: the wording “including internal fixa- Q:to pay on 63047 and 22630 when they ontoid screw fixation for treatment of an tion” was removed from the former spine are submitted together. If performed at dif- odontoid fracture. Such a code has been arthrodesis codes. Since the values of those ferent levels (eg. L4L5 and L5S1), how developed and submitted to the AMA CPT arthrodesis codes were not decreased, there should this be coded? Editorial Panel. Although not anticipated were no relative value units attributed to until CPT 2000, the most appropriate way the code 22481. There is no payment for The code 22630 was valued to include to code for this in the interim would be that code under the Medicare fee schedule A: laminectomy, facetectomy, and with the unlisted procedure code 22899 or or for any fee schedule linked to RBRVS. A discectomy in preparing the disc space for the arthrodesis of the axis through an physician can certainly establish a fee and a posterior lumbar interbody fusion. The extraoral approach without odontoid re- charge for that code if appropriate, as some code 22851 can be additionally used if an section 22548. ■ insurance companies are willing to pay it. intervertebral threaded cage is placed. How- ever, this code should only be used once per Is it appropriate for the surgeon to interspace rather than per device and, there- Gregory Przybylski, MD, is a neurosurgeon at Thomas Q:code 20660 for the application of a fore, only applies once in this operation. If Jefferson University and a faculty member for the frame and to code 61793 with a modifier a decompression also is performed and it AANS PDP course on Reimbursement Foundations. as either a co-surgeon or an assistant sur- goes beyond that involved in the bony re- The coding procedures expressed in this article geon? This, of course, assumes that the moval necessary to carry out the posterior should not be construed as AANS policy, procedure or radiation therapist would code 61793 as interbody fusion, then one also could code standard of care. The AANS disclaims any liability or responsibility for the consequences of any actions well. It is my understanding that coding 63047-51. The additional use of the -59 taken in reliance on the coding procedure suggested.

18 Spring 1999 • AANS Bulletin Meet Your President Martin H. Weiss, MD, Prepares to Lead AANS Members Into the Next Millennium.

artin Harvey Weiss, MD, was elected President of Following are some Martin H. Weiss, MD, The American Association of Neurological Sur- brief comments from is President of the AANS geons (AANS) at the AANS Annual Meeting Dr. Weiss as he em- and Professor and recently held in New Orleans, Louisiana. Active in barks upon his year as Chairman of the Depart- Mthe AANS since 1973, Dr. Weiss has served as a President of the AANS. ment of Neurological member of the Board of Directors (1988-1991) and as Secretary (1994- If you have questions, Surgery at the School of 1997) of the Association, as well as Chairman of the Editorial Board of e-mail him at: Medicine of the University its official scientific publication—the Journal of Neurosurgery. [email protected]. of Southern California. Dr. Weiss is Professor and Chairman of the Department of Neu- rological Surgery at the School of Medicine of the University of What are some of the key issues facing neurosurgery in the year ahead? Southern California. He also serves as Chief of Neurosurgery at the We must advance the discipline of neurosurgery both intellectually USC Medical Center, as well as attending neurosurgeon at the USC and technologically to meet the needs of future medical care. As we University Hospital. Dr. Weiss is the first to hold The Martin H. Weiss face the development of evidence-based medicine permeating medi- Chair in Neurological Surgery at USC, which was established in his cal practice, we must make a valid contribution to the public health of honor by an endowment funded by the William Wrigley Family. our nation. We will have to do better with intrinsic tumors, learning After earning his bachelor’s degree magna cum laude from more about the molecular biology to apply methodologies to their Dartmouth College and his medical degree from the Cornell Univer- management and to enhance survival far beyond our present capaci- sity Medical College, Dr. Weiss served his surgical internship at the ties. We need to enhance our involvement in evidence-based medicine University Hospitals of Cleveland. He subsequently spent two years as in order to compete with related disciplines and justify our practices. an associate in general surgery at the United States Military Academy If you could accomplish just one thing in your Presidency, what would it be? at West Point (New York), following which he returned to complete I hope to incorporate a better integration of technology and basic his residency in neurosurgery at University Hospitals of Cleveland. neuroscience into our practice to meet the challenges of the future. In addition to his involvement with the AANS, Dr. Weiss has served as Chairman of the American Board of Neurological Sur- As you begin your Presidential year, is there one message that you gery, Chairman of the Residency Review Committee for Neuro- have for AANS members? logical Surgery and Chairman of the Neurology B Study Section of Although we face significant economic challenges to our stability, the National Institutes of Health, as well as Vice President of the neurosurgery is more exciting and offers more opportunity for American Academy of Neurological Surgery, Vice President of The patient service and career satisfaction than ever before. Society of Neurological Surgeons, Vice President of the Congress of Neurological Surgeons and President of the Southern California What have been some of the most significant changes in neurosur- Neurosurgical Society. He also is a member in the American Col- gery since you began your career? lege of Surgeons (past Chair of the Neurosurgical Advisory Coun- In the past 30 years, we have witnessed the development of allied cil), the American Medical Association, Western Neurosurgical disciplines in neuroradiology (CT, MR and functional imaging), Society, Neurosurgical Society of America, Research Society of Neu- neuroanesthesia and neurology (cortical mapping), in addition to rological Surgeons and The Neurosurgical Forum. the evolution of neurosurgical techniques for the spine, skull base A prolific writer and scientific investigator, Dr. Weiss has served and deep brain nuclei that have revolutionized our practices. as Editor-In-Chief of Clinical Neurosurgery and as a founding What advice would you give to a neurosurgeon who is just starting his member of the Editorial Board of Neurosurgery. He is presently or her career? Associate Editor of Neurosurgical Focus, the online version of the Journal of Neurosurgery. Retain the dedication to your profession that propelled you to your Dr. Weiss and his wife of 38 years, Debora, are the parents of present position, never forget the need for continuing education as three children; Brad, an Associate Professor of Anthropology at the our discipline evolves, and don’t forget or neglect your family. College of William & Mary; Jessica, a former Montessori teacher What are some of your interests outside of medicine? and now President of YOGAMOMS in suburban Washington, D.C.; My family and fly fishing. and Elisabeth, a cable TV producer in San Francisco. All are mar- ried; and Dr. and Mrs. Weiss delight in their two grandchildren, What do you plan to be doing 10 years from today? Ezra and Madison (and one on the way). Operating with the USC residents (my greatest neurosurgical legacy). ■

Spring 1999 • AANS Bulletin 23 New Orleans: 1999 Annual Meeting Draws More Than 5,700 Attendees.

ore than 5,700 neurosurgeons, neuroscience nurses, and medical statesmanship. I personally plan on sticking around a physician assistants, and technical exhibitors gath- while longer to assure the future of the tremendous young talent ered in New Orleans, Louisiana, April 24 to 29 for that I see in neurosurgery, as well as the future of our patients.” the 67th Annual Meeting of The American Asso- The full text of Dr. Travis’ address will be published in its en- Mciation of Neurological Surgeons (AANS). Packed tirety in the Journal of Neurosurgery. with clinical skill courses and socioeconomic information, this year’s gathering set the standard as one of the premiere gatherings for Cushing Orator neurosurgeons in the world. On Tuesday, April 27, former President George Bush delivered the L.N. Hopkins, MD, Annual Meeting Chairman, and Steven L. Cushing Oration to a crowd of cheering meeting attendees. In his Giannotta, MD, Scientific Program Chairman, assembled an out- talk, Mr. Bush shared several light-hearted stories about his life af- standing program, which included 8 symposia, 124 research papers, ter the White House, and offered his thoughts on foreign policy 35 hands-on clinics, 78 educational seminars, and 561 posters. In and the conflict in Yugoslavia. addition, a record-setting 669 technical and institutional exhibits He said, “Yugoslav President Slobodan Milosevic is a serious showcased the latest neurosurgical instrumentation and equipment. threat to the world we seek to build on more peaceful and demo- Following is a summary of meeting highlights: cratic values. I do believe that he has committed crimes against humanity, and the brutality of this dictator must be stopped. Presidential Address “But as the airstrikes continue, I am very deeply troubled with On Monday, April 26, Russell L. Travis, MD, the 1998-99 President what I see over there. If I were to give advice, I would say define the of the AANS, highlighted a myriad of historic and contemporary mission. If you need military force, let them fight it with plenty of heroes in his Presidential Address. He focused his remarks on indi- overwhelming military power…and then come home.” viduals whose actions had a profound influence on the develop- He said he relied on those same principles when defending the ment of our nation. United States’ policy not to invade Baghdad in the Gulf War. “My “Just as there are military heroes, political heroes, cultural heroes decision to move forward with Operation Desert Storm was in an and athletic heroes, there are heroes in medicine as well,” Dr. Travis effort to drive Iraq out of Kuwait, not Saddam Hussein out of said. “To act courageously and be heroes for our patients in this envi- power.” He explained, “Driving Saddam out of power would have ronment of corporate medicine will require more than physical cour- been impractical because the United States would have been alone age; it will require fortitude. Fortitude is the stuff of heroes…it is the in that job and become an occupying force with no easy way out.” kind of tenacity that helps physicians move the powers that be to Concluding his presentation, Mr. Bush noted, “As the sole re- continue to provide patients appropriate treatment. maining superpower, if you want your children to live prosperously “For us as neurosurgeons to be heroes, we must remember that in the 21st century, the United States must lead. American leadership the real heroes in medicine are our patients — the people who lit- is an absolutely indispensable ingredient for extending the promise erally lay their lives down before us and trust that we will do the of democratic capitalism and freedom into the next millennium.” right things for them.” Honors and Awards Dr. Travis also thanked the membership for their strong sup- In addition to the Scientific Program, the following Thailand, providing patient care and raising funds port and addressed some of the AANS members were recognized with honors: to establish training fellowships there. David L. Kelly Jr., MD, received the 1999 Cushing obstacles organized medicine will W. Ben Blackett, MD, JD, received the 1999 Medal. He was recognized for his many years of face in the next millennium. “The Distinguished Service Award. He was recognized outstanding leadership and dedication to the field of 21st century will strain our for his work as neurosurgery delegate to the AMA neurosurgery. Dr. Kelly, the 1990-91 AANS President, House of Delegates and as Chairman of the healthcare system and bring chal- is an active clinician and researcher in such areas Professional Conduct Committee. as brain tumors and arteriovenous malformations. lenges well beyond the ones we’ve Thomas B. Flynn, MD, received the 1999 Theodore H. Schwartz, MD, was named the 1999 seen in the 1990s. Given this, our Humanitarian Award in recognition of his exten- Van Wagenen Fellow. He will use the Fellowship to patients, the sick among us and sive volunteer work overseas, providing neurosur- study under Tobias Bonhoeffer, MD, at the Max- gical care to disadvantaged patients in Southeast Planck Institute for Neurobiology in Germany. the healthcare system will desper- Asia. Dr. Flynn has made numerous trips to ately need our moral leadership

24 Spring 1999 • AANS Bulletin Consolidation CSNS Passes Resolution Suggesting Consolidation of AANS and CNS.

he Council of State Neurosurgical Societies (CSNS), com- posed of delegates from all state neurosurgical societies and appointed representatives from The American Association of Neurological Surgeons and Congress of Neurological TSurgeons, has passed a resolution requesting the AANS and CNS to: 1) Develop a joint strategic plan, and 2) consolidate resources. The resolution was developed by the CSNS Executive Committee and approved at the Council’s session on April 24, 1999, in New Orleans. The motion comes after more than one year of debate between the AANS and CNS on differences surrounding meeting management, marketing and other issues. “While it is true that the AANS and CNS have become focused on the same mission,” H. Hunt Batjer, MD, President of the CNS, said at the CSNS open debate on the resolution, “the two organizations go about conducting their business in two very different ways. Many joint programs, like the Washington Committee, ben- Recent debate between the two organizations has focused on efit from having both the young, committed, passionate leaders the CNS’ recent decision to move the management of its meeting of the CNS mix with the older, more experienced AANS leader- to an outside vendor. ship. Competition is also good in some areas.” “This decision was purely a business decision,” Daniel Barrow, The resolution must now go to the AANS Board of Directors MD, President-Elect of the CNS, said at the open debate. “Our An- and the CNS Executive Committee for approval. Prior to the CSNS nual Meeting is our most important product, and this is the only resolution, both organizations discussed motions of their own to area where we compete directly with the AANS. It’s hard to con- consider a joint strategic plan. tract with someone who is your competition. Right now, everyone “This needs to happen, but it needs to happen in an evolution- needs to decide if these two organizations are servicing their mem- ary, not a revolutionary way,” Martin H. Weiss, MD, President of bers and, if not, stop paying their dues.” the AANS, said at the CSNS open debate. “The message from the The management of the CNS Annual Meeting has often been CSNS has been heard loud and clear.” an issue for debate between the two organizations, with the CNS Currently, the AANS and CNS are separate organizations with seeking proposals for outside administration on several occasions, separate boards, annual meetings, journals and committees. They including 1994. The AANS National Office also administers the An- participate in several jointly sponsored projects and committees nual Meetings of the AANS/CNS Sections on Spine, Pediatrics and including: the Washington Committee and Office; the Sections; Cerebrovascular Surgery and the symposiums of the Pain and Tu- NEUROSURGERY://ON-CALL®, the official Web site of both mor Sections. organizations; the CSNS; the Outcomes Committee and several “I’m not sure if complete consolidation of the two groups is others. The Joint Officers, which consists of the Officers of the the answer,” Russell L. Travis, MD, Past-President of the AANS, two groups, was formed several years ago to facilitate communica- said in the open debate. “But I am sure that having two complete, tion and planning between the two groups. They meet three times separate entities who were in direct competition would be the a year and have frequent conference calls. worst for all of neurosurgery.” The AANS runs a National Office in Park Ridge, Illinois, that Dr. Travis continued, “We have made a proposal for the CNS to includes convention planning; continuing medical education house any infrastructure needs they may have at the AANS Na- tracking and course development; membership services; commu- tional Office, and to share any resources that we may have in com- nications; marketing; and accounting. The CNS maintains a small mon. We at the AANS are doing everything possible to keep orga- support staff for its Executive Committee in the office of its Secre- nized neurosurgery under one roof.” tary and currently contracts with the AANS for administration of Progress by the AANS and CNS on the resolution will be dis- its Annual Meeting, including meeting planning, exhibit sales, pro- cussed at the CSNS session in Boston on October 29, 1999, prior to motion, registration and financial tracking. the start of the CNS Annual Meeting.

Spring 1999 • AANS Bulletin 25 R ESEARCH FOUNDATION

contributing to the Research Foundation Reaching New Heights has fallen. Support Your Foundation Research Foundation Sets an All-Time Record in 1998 Gifts can be made at anytime during the Fundraising Campaign. year. Gifts of appreciated stock can help to avoid certain taxes. A gift through your will, or though a life insurance beneficiary designation can help ensure that this important he Executive Council of the Research overall mission of your Foundation. As we research is funded long after your death. Give Foundation of the AANS is pleased to approach the new millennium, we foresee to the future of your specialty by giving back Treport that 1998 was the best year ever great strides in the results of our funded stud- a little to the career that benefited you. for overall financial support to your Foun- ies, and in our ability to review evermore For more information on special ways dation. Donations increased to $488,633 — relevant and exciting studies in basic, out- to support the Research Foundation of the a 29 percent increase over the 1997 cam- comes, and ultimately translational research. AANS, contact us at (847) 692-9500. ■ paign. These results are highlighted by an A major gift and bequest campaign to Julian T. Hoff, MD, Chairman, AANS Research increase in funds from our membership, up expand our ability to meet the growing Foundation Executive Council, and John R. nearly 47 percent from $120,469 to demand for funding is currently being O’Connell, AANS Director of Development, $175,448. Also up is support for the Cor- planned. In 1999, a record 45 grant appli- contributed to this report. porate Associates program, which increased cations were received for funding consid- Corporate Associates Roster 23 percent to $302,000 and now boasts 22 eration, but despite the pleasing financial The Executive Council of the Research Founda- members. Included in these totals is a sig- results, the number of members actually tion of the AANS gratefully acknowledges the nificant gift of $50,000 from an AANS Neurosurgical Group Supporters financial support given by the following companies. member to endow a scholarship program. The following list recognizes University pro- Superior Associate To the right is a list of those donors who grams, foundations and organizations that con- (Gifts of $75,000 to $100,000) cared enough about the future of this spe- tributed to the Research Foundation of the AANS Rhone Poulenc Rorer Pharmaceuticals cialty that they participated in the 1998 in 1998: Supporting Associate campaign and gave $100 or more. These (Gifts of $25,000 to $50,000) Corporate Supporter (up to $5,000) visionaries have allowed this Foundation to Codman/Johnson & Johnson Professional Inc. increase the 1998 grant approvals from four Advanced Neuralmodulation Systems Elekta to five, bringing the total number of AANS Cyberonics Pharmacia & Upjohn Electra Products of Dallas, in memory of Research Fellows or Young Clinician Inves- Sofamor Danek Group, Inc. Richard Muller Synthes Spine/Synthes Maxillofacial tigators supported over the past 18 years to Ohio Medical Instrument Company 56. Please join with us in applauding these Contributing Associate individuals, groups and companies who Group Supporter ($1,000 or more) (Gifts of $10,000 to $25,000) have answered the challenge to maintain American Academy of Pain Medicine Depuy Acromed Medtronic our commitment to neuroscience research. Massachusetts General Hospital Michigan Association of Neurological Surgeons Sulzer Spinetech, Inc. Neurosurgery Foundation, Inc. 1999 Campaign in Progress Associates Southeastern Neurosurgical & Spine Institute, (Gifts of $5,000 to $10,000) The 1999 campaign is well underway, P.A., in memory of Charles Drake, MD Aesculap with the first levels of support already com- University Neurosurgical Associates Baxter ing in. You can help the Research Founda- USC Neurosurgeons, Inc. Bayer Corporation tion to get ahead of last year’s record-break- Brainlab ing results by making a tax-deductible gift. Miscellaneous Carl Zeiss, Inc. Your donations go toward expanding our AANS, in memory of Paula Draba Leica, Inc. AANS, in memory of Charles Drake, MD endowment, which is used to fund key stud- Midas Rex Institute American College of Osteopathic Family NMT Neurosciences ies in basic and outcomes research. Physicians, Inc, in memory of Paula Draba OMNA Medical Partners The Executive Council is committed IBM employees’ payroll deduction plan PMT Corporation more than ever to reviewing not only the lat- Louisiana Neurosurgical Society Radionics est and most promising studies being con- St. Jude Hospital medical staff, in memory of Stryker Howmedica Osteonics ducted in the United States today, but the John Marsh, MD Surgical Dynamics

26 Spring 1999 • AANS Bulletin R ESEARCH FFOUNDATION CC USHINGUSHING SSCHOLARSCHOLARS CCIRCLEIRCLE

Cushing Scholars Circle Summa Cum Laude Robert B. King, MD Liang Yee Soo, MD Jose G. Duarte, MD ($5,000 or more) Alexandra Kunz, MD, in memory of M. Christopher Wallace, MD John Duncan, MD Timir Banerjee, MD Jacob A. Kunz Jack Wilberger, MD Dr. and Mrs. Stewart B. Dunsker, in L. Dade Lunsford, MD Michael Lavyne, MD Fremont P. Wirth, MD memory of Paula Draba Harold & Mimi Steinberg Charitable Dr. & Mrs. Lyal G. Leibrock Daniel J. Won, MD Felix Durity, MD Trust Robert Levinthal, MD Eric L. Zager, MD Eagle Harbor Golf Club, in memory Philip J. Marra, MD of Wayne Allen Magna Cum Laude Carole A. Miller, MD Sponsor Dr. & Mrs. Fredric Edelman ($2,500 to $4,999) Eleanor D. Miller, in memory of Leroy ($250 -$499) Mr. and Mrs. Richard Elke, in Hans Coester, MD J. Miller, MD M. Ross Bullock, MD, PhD memory of Richard Muller Julian T. Hoff, MD Dr. & Mrs. William J. Nelson Philip H. Cogen, MD Mel Epstein, MD John Jane, MD, PhD Christopher Ogilvy, MD Dr. & Mrs. W.F. Collins, Jr. Richard Fessler, MD Dr. & Mrs. Herbert M. Oestreich Robert G. Ojemann, MD David Danoff, MD Michael Freed, MD Dr. & Mrs. Russel H. Patterson Frank Padberg, MD Dr. & Mrs. Robert J. Dempsey Gerhard Friehs, MD Tae Sung Park, MD Kenneth A. Follett, MD, PhD David M. Frim, MD Cum Laude Rob G. Parrish, MD, PhD Stephen R. Gardner, MD H. Harvey Gass, MD ($1,000 to $2,499) Stan Pelofsky, MD Ronald Greenwald, MD Samuel Greenblatt, MD Dr. & Mrs. George Ablin Dr. & Mrs. Robert A. Ratcheson Mary Gumerlock, MD Brent H. Greenwald, MD Douglas Anderson, MD Kenneth Richland, MD, in honor of Dan S. Heffez, MD J. Frederick Harrington, MD Ronald Apfelbaum, MD Philip Vogel, MD Eric K. Holm, MD Dr. & Mrs. Robert D. Harris Michael Apuzzo, MD Gail Rosseau, MD Dr. & Mrs. Jerry L. Hubbard M. Peter Heilbrun, MD Walter L. Bailey, MD Richard L. Rovit, MD Saied Jamshido, MD Mary Louise Hlavin, MD Richard E. Balch, MD Arthur O. Schilp, MD John K. Johnson, MD George B. Jacobs, MD Carl H.H. Baumann, MD, in memory John F. Schuhmacher, MD Douglas E. Kennemore, MD Robert Johnson II, MD of Paul C. Bucy Dr. & Mrs. Edward Seljeskog Dr. & Mrs. Mark J. Kubala Dr. & Mrs. Kevin D. Judy Donald P. Becker, MD Dr. & Mrs. John L. Seymour Ranjit Kumar Laha, MD Ellis B. Keener, MD Vallo Benjamin, MD Dr. & Mrs. Michael Shannon Dr. & Mrs. John J. Lowrey Paul K. King, MD Charles H. Bill, MD, PhD Dennis Shubert, MD Richard P. Moser, MD Dr. & Mrs. Laurence I. Kleiner, in Lawrence F. Borges, MD Robert F. Spetzler, MD Alfred T. Nelson, Jr., MD honor of Richard Katz Derek A. Bruce, MD John E. Stevenson, MD Dr. & Mrs. Paul B. Nelson Dr. & Mrs. Edward Kosnik David W. Cahill, MD Dr. & Mrs. Oscar Sugar William G. Obana, MD Robert Lacin, MD, in memory of Dr. & Mrs. Israel Chambi Brooke Swearingen, MD Richard Ostrup, MD Professor Algis Narakas Paul H. Chapman, MD Russell L. Travis, MD Andrew D. Parent, MD Mark S. LeDoux, MD, PhD Robert W. Chow, MD Dennis Turner, MD Dr. & Mrs. Kee B. Park Dr. & Mrs. N. Scott Litofsky G. Rees Cosgrove, MD Dr. & Mrs. John S. Tytus William L. Pritchard, MD Dr. & Mrs. James Mansfield Robert M. Crowell, MD Edward Von Der Schmidt III, MD Dr. & Mrs. Justin Renaudin Jerry V. Marlin, MD Robert E. Draba, PhD, in memory of Martin Weiss, MD Dr. & Mrs. Gerald E. Rodts, Jr. Dr. and Mrs. William E. Mayher, III, in Paula Draba Dr. & Mrs. H. Richard Winn James Rutka, MD memory of Paula Draba Dr. & Mrs. Stewart Dunsker Shokei Yamada, MD Raymond Sawaya, MD Daniel B. Michael, MD Quentin J. Durward, MD, in memory Nicholas T. Zervas, MD P. Robert Schwetschenau, MD Mary M. Morehead, in memory of of Charles Drake, MD Edie Zusman, MD Michael Schulder, MD Wayne Allen Dr. & Mrs. S.M. Farhat Dr. & Mrs. Randall W. Smith, in Karl D. Nielson, MD Robert Feldman, MD, in honor of Honor Roll memory of Arthur A. Ward, MD Georg Noren, MD Molly and Bob King ($500 - $999) Volker K.H. Sonntag, MD Dwight Parkinson, MD Dr. & Mrs. Malcolm Field AANS, in memory of Charles Drake, MD A.A. Steinberger, MD Chris Philips Dr & Mrs. Robert Florin, in memory Russell H. Amundson, MD John Wilson, MD Dr. & Mrs. Hal W. Pittman of John S. Marsh, MD Mitchel S. Berger, MD Dr. & Mrs. John F. Raggio Dr. & Mrs. Thomas B. Flynn, in Aaron Berman, MD Supporter Setti Rengachary, MD memory of Homer Kivgis, MD Albert J. Camma, MD ($100 - $249) Dr. & Mrs. Howard A. Richter Paul D. Forrest, MD Thomas E. Carter, MD Lloyd Alderson, MD James F. Schmidt, MD Dr. & Mrs. C. Babson Fresh Stephen R. Freidberg, MD American College of Osteopathic Robert Schultz, MD Allan Friedman, MD Sidney Goldring, MD Emergency Physicians, in memory Brett A. Scott, MD Steven Giannotta, MD Dr. & Mrs. Jonathan E. Hodes of Paula Draba Andrew E. Sloan, MD Julius M. Goodman, MD Dr. & Mrs. F. Douglas Jones John L.D. Atkinson, MD Mark A. Spatola, MD Dr. & Mrs. Robert L. Grubb, Jr. David L. Kelly, Jr., MD Laurie Behncke, in memory of Paula Charles H. Tator, MD John Peter Gruen, MD Thomas A. Kingman, MD Draba Dr. and Mrs. Greg Thompson, in Dr. & Mrs. Murali Guthikonda C.L. Marquart, MD Ricardo H. Brau, MD memory of Amy Jeanne Thompson Dr. & Mrs. Regis William Haid, Jr. Walter R. Neill, MD Dr. & Mrs. Arnold B. Calica Suzie C. Tindall, MD Griffith Harsh IV, MD A. John Popp, MD Shelley N. Chou, MD A. Roy Tyrer, Jr., MD Lucien Hodges, MD Dr. & Mrs. Donald O. Quest E. Sander Connolly, Jr., MD Alex P. Valadka, MD Dr. & Mrs. L. Nelson Hopkins III Warren Selman, MD Dr. & Mrs. Edward S. Connolly Beverly Walters, MD Howard H. Kaufman, MD Scott Shapiro, MD, in honor of John Paul D.Croissant, MD William C. Welch, MD Dr. & Mrs. Patrick J. Kelly Mealey, MD, & John Kazsbeck, MD Fernando Diaz, MD S. Randy Winston, MD Curtis Doberstein, MD Lucia Zamorano, MD

Spring 1999 • AANS Bulletin 27 C ONTINUING MEDICAL E DUCATION

Kim J. Burchiel, MD, Meeting Your Needs is Chair of the AANS Professional The AANS Professional Development Program Offers Development Program’s a Comprehensive Pain Management Course. Pain Management Course.

im J. Burchiel, MD, a recognized Health Sciences University — site of one University, Secretary/Treasurer of the expert on the management and of the nation’s premiere multidisciplinary AANS/CNS Section on Pain, and a former K treatment of pain, will chair the pain clinics. The University’s support in President of the American Board of Pain upcoming AANS Professional Develop- offering its lab facilities for this course is Medicine. ment course, “Advanced Surgical Pain Man- gratefully acknowledged. If you would like to learn more about agement: Hands-On.” Created in response In addition to serving as Chair of the the AANS Pain Management course, to AANS members’ needs, this in-depth, Pain Management course, Dr. Burchiel is please contact the Professional Develop- comprehensive, neurosurgical pain manage- Chairman of the Department of Neuro- ment Program at (847) 692-9500. ■ ment course is designed specifically for logical Surgery at Oregon Health Sciences neurosurgeons, nurse practitioners, physician assistants and anesthesiologists. “There are very few neurosurgeons who are interested in the study of pain, and those who are can make a tremendous Attention Neurosurgeons! Mark your impact on the quality of a patient’s life,” calendar now and register for these upcoming said Dr. Burchiel. “Recognizing this, I, along with my colleagues from Oregon AANS PDP courses Health Sciences University, have designed a course that seeks to progressively increase knowledge on the subject of pain manage- Sharpen your skills in neuroendoscopy and ventral ment and provide attendees with the in- thoracolumbar spine disorders formation they need to develop a top- notch multidisciplinary pain clinic in their Minimally Invasive Ventral Surgical own communities.” Hands-on A comprehensive Neurosurgery: review of Approaches for the In describing the knowledge and skills practical instruction in Neuroendoscopy— techniques, Thoracic and taught in the course, he said, “Registrants neuroendoscopy Hands-On instrumentation Lumbar Spine are motivated to take this course because October 1-2, 1999 and surgical September 24-25, 1999 decision making it goes beyond the surface knowledge Cleveland, Ohio San Antonio, Texas gained in other seminars and explores in- tensive neuroablative procedures. The This course is designed to give neurosurgeons This course is designed to provide comprehen- unique program allows participants to experience with the clinical and surgical sive, didactic sessions on the latest techniques design their own educational experience aspects of state-of-the-art endoscopy. Expert and instrumentation systems for treating faculty will assist participants in performing a disorders of the ventral thoracolumbar spine. via a variety of practical, hands-on series of hands-on dissections using different Attendees will participate in in-depth discus- breakout sessions, with topics ranging endoscopic and microinstruments. sions and hands-on sessions on the most from trigeminal neurectomy to DREZ common approaches to pedicle cannulation, lesions. Attendees will leave the course pedicle screw fixation and anterior fixation. well-rounded pain specialists armed with the tools to offer their patients more than one avenue of pain treatment.” N A ICA SSO R C E I M A T A Guarantee your place at these popular courses. Call the AANS Professional I E O

N H The Pain Management course, which is T

S F N N Development Program for more information at (847) 692-9500, e-mail us at O E U E R G slated to take place August 5-7, 1999, in O R L S U O G IC A L [email protected] or visit our Web site at www.neurosurgery.org. Portland, Oregon, will be held at Oregon

28 Spring 1999 • AANS Bulletin AANSAANS MMEMBERSHIPEMBERSHIP

Membership Opportunities Apply for AANS for Residents Abound Membership Online The AANS is pleased to offer a convenient Nearly 100 Applicants Approved for Candidate Membership. way to apply for AANS membership — via

andidate membership in the AANS, of the AANS are entitled to the following the offical Web site of the AANS— which has flourished in recent years, products and services: NEUROSURGERY://ON-CALL®. Cprovides an excellent avenue for our • Complimentary Fellowship Manual future neurosurgical leaders to gain insight for Neurosurgeons To take advantage of this member ser- into the issues affecting organized neuro- • Free Directory of Neurological Surgery: surgery, as well as build professional rela- vice, visit www.neurosurgery.org and North America tionships. Since 1993, the total number of click on “Professional Pages.” On the • Reduced Annual Meeting registration Candidate members has risen from 61 to fees welcome page, select the “Member- more than 400 members, giving the AANS • Reduced Professional Development more resident members than any other ship” text link. To download the applica- course fees neurosurgical society. • Quarterly AANS Bulletin tion, you will need an Adobe Acrobat Open to all residents who are enrolled • Special Journal of Neurosurgery plug-in. A free download is available in a neurosurgical residency training pro- subscription rate gram recognized by the Accreditation from the Adobe Web site at • Opportunity to become involved on Council for Graduate Medical Education AANS Committees www.adobe.com. (ACGME), the Royal College of Physicians • Continuing Medical Education in and Surgeons of Canada, or the Mexican Neurosurgery Once the form is in your computer, Council of Neurological Surgery, A.C., Can- didate membership in the AANS provides To learn how you, or someone you know, just print it, fill it out and fax it to us young neurosurgeons with a forum for the can become a Candidate member of the at (847) 692-6770 exchange of issues, ideas, problems, solu- AANS, or to receive a membership appli- tions and developments in the field of neu- cation, contact the AANS Membership rosurgery. In addition, Candidate members Department at (847) 692-9500. ■

CANDIDATE MEMBERS Allen H. Fergus Sean Lew Afser Shariff Mathew T. Alexander Jeffrey E. Florman John C. Mace Fernando E. Silva Gordon B. Anderson Edward R. Flotte Cormac O. Maher Julian Spears Donald P. Atkins James S. Forage Geoffrey T. Manley Caple A. Spence Nathan Avery Jonathan A. Friedman Matthew T. Mayr Carl J. S. Spivak Steven Bailey Victor T. Freund Sean P. McDonald Richard B.Stovall Kaveh Barami Jason E. Garber Patrice D. McNeely Sandeep Teja Christopher J. Barry Ira M. Garonzik WonHong D. Min Philip V. Theodosopoulos Juan Carlos Bartolomei Stephen M. Gutting William Mitchell Daniel J. Tomes Andrew V. Beykovsky Raymond I. Haroun Fardad Mobin Donald R. Tyler, II Miroslav P. Bobek Jeffrey S. Henn Graham J. Mouw Elizabeth C. Tyler-Kabara Sharyn D. Brekhus Johnnie H. Honeycutt, Jr. Wai Pui Ng G. Edward Vates Peter G. Brown John L. Hudson David B. Niemann Erol Veznedaroglu Dhany Charest Omar F. Jimenez Henry F. Pallatroni, III Kenneth P. Vives Peng Chen Richard L. Kern, Jr. John Keum Ratliff Lyndell Y. Wang Andrew S. J. Chiou Sami Khoshyomn George T. Reiter Marjorie C. Wang Sean D. Christie Deven Khosla Benjamin J. Remington Michael Y. Wang Aaron A. Cohen-Gadol Richard J. Koesel Dennis J. Rivet, II Peter M. Ward Fabrizio Cohn Adam Kremer Ali Sadrolhefazi Benjamin T. White Amos O. Dare Jae Hong Lee David I. Sandberg Jonathan A. White Phillip G. Esce Peter J. Lennarson Thomas C. Schermerhorn Diana B. Wiseman James J. Evans Michael A. Leonard Jason M. Schwalb Robert P. Feldman Maciej S. Lesniak George B. Shanno

Spring 1999 • AANS Bulletin 29 GG OVERNANCEOVERNANCE SS TANTAN PPELOFSKYELOFSKY,, MDMD

demic careers, and hope that the fellowships will be supported for an additional two years. Secretary’s Report The Task Force also continues to work on Highlights From the Report Presented at the 1999 AANS establishing training guidelines Meanwhile, the Neurosurgical Surgery Annual Business Meeting in New Orleans. Residency Review Committee (RRC) has successfully revised their program requirements for residency training. Robert Ojemann, MD, and his committee were able his has been an especially challenging membership needs (read more on this is- to get these revisions accepted by the Ac- and difficult year. Internally, the AANS sue in an article on page 25). creditation Council for Graduate Medical TNational Office is undergoing a change It is unfortunate that these sorts of issues Education (ACGME), and the revisions will in leadership with the departure of our Ex- arise at such a difficult time in the field of become effective on July 1, 1999. This com- ecutive Director, Robert Draba, PhD. Al- medicine, since they distract from more im- mittee also has worked with the Sections to though finding Dr. Draba’s replacement con- portant tasks at hand. Luckily, our commit- develop guidelines for fellowship training, tinues to be a top priority, longtime AANS tee leaders and members have continued and is currently distributing their sugges- staffers, Laurie Behncke and Robert Cowan, their efforts to influence the future of neu- tions to the appropriate organizations for will serve as exceptional interim directors. rosurgery, and we can thank them for their comments. This sort of exchange, inviting Russell Travis, MD, 1998-99 AANS President, many accomplishments over the past year. new ideas as well as revising old ones, is vi- has exhibited the incredible strength of char- tal to the improvement of our specialty. acter necessary to lead a determined search Membership The exchange of ideas and the commit- for the most qualified candidate — this is no The AANS membership has continued to ment to excellence are always at the heart of easy feat given the vast intellect, expertise and increase, climbing 2.4 percent from last our Annual Meetings. This year’s meeting in innovation we expect from our Executive Di- year’s count of 5,263 to this year’s total of New Orleans featured a top-notch Scientific rector. We must find someone able to carry 5,387. Most notable was the increase in our Program, showcasing contemporary innova- us into the next millennium and beyond in a Candidate (Resident) and International tions and research advances from all realms health care environment that is usually hos- Associate categories, up 5 percent and 11 of neurosurgery, as well as a spectacular line tile and always changeable, but we are confi- percent, respectively. These increases are up of social activities. Annual Meeting Chair, dent that our efforts will be successful (see particularly encouraging, not only because L.N. Hopkins, MD, and those who comprised late breaking announcement on the new more members lead to a stronger organi- his committee, deserve to be applauded and AANS Executive Director on page 4). zation, but because they indicate that we praised for their tremendous efforts on put- Another challenge we are facing is the re- are reaching beyond age and geographical ting together another memorable meeting. cent decision by the Congress of Neurologi- boundaries. Since the average age of our cal Surgeons (CNS) to divest themselves from Active member is 49, we seem to be hav- Research the AANS for their Meeting Planning and ing some success at attracting younger Research is the basis of our specialty, defin- Exhibit Management. This divestiture will neurosurgeons to the AANS, something ing where we have been and where we are occur after the 2000 meeting, and is a devel- that will have to continue if the organiza- going. Julian Hoff, MD, one of two neuro- opment that greatly troubles the entire AANS tion is to survive into the next millennium. surgical representatives to the National Board. Our Board believes that this schism Institute of Neurological Disorders and will benefit neither organization. Despite Education Stroke (NINDS), reports that there has been many efforts to negotiate a mutually accept- Supporting the continuing education of considerable enthusiasm recently regarding able solution, we have been unable to reach a young neurosurgeons is one of several on- the appointment of NINDS Director, Dr. compromise with the CNS. The AANS Board, going initiatives of the Neuroendovascular Gerald Fischbach. Administrative changes however, will continue to pursue opportuni- Task Force, headed by Mark Mayberg, MD. initiated by Dr. Fischbach have been well ties to integrate the activities of the two orga- Through the combined financial support of received and should allow for increased in- nizations, and we have left an offer on the table the AANS and CNS, three fellowships will volvement of the neuroscience community, that would allow the CNS to share office space be funded this year, as opposed to the two especially on the Study Section level. These and fixed facilities, which would provide sav- that were available last year. Members of the developments, as well as significant fund- ings for both groups. In addition, we are com- Task Force believe that these fellowships have ing increases and internal changes within mitted to a joint strategic planning process promoted interest in the field, especially the National Institutes of Health, led Dr. that we believe will best serve our future among graduating residents pursuing aca- Hoff to conclude that the environment for

30 Spring 1999 • AANS Bulletin GG OVERNANCEOVERNANCE CONTINUEDCONTINUED

both neuroscience and neurosurgery is tional service; and a new socioeconomic sec- tient and employer choice, reducing com- highly favorable. tion. To make the most of these incredible im- petition and further eroding the ability of Dr. Hoff also reports that the Executive provements, a Web site promotion plan also is physicians to deliver medically necessary Council of our own Research Foundation plans being developed in order to increase traffic on care.” Russell L. Travis, MD, 1998-99 AANS a major fund-raising campaign. These plans both the Public and Professional Pages. President, and Hunt Batjer, MD, 1998-99 will consist of focus groups, a survey, and a re- In direct response to membership sugges- CNS President, signed the letter. port, and will assist the Foundation in devel- tions, the Bulletin has become the socioeco- Professional Conduct oping effective fund-raising strategies. The tar- nomic and professional quarterly for AANS Supporting our committees and one an- get of the study will be our own membership, members. New features include a Coding Cor- other is critical to our continued success as who shockingly have donated only 4 percent ner; Practice Management Column; Practice professionals. There are times, however, to the endowment in recent years, and who Profiles; and an Editor’s Perspective. This shift when some neurosurgeons step outside the must be encouraged to contribute much more in direction will help all of us stay abreast of lines of professionalism and when we must substantially in the future if we are to expand the complicated “business” of neurosurgery. take disciplinary action against them. The our grants and fellowships awarded to young Communicating with patients is the “busi- AANS Professional Conduct Committee, neurosurgeons. The Executive Council also is ness” of the Lumbar Stenosis Getting SMART headed by W. Ben Blackett, MD, has the considering co-sponsorship of additional program, which has been the most successful difficult task of conducting hearings in such grants with any or all of the Sections. product in the history of the AANS or CNS. cases, then making conclusions and recom- Finally, research continues in the develop- To date, we have distributed 98,550 patient mendations to our Board of Directors. ment of neurosurgical outcomes under the brochures; 52,500 physician brochures; 424 direction of Robert Harbaugh, MD. Studies in slide sets; and 482 press kits. This successful Summit carotid endarterectomy and aneurysm surgery marketing tool is just one of the many ways to Once again, our Annual Meeting was the are being developed and should ultimately increase the visibility of neurosurgeons while site of a “summit conference” for the lead- improve the quality of care of these patients. helping our patients better understand their ership of the AANS, CNS, Senior Society, The Outcomes Section on N://OC® also has treatments. Phase II of this marketing cam- American Board of Neurological Surgery, been enhanced to include information and paign, “Getting SMART About Cerebrovascu- and the RRC. At this meeting, discussions links to an online outcomes reporting database. lar Disease: An Educational Program on Stroke” continued regarding issues such as neuro- was unveiled at the 1999 AANS meeting. surgical fellowships, the timing of board Communications certification, and recertification. This meet- Research is of little use if it is not properly Socioeconomic Issues ing was an excellent opportunity for our disseminated, a fact which makes the Jour- Because neurosurgical practices have be- leaders to get reacquainted and network. nal of Neurosurgery a vital link between neu- come so complex, it is necessary for us to rosurgeons and the cutting edge. To increase have a strong presence in Washington ca- Other Notable Activities readership worldwide, Journal editor John pable of defending our specialty in an envi- Following are a few other important devel- Jane, MD, reports that an aggressive market- ronment that favors primary care. Art Day, opments that are currently underway. ing campaign continued in Turkey, Germany, MD, and Katie Orrico continue to fight the • Bob Page, MD, and A. John Popp, Chile, Japan, and Asia during 1998. This, battle, along with our Washington Commit- MD, are analyzing and updating our along with the introduction of the Journal tee and Robert Florin, MD. At issue, among policy manual; • David Jimenez, MD, and the Young of Neurosurgery: Spine and the success of other things, is the current Medicare Fee Neurosurgeons Committee have vol- Neurosurgical Focus on our Web site, repre- Schedule determined by the Health Care unteered to help serve the THINK sents an exciting expansion of our scope. Financing Administration (HCFA), which FIRST Program; To meet the growing needs of our mem- we feel grossly miscalculates practice ex- • James Ecklund, MD, is revitalizing the bers, NEUROSURGERY://ON-CALL® penses for neurosurgeons. This issue has been, Committee of Military Neurosurgeons; plans several new additions in the coming year, and will remain, a top priority for our Wash- • The AANS National Office has ral- including: a new outcomes section; world di- ington Committee, as they collect the data lied and united even without the directory of neurological surgeons; education necessary to argue convincingly in our favor. rection of an Executive Director, and section; new Web server, which will improve In addition, the Washington Committee • Our Sections are vibrant, alive and the current search function; expanded Section spearheaded a letter to the Department of functioning well. ■ pages; upgraded online abstract center; site Justice and the Federal Trade Commission called Young Neurosurgeons Online for resi- objecting to the impending merger between Stan Pelofsky, MD, is President of the Neuroscience Institute. Dr. Pelofsky, a 23-year member of the AANS, dents in training and recent graduates; updated Aetna and Prudential, a merger which could is Past President of the Council of State Neurosurgical look for the Public Pages; online chat educa- “pose a threat to patient care by limiting pa- Societies and currently serves as AANS Secretary.

Spring 1999 • AANS Bulletin 31 NN EWSEWS.O.ORGRG SectionsCommitteesAssociationsSocieties

Names in the News Section on Pain At this year’s AANS Annual Meet- Section News ing, the AANS/CNS Section on Pain sponsored a Sat- Russell L. Travis, MD, the ellite Symposium on Pain Management. The Sym-

1998–99 AANS President, ○○○○○○○○○○○○○○○○○○○○○○○○○○ posium, organized by Ken Follett, MD, PhD, and was recently recognized by Samuel Hassenbusch, MD, PhD, was well-received the U.S. House of Represen- Section on Cerebrovascular Surgery The AANS/ and included both didactic and practical sessions. tatives for his lifetime com- CNS Section on Cerebrovascular Surgery is launch- mitment of service to his pa- ing an International Outreach Program. The goals of Highlights from the presentations, as well as a com- tients, profession, and com- this program include: 1) Attract international neuro- plete set of digitized slides will be available on CD- ROM. Please watch for more details. munity. For nearly three de- surgeons with a major interest in cerebrovascular sur-

cades, Dr. Travis has re- ○○○○○○○○○○○○○○○○○○○○○○○○○○ gery to become participating members; 2) promote sponded to the neurosurgical Section on Pediatric Neurological Surgery The the active participation of international members at needs of people in Kentucky AANS/CNS Section on Pediatric Neurological Surgery by volunteering his time and the Section Annual Meeting; 3) foster an exchange of has established a one-month fellowship intended to surgical care. Dr. Travis is a scientific, educational, cultural and socioeconomic 25-year AANS member, the information related to cerebrovascular surgery; and cover travel and living expenses for a resident who wishes to broaden his or her exposure to pediatric 1998-99 AANS President, 4) promote international activities of the Section. and former Chairman of the neurosurgery. Two fellowships are awarded each year

AANS Physician Reimburse- ○○○○○○○○○○○○○○○○○○○○○○○○○○ on the basis of an evaluation by a committee of the ment and Humanitarian Award Section on Neurotrauma and Critical Care Pediatric Section, and the maximum fellowship Committees. He is in private The Surgical Trial in Acute Spinal Cord Injury Studies stipend is $2,500. Residents interested in applying practice in Lexington, Ken- should send 1) Statement regarding the purpose of tucky. (STASCIS), sponsored by the AANS/CNS Section on the proposed fellowship and estimated expenses; 2) Neurotrauma and Critical Care and AANS/CNS Sec- written permission to apply for the fellowship from Albert L. Rhoton, MD, Chair- tion on Disorders of the Spine and Peripheral Nerves, the applicant’s program director; and 3) letter of accep- man of the Department of recently completed a series of clinical studies on the tance from the institution where the applicant will seek Neurosurgery at the University management of spinal cord injuries. The studies, of Florida, was recently hon- which include an evidence based review of the role the fellowship to: R. Michael Scott, MD, The Children’s ored with the establishment of decompression after spinal cord injury and a ret- Hospital, Department of Neurosurgery, 300 Longwood of the Albert Rhoton Profes- Avenue, Bader 319, Boston, MA 02115. The deadline rospective study of spinal cord injury management, sorship in Neurosurgery — a for application submission is October 15, 1999. $4 million endowed profes- were featured in the January 1999 issue of Neurosur- ®

sorship to be directed toward gical Focus, posted on N://OC , and will be published ○○○○○○○○○○○○○○○○○○○○○○○○○○ the advancement of brain in Journal of Nerosurgery: Spine later this year. The Section on Tumors science and surgery. The pro- STASCIS group also has developed a simple, The Membership Services Com- fessorship, offered at Dr. quantitative technique to assess spinal cord mittee of the AANS/CNS Section on Tumors has Rhoton’s retirement, is the partnered with N://OC® to develop Internet-based sompression on sagittal MR images. The tech- accumulation of $2 million resources related to brain tumor research and therapy. nique was validated by conducting a multicenter worth of gifts from neurosur- The services under development include: 1) Ex- geons trained under his tute- trial, and results were published in the March is- panded lists of neuro-oncology fellowships, funding lage, medical/surgical col- sue of Journal of Neurosurgery: Spine. leagues and the staff at the sources and meetings of interest; 2) links to related University of Florida, as well Neurotrauma and Critical Care Fellowship Award Web sites; 3) online listing of tumor-related publica- as friends, families and The AANS/CNS Section on Neurotrauma and tions; 4) online membership directory that allows former patients. Dr. Rhoton is Critical Care announce the Codman Neurotrauma searches by name, institution or geographic location; a 30-year AANS member, the Fellowship Award 5) national survey on negative brain tumor trials; 6) ■ 1989-90 AANS President Up to $45,000 to Support Specific Research Proposal listing of support resources for brain tumor patients ■ and recipient of the 1998 Open to Neurosurgical Residents and Fellows Inter- and their families; and 7) multidisciplinary online AANS Cushing Medal. ested in Clinical or Basic Research Training discussion groups. ■ ■ Research Related to Neurotrauma and Critical Care Contact: Jack Wilberger, MD, Allegheny Univer- sity of the Health Sciences, Phone: (412) 359-6200, Fax: (412) 359-6615

32 Spring 1999 • AANS Bulletin New Orleans: 1999 Annual Meeting Moments

Former President George Bush delivered the Cushing Oration. President-Elect Stewart Dunsker, MD, (left) presents W. Ben Blackett, MD, with the 1999 Distinguished Service Award.

Outgoing President Russell L. Travis, MD, (left) congratulates David L. Kelly, Jr., MD, 1999 recipient of the Cushing Medal.

Stewart Dunsker, MD, presents Russell L. Travis, MD, with his Presidential Portrait.

Just as the AANS Annual Meeting was getting underway on one side of the Ernest N. Morial Convention Center in New Orleans, the AANS/CNS neurosurgical marketing booth was the center of attention at the American College of Physicians Annual Meeting, which was being held on the other side of the Convention Center. Neurosurgeons Incoming President Martin Paul Camarata, MD, (center foreground) and James Weiss, MD, (left) congratulates Bean, MD, (seated, center background) spoke Thomas B. Flynn, MD, 1999 about spine and brain disorders with physicians Recipient of the Humanitarian visiting the AANS/CNS booth. Award. troke is a growing threat to Recognizing this, the AANS and CNS have created the CV SMART the well being and produc- program—a marketing communications tool that allows neurosur- Stivity of aging Americans, geons to use their knowledge in cerebrovascular diseases to posi- including those now entering tion themselves as leaders in stroke care. The program is ready-to- middle age. Each year, more than use when you receive it, and includes the following materials aimed 700,000 Americans suffer stroke — at referring physicians as well as patients: that’s more than all other neurological disorders combined. How- ■ Two Comprehensive Presentations ever, the extent of treatment The presentations, tailored for both professional and patient audi- available to prevent, stop and treat ences, use custom images to discuss hemorrhagic and ischemic stroke has increased tremendously stroke, including prevention and the role of carotid endarterectomy. within the last decade due, in large The presentations are available on Zip disk in PowerPoint format, on CD-ROM or as 35mm slides. part, to the neurosurgeon’s ability

to evaluate, use and recommend ■ 200 Patient Education Brochures aggressive management. The easy-to-understand brochure provides a complete discussion of hemorrhagic and ischemic stroke, including the importance of early recognition and treatment of carotid stenosis, TIAs, aneurysms, and vascular malformations.

To order your ■ 100 Referring Physician Booklets Providing a more technical discussion on stroke and related disor- Getting SMART ders, the physician brochure highlights recommended diagnostic tests, operative and non-operative treatment options, and more. program materials, ■ Guidelines for Developing a Stroke Team at Your Medical Center call (847) 692-9500, The packet includes care path guidelines and stroke scales. ■ Press Releases or visit our The easy-to-use news releases can be tailored and distributed to Web site at your local media. www.neurosurgery.org The cost for the program is $300, plus $10 shipping. Selected program materials also can be purchased separately. Neurosurgeons

Springfield Clinic, located in Springfield, Illinois is seeking two BC/BE Neurosurgeons. Springfield Clinic is a 130-physician owned and operated multispecialty group practice.

Springfield is located only 1 ½ hours form St. Louis and 3 ½ hours from Chicago and Indianapolis. Springfield is both the capital of Illinois and the home of Abraham Lincoln. The Springfield area boasts excellence in education, healthcare, arts and entertainment, housing and recreation, which provides a setting for both professional and personal satisfaction.

This position offers a very competitive salary and attractive benefits package. Partnership opportunity available after 18 months of employment.

Interested candidates submit CV by fax to: Tracy at 217-383-8249 or call 800-528-8286 ext 8224.

Mid-South Neurosurgery

Join thriving medical center with a drawing area of 500,000. Call 1:3. Expect to walk into busy surgical schedule of spine and cranial cases. Exceptional income potential.

Call Jack Goggin at 800-765-3055 ID# 6524HS Fax: 314-726-3009 E-mail: [email protected] Visit our Web page: www.cejka.com

Although the AANS believes these classified advertisements to be from reputable sources, the Association does not investi- gate offers and assumes no liability concerning them. Journal of Neurosurgery AD PP ROFESSIONALROFESSIONAL CCONDUCTONDUCT W.W. BBENEN BBLACKETTLACKETT,, MD,MD, JDJD

3) Not concern himself with the legal issues of the matter in question. Advocacy and the 4) Identify as such, personal opinions not generally accepted by other neu- Standard of Care rosurgeons. In this manner, the neurosurgical ex- AANS Guidelines for Providing Expert Medical Testimony. pert witness should be reasonable and commensurate with the time and effort dvocacy testimony continues to be AANS Code of Ethics, Adopted 1981, Section given to preparing for his deposition or one of the most frequent complaints V, Item B: court appearance. Abrought before the AANS Profes- The neurological surgeon, as an expert wit- sional Development Conduct Committee ness, shall diligently and thoroughly pre- Position Statement on Testimony in Profes- and is the most frequent basis for sanc- pare himself or herself with relative facts sional Liability Cases, Adopted in 1987: tions of members by the AANS Board of so that he or she can, to the best of his or The American legal system requires expert Directors. The core of the complaint is her ability, provide the court with accu- testimony for both plaintiff and defendant. usually a statement under oath that some rate and documentable options on the The committee believes it is of central im- action or inaction was “below the stan- matters at hand. portance that such testimony be truly ex- dard of care.” pert and as impartial as possible. The com- Neurosurgeons obviously differ about Expert Witness Guidelines, 16A-1 through 4, mittee proposes the following guidelines for the best strategies for diagnosis or treat- Adopted by the AANS Board of Directors in expert witness: ment, and these differences are the sub- 1983: 1) “Expert” testimony should reflect not stance of most of our journals. Despite pref- A. The following are guidelines for testi- only the opinions of the individual erences, however, there is general recogni- mony by neurosurgeons acting as expert but also honestly describe where such tion of a range of acceptable management. witnesses: opinions vary from common prac- This range of the standard of care changes In our society, it is customary that testi- tice. The expert should not present over time and must be considered when mony be given in all adversary proceedings his or her views as the only correct stating that some past action or omission brought before the court system. The AANS ones if they differ from what might was outside the standard of care. The mar- has adopted a position advising all neuro- be done by other neurosurgeons. gins of acceptable care are not always clear surgeons to testify impartially and pru- 2) An expert should be a surgeon who cut and experts may reasonably disagree. dently for both the defendant and plaintiff is still engaged in the active practice In such cases, they should recognize a close in matters brought before the courts. of surgery, or can demonstrate call and testify. Witnesses are designated as expert wit- enough familiarity with present prac- A flagrant misstatement of the neuro- nesses if they have knowledge of any spe- tices to warrant designation as an surgical standard of care is readily recog- cific topic thought to be beyond the com- expert. nized by most neurosurgeons but not by prehension of the average layman. Expert 3) The neurosurgeon should champion lay jurors who must try to decide which witnesses are expected to be impartial and what he/she believes to be the truth, of two conflicting statements to believe. should not adopt a position of advocacy, not the cause of one party or the other. Misstatements in discovery depositions except as spokesman for the field of spe- 4) The neurosurgeon should not ac- may cause defensible cases to be compro- cial knowledge that they represent. The cept a contingency fee as an expert mised or meritorious cases to be dropped. neurosurgical expert witness must testify witness. ■ The AANS Code of Ethics, Expert Wit- as to the practice behavior of a prudent ness Guidelines and Position Statement on neurosurgeon giving differing viewpoints, Testimony in Professional Liability Cases if there are such. make clear the role of the neurosurgical Prior to offering any testimony, the ex- expert witness as an educator of the ju- pert witness should: rors in the art and science of our specialty, 1) Become familiar with all the pertinent and not as a hired teammate of the attor- data of the particular matter at hand. W. Ben Blackett, MD, JD, is a neurosurgeon in private ney for one side or the other. 2) Review prior and current concepts practice in Tacoma, Washington. He is a 31-year member of the AANS, Chairman of the Professional related to standard neurosurgical Conduct Committee, and recipient of the 1999 AANS practice on the matter at hand. Distinguished Service Award.

Spring 1999 • AANS Bulletin 37 PP RACTICERACTICE PPROFILEROFILE

to practice what he or she was taught as a resident will be left in the dust. Given this, Commitment to Quality we must stay abreast of the rapidly changing medical technology, and continually advance our technological expertise in Patient Care spinal, vascular and intracranial Puget Sound Practice Prides Itself on Patient Satisfaction. neurosurgical procedures. Further, neuronavigational tools must be utilized and mastered to refine our approaches and Name of practice: Neurosurgical Consultants companies and referral physicians also pro- enhance our surgical results. of Washington, Inc. P.S. file these parameters, and are aware of the high standard of services provided by our Location: Puget Sound Region of Washington Neurosurgery and the next millennium neurosurgeons. As we approach the year 2000, we will see Number of neurosurgeons: Eight in four care a shift in the way we practice medicine. I centers Biggest investment you have made in your envision that there will be a stronger em- practice in recent years phasis on minimally invasive surgery, ste- Total number of employees: 15 As Vice President of Neurosurgical Consult- reotactic surgery, and computer-guided or ants of Washington, Inc. P.S., I have invested enhanced surgery. Also, I think our future Number of medical centers served: Nine a great amount of time and energy into my (soon to be 10) neurosurgeons to come will find a cure for education. Two years ago, I earned a Mas- glioblastoma. Approximate number of patients cared for in your ters of Business Administration Degree practice per week: 400 from the University of Washington. Since Closing thoughts then, I have become involved in the busi- Neurosurgery is and should remain at the ness of our neurosurgical practice on both pinnacle of medicine intellectually, tech- Practice philosophy a micro and macro level. nologically and in providing gratification In our offices, hospitals and outpatient sur- to its practitioners and patients alike. gery centers, we are dedicated to providing However, neurosurgeons can no longer timely, compassionate and technologically practice in a void. In order to keep ad- Richard N. Wohns, advanced neurosurgical care to our patients. verse forces from undermining the fun- MD, Vice President of We enjoy a reputation for being among the damentals of quality, independent neu- Neurosurgical Consultants best in our area, and constantly strive for rosurgical practices, we need to be pro- of Washington, Inc. P.S., the highest levels of patient satisfaction. active in the political and socioeconomic and 12-year AANS member. arenas, as well as in the growing field of Most innovative back office management information technology. ■ solution Our office is very high-tech and prides itself on the efficiencies gained through the use of electronic medical records Advice you would give to neurosurgeons start- This is the second in a series of profiles that highlight (“paperless office”), teleradiology and ing their own practice an AANS member and his or her innovative practice- online communications with our insurance Don’t try to be a “jack of all trades”, instead building techniques. providers and local hospitals. specialize in three or four areas of neurosurgery, at most, and annually upgrade your Most innovative approach to managing ex- skills and techniques. Also, gain economies ternal relationships of scale and marketability by joining forces Our offices have the ability to perform out- with neurosurgeons of a high quality, for- patient spine surgery in several locations, ward thinking philosophy. with outcomes tracked using an Internet- based database that allows national Future of neurosurgical private practice benchmarking. We pride ourselves on our The future of our specialty is in the hands quality outcomes, short length of stays, and of those neurosurgeons who are learning overall lower costs. The local insurance machines. The neurosurgeon who expects

38 Spring 1999 • AANS Bulletin EE VENTSVENTS Calendar of Neurosurgical Events

10th Annual Meeting of the North Ameri- 2nd Symposium of the International Western Neurosurgical Society Annual American Association of Neurological can Skull Base Society Society for Neuroemergencies Meeting Surgeons Annual Meeting May 28-31, 1999 July 4-9, 1999 September 18-21, 1999 April 8-13, 2000 Chicago, Illinois Albano-Terme, Italy Coeur d’Alene, Idaho San Francisco, California (301) 664-6802 39-49-8213090 (619) 268-0562 (847) 692-9500

15th Annual Meeting of the German Quadrennial Meeting for the American 11th European Congress of Neurosurgery World Spine 1: First Interdisciplinary Society of Neurosurgery and Joint Society of Stereotactic and Functional September 19-24, 1999 World Congress on Spinal Surgery Meeting With the Swiss Society of Neurosurgery Copenhagen, Denmark August 27-September 1, 2000 Neurosurgery July 7-10, 1999 45-3452390 Berlin, Germany June 5-9, 1999 Snowbird, Utah 49-30-857903-0 Munich, Germany Review and Update in Neurobiology for 89-7095-2590 15th Mexican Congress of Neurological Neurosurgeons 15th International Congress of Head and Surgery October 9-16, 1999 Neck Radiology 11th International Symposium of Brain July 25-31, 1999 Madison, Connecticut October 18-21, 2000 Edema and Mechanisms of Cellular Cancun, Mexico (203) 421-5886 Kumamoto, Japan Injury 52-5-5430013 81-96-373-5258 June 6-10, 1999 Congress of Neurological Surgeons Newcastle-upon-Tyne, England Brazilian Academy of Neurosurgery and Annual Meeting 4th World Stroke Congress 191-2738811 World Federation of Neurosurgical October 30-November 4, 1999 November 25-29, 2000 Societies Boston, Massachusetts Melbourne, Australia 51st Annual Meeting of the Scandinavian September 1-7, 1999 (847) 692-9500 61-3-9682-0288 Neurosurgical Society Rio Grande do Sul, Brazil June 10-13, 1999 55-51-2225 Skull Base Surgery 2000 Goteborg, Sweden March 17-20, 2000 46-31-342-10-00 Scottsdale, Arizona (301) 654- 6802

Japan Neurosurgery

Spring 1999 • AANS Bulletin 39 P ERSONAL P ERSPECTIVE A. JOHN PPOPP,, MDMD

proper experience during neurosurgical residency to deliver superb care to that child; I Subspecialization believe that is what occurs most of the time. Yet that same practitioner may be viewed with suspicion by the very family of the child Certification to whom care has been rendered since care was rendered by a “non certified” surgeon. Examining the Issues Facing Neurosurgery. From my personal perspective, I believe that the move toward subspecialty certification n this issue of the AANS Bulletin, our in the field if most of the experience accrues must take into account the realities of neuro- featured subject explores the ramifica- to a relatively small group of physicians spe- surgical practice. Residency training should Itions of subspecialty certification in cializing in that area? educate residents to deliver care to the spec- neurosurgery. While the subject of this re- trum of patients with surgically treatable prob- view may appear innocuous to the practic- Realities of Neurosurgical Practice lems of the nervous system and when to refer ing neurosurgeon, aspects of this topic are Despite the apparent rectitude of this theo- patients requiring care beyond their abilities. explosive and evoke great passion in a sub- retical stance, when one contemplates the I believe that the ABNS and RRC do an stantial proportion of the AANS member- realities of neurosurgical practice the pro- excellent job in assuring that training pro- ship. The mere process of certification brings priety of such thinking becomes less cer- grams meet these goals and that certification with it differentiation and, hence, an impli- in neurosurgery denotes competence in the cation about quality of care delivered by two A. John Popp, MD, entire field. Furthermore, the AANS, as an groups of neurosurgical practitioners – those Editor of the AANS association that exists for the betterment of with subspecialty certification and those Bulletin, is the Henry and its membership, recognizes that continuing without. Sally Schaffer Chair of education in the form of meetings, publica- Surgery at Albany tions and CME courses is essential to main- A Brief History Medical College. tain competency after residency training. As our knowledge base grows and as we refine patient care delivery, the trend toward Value of Subspecialization subspecialization seems inevitable. For ex- tain. While no one doubts the need for re- We owe gratitude to those individuals that ample, as medicine evolved it became ap- ferral to specialty centers for certain rare have led neurosurgery by specialization. parent that mastery in surgery required fo- disorders or for some complex operative They have advanced our speciality by broad- cus on progressively smaller segments of the procedures that are beyond the experience ening our scope of practice. Recall the ad- surgical universe. or ability of an individual practitioner, what vances in spinal surgery —a field extended Indeed, the specialty of neurosurgery was happens to those patients with less com- and preserved for all neurosurgeons by a born out of that evolution driven by a real- plicated but equally emergent problems few who chose to subspecialize. ization that research and patient care for prob- who are often distant from the tertiary care We must not rush to judgment about the lems of the nervous system were quite differ- centers that offer subspecialty care? best approach to answer these questions ent from those in other areas of surgery. From Despite having approximately 4,500 neu- about subspecialty certification, but we this historical perspective, it would appear that rosurgical practitioners in the United States, must develop a strategy. As H.L. Mencken those who wish to sub-divide the specialty of a significant portion of our population is wrote, “For every complex problem there neurosurgery by subspecialty certification remote from subspecialty care and even the is a solution that is simple, neat and wrong”. have legitimate historical support and patient most sophisticated medical centers may have Fully airing this complex topic may help care focus that lend credibility to their argu- only one or two individuals subspecializing the neurosurgical community come closer ment. Indeed, when one moves from the facts in a particular area of neurosurgery. What to consensus. Continuing the debate with- of history to a theoretical plane the argument happens, then, when the pediatric patient out a conclusion merely prolongs the life becomes even more persuasive. Would it not with shunt failure arrives in the emergency of a fractious dispute at a time when unity be better, for example, to have all pediatric room of the tertiary care center on Saturday in neurosurgery is necessary. Neurosurgery neurosurgical care rendered by individuals night and the staff pediatric neurosurgeon must continue to evolve. Will the process whose sole interest and experience focused on is not on call? Generally, care is rendered by of subcertification facilitate this evolution, caring for children with neurosurgical disor- a neurosurgical colleague of the pediatric enhance our field, and assure excellence? ders? Furthermore, would this concentration neurosurgeon who is on call that night. The answers to these questions are critical on a specialty area not lead to greater advances Hopefully that individual will have had the to the future of our speciality. ■

40 Spring 1999 • AANS Bulletin