A M E R I C A N A SSOCIATION OF N EUROLOGICAL S URGEONS

The Socioeconomic and Professional Magazine for AANS Members • Volume 15 Number 2 • 2006

COMPLETING THE PICTURE Assessing Neurosurgical ER Coverage Whom Does Credentialing Protect? 30 Texas Teaches That Tort Reform Works, 34 AANS Board Approves Professional Conduct Recommendations, 36

AANS NON-PROFIT ORG 5550 MEADOWBROOK DRIVE U.S. POSTAGE PAID ROLLING MEADOWS, IL 60008 AMERICAN ASSOCIATION OF NEUROLOGICAL SURGEONS C ONTENTS VOLUME 15 NO. 2

Egyptian, Coptic, “Portion of a Hanging Showing a Figure of a Warrior,” 5th/6th century, linen and wool, plain weave with weft pile and embroidered linen pile in back and stem stitches, 136.5 x 88.3 cm, Grace R. Smith Textile Endowment, FEATURES 1982.1578, The Art Institute of Chicago. 16 | Sweet Success in San Francisco Photography © The Art The 74th Annual Meeting initiates the AANS’ diamond Institute of Chicago. jubilee year. Manda J. Seaver

22 | Inspirations and Epiphanies Juan Cardenas, Stephen Mahaley, Edgar Kahn, Keasley Welch, and the Mona Lisa are among neurosurgeons’ inspirations. NEWS AND EVENTS

5 | Newsline ON THE COVER The AANS, CNS and ASTRO define stereotactic radiosurgery.

8 | Completing the Picture: AANS 2006 Workforce 42 | News.org Survey Assesses Neurosurgical ER Coverage NERVES releases 2005 practice survey results. A new survey finds that the vast majority of neuro- surgeons are participating in the emergency care 44 | Calendar of Neurosurgical Events system, but most also report problems with call AANS/CNS Section on Pediatric Neurological Surgery coverage in their practice areas. annual meeting will be held Nov. 29–Dec. 1. Manda J. Seaver OPINION 12 | What Will Improve Neurosurgical Emergency Coverage? 35 | Letters In the wake of the IOM report on emergency care, A reader questions the motivations of defense attorneys. surgery’s views on the proposed specialty of acute care surgery and regionalization are explored. 7 | Personal Perspective The case for regionalization of neurosurgical emergency Manda J. Seaver services grows stronger. PRESIDENT’S MESSAGE William T. Couldwell, MD

3 | Professional Conduct: Witness Testimony Continued on page 2 Obligations of membership include adherence to the AANS Code of Ethics. Donald O. Quest, MD

Vol. 15, No. 2 • 2006 • AANS Bulletin 1 C ONTENTS

DEPARTMENTS 34 | Medicolegal Update Texas teaches that tort reform works. 38 | Advancing Neuroresearch David F. Jimenez, MD Two NREF milestones give reason to cheer. 30 | Patient Safety Michele S. Gregory Whom does credentialing protect? 40 | Bookshelf Patrick W. McCormick, MD Character is at the core of two new books by neurosurgeons. 21 | Practice Management When insurers share savings, you don’t have to suffer. Gary Vander Ark, MD Nick Green 28 | Coding Corner Coding for concurrent spinal procedures 24 | Residents’ Forum is explored. You can clip an aneurysm, but can you compute cost per RVU? Gregory J. Przybylski, MD Lawrence S. Chin, MD 33 | Education A new endovascular course for residents illustrates 32 | Timeline how collaboration benefits education. Two world wars had an “acute” impact on neurosurgi- cal training. Joni L. Shulman Michael Schulder, MD 36 | Governance AANS Board of Directors approves four Professional 26 | Washington Update Conduct Committee recommendations. Tort reform falls short in the Senate, but the DMLR campaign presses forward. W. Ben Blackett, MD, JD, and Russell M. Pelton, JD Katie O. Orrico, JD

AANS MISSION Forum; Monica Wehby, MD, and Michael Chabraja, JD, in a future issue edited for length, clarity and style. The American Association of Neurological Surgeons Risk Management Correspondence is assumed to be for publication unless (AANS) is the organization that speaks for all of neurosurgery. otherwise specified. The AANS is dedicated to advancing the specialty of WRITING GUIDELINES neurological surgery in order to promote the highest www.aans.org/bulletin Bulletin Online quality of patient care. The current issue and searchable archives since 1995 are avail- ARTICLE SUBMISSIONS AND IDEAS able at www.aans.org/bulletin. AANS BULLETIN Articles or article ideas concerning socioeconomic topics The official publication of the American Association of related to neurosurgery can be submitted to the Bulletin, PUBLICATION INFORMATION Neurological Surgeons, the Bulletin features news about the [email protected]. Objective, nonpromotional articles that The AANS Bulletin, ISSN 1072-0456, is published four times AANS and the field of neurosurgery, with a special emphasis on are in accordance with the writing guidelines, are original, a year by the AANS, 5550 Meadowbrook Drive, Rolling socioeconomic topics. and have not been published previously may be considered Meadows, Ill., 60008, and distributed without charge to the for publication. neurosurgical community. Unless specifically stated other- William T. Couldwell, MD, editor wise, the opinions expressed and statements made in this Patrick W. McCormick, MD, associate editor The AANS reserves the right to edit articles for compliance publication are the authors’ and do not imply endorsement with publication standards and available space and to Manda J. Seaver, staff editor by the AANS. publish them in the vehicle it deems most appropriate. Articles accepted for publication become the property of the BULLETIN ADVISORY BOARD © 2006 by the American Association of Neurological Surgeons, AANS unless another written arrangement has been agreed a 501(c)(6) organization, all rights reserved. Contents may not Gregory J. Przybylski, MD Deborah L. Benzil, MD upon between the author(s) and the AANS. be reproduced, stored in a retrieval system, or transmitted in Frederick A. Boop, MD Gail Rosseau, MD any form by any means without prior written permission of Lawrence S. Chin, MD Michael Schulder, MD PEER-REVIEWED RESEARCH the publisher. The Bulletin seeks submissions of rigorously researched, Fernando G. Diaz, MD, PhD Gary D. Vander Ark, MD hypothesis-driven articles concerning socioeconomic topics ADVERTISING SALES David F. Jimenez, MD K. Michael Webb, MD related to neurosurgery. Selected articles are reviewed by peer- Richard Devanna, Cunningham Associates, (201) 767-4170, Monica C. Wehby, MD Katie O. Orrico, JD review panelists. Papers must comport with the writing guide- or [email protected]. Mick J. Perez-Cruet, MD Richard N. Wohns, MD lines at www.aans.org/bulletin. Rate card, www.aans.org/bulletin. A. John Popp, MD Peer-Review Panel led by Deborah L. Benzil, MD William E. Bingaman Jr., MD; Frederick A. Boop, MD; Fernan- DEPARTMENT EDITORS AND CORRESPONDENTS do G. Diaz, MD; Domenic Esposito, MD; David F. Jimenez, MD; Mark E. Linskey, MD; Mick Perez-Cruet, MD; Richard N. Frederick Boop, Newsline; Lawrence Chin, MD, Education; Wohns, MD Fernando Diaz, MD, PhD, CSNS Report; David Jimenez, Patient Safety; Katie O. Orrico, JD, Washington Update; Mick LETTERS Perez-Cruet, MD, NS Innovations; Gregory J. Przybylski, MD, Send your comments on articles you’ve read in these Coding Corner; Michael Schulder, MD, Timeline; pages or on a topic related to the practice of neurosurgery Gary Vander Ark, Bookshelf; K.Michael Webb, MD, Residents’ to [email protected]. Correspondence may be published

2 Vol. 15, No. 2 • 2006 • AANS Bulletin P RESIDENT’ S M ESSAGE D ONALD O .QUEST, MD

Professional Conduct: Witness Testimony

embership in the AANS is volun- evidence in court, the general qualifica- tary and not a prerequisite to the tions necessary for those who testify, and When the Professional practice of neurosurgery. Never- the importance of honest testimony. This Conduct Program was initi- M theless there are obligations of report states that “expert witnesses should membership, and one of these is adherence avoid inflammatory accusations…and ated, guidelines for expert to the AANS Code of Ethics. must not merely offer speculations but The AANS Code of Ethics addresses, in rather be able to substantiate claims on witness testimony were part, expert witness testimony. Such testi- the basis of experience, published re- developed to ensure a mony as part of the practice of medicine is search, consensus statements or evidence- indeed an obligation of members of the based guidelines….” standard of quality and medical profession. The AANS is joined in The AMA report also stresses that testi- this view by many prominent medical soci- mony is to be impartial and has a higher impartiality on both sides of eties, among them the American Medical goal than that of supporting the claims of professional liability cases. Association and the American College of Surgeons. The AANS, the AMA and the ACS all provide their members with guid- Donald O. Quest, MD, The AANS Code of Ethics states in part ance on how to act professionally and is the 2006–2007 that “expert testimony should reflect not ethically in the legal arena. While documen- AANS president. only the opinions of the individual but also tation of this guidance is readily available describe where such opinions vary from from each of these organizations, a brief common practice; the expert should be review of salient points follows. engaged in active practice of surgery or be The ACS Statements of Principles, most able to demonstrate enough familiarity recently updated in 2004, avers that “expert with present practice to warrant designa- witnesses are expected to be impartial and either prosecution or defense: “Although tion as an expert, and should champion the should not adopt a position as an advocate the testifying physicians’ services may have truth [rather than] the cause of one party or partisan in the legal proceedings.” The been sought primarily by one party, [physi- or other.” expert also should be “familiar with the cians] testify to educate the court as a The AANS also developed the Rules standard of care provided at the time of the whole.” The report further calls for impar- for Neurosurgical Medical/Legal Expert alleged occurrence and should be actively tial testimony that must not be false or mis- Opinion Services document, which calls engaged in practice of the specialty or the leading and for physicians providing expert upon the neurosurgeon “to be an impar- subject matter of the case at the time the testimony to have “recent and substantive tial educator for attorneys, jurors, and the testimony or opinion is provided.”The ACS experience or knowledge in the area in court…not to be evasive for the purpose additionally asks its members to sign and which they testify.” of favoring one litigant over another abide by the Expert Witness Affirmation, The report’s conclusion reinforces the …and to review all pertinent available which sets forth 10 principles for expert concept of professional conduct through medical information prior to rendering witness testimony that include conducting adjudication of ethical infractions via a an opinion.” a thorough, fair, and impartial review of the program that employs due process: Complaints of ethics code violations facts, and providing testimony that is objec- are evaluated by the Professional Conduct tive, scientifically based and helpful to a just “Organized medicine…[has] impor- Committee through the Professional resolution of the case. tant roles to play in promoting the Conduct Program. The program was ini- The AMA offers guidance on medical ethical conduct of physician witness tiated 25 years ago, and its procedures testimony in its Code of Medical Ethics, activities. With careful attention to due have undergone some modifications over which affirms that a physician’s participa- process…organizations can help main- time. The program’s premise is that mem- tion in the legal system is “an ethical obli- tain high standards for medical wit- bership in a professional organization gation.” In 2004 the AMA issued a report nesses by assessing claims of false or requires conduct which meets a high pro- on medical testimony that addresses the misleading testimony and issuing fessional standard. physician’s ethical obligation to provide disciplinary sanctions as appropriate.” Continued on page 4

Vol. 15, No. 2 • 2006 • AANS Bulletin 3 P RESIDENT’ S M ESSAGE

Continued from page 3 of professional self-regulation furthers, When the Professional Conduct Pro- The AANS Rules for rather than impedes, the cause of justice” gram was initiated, guidelines for expert and acknowledging that “judges need the witness testimony were developed to Neurosurgical Medical/ help of professional associations in screen- ensure a standard of quality and impar- Legal Expert Opinion ing experts.” A number of other medical tiality on both sides of professional liabil- societies have used the AANS Professional ity cases. Violation of these guidelines Services document calls Conduct Program as a model for their own. could be a cause for a member to bring a The goal of the AANS Professional Con- charge of unprofessional conduct against upon the neurosurgeon duct Program in hearing these complaints another member. “to be an impartial is not to discourage members from testify- The AANS bylaws detail the process that ing on behalf of either plaintiffs or defen- ensues when a charge of unprofessional educator for attorneys, dants but rather to promote the integrity of conduct is brought by one AANS member jurors, and the court….” testimony on both sides of the litigation against another. It is the duty of the AANS process. Medical malpractice occurs, and Professional Conduct Committee to when it results in litigation expert witness- address complaints on an impartial basis, to es are necessary to plaintiffs and defendants conduct hearings where appropriate with and makes a decision as to whether or not so that justice can prevail. due process protection for all parties unprofessional conduct is apparent. Either a It is essential that AANS members par- involved, and to make unbiased recommen- hearing is scheduled or the case is dismissed ticipate in the judicial process as expert dations to the AANS Board of Directors. (and 35 percent of the cases brought before witnesses, and it is incumbent on every Members of the committee, experienced the committee are dismissed). The com- member who testifies as an expert to be and well-respected senior neurosurgeons, plainant and respondent may each have familiar with the AANS Code of Ethics and are appointed by the AANS president with counsel in attendance at the hearings, and Rules for Neurosurgical Medical/Legal ratification by the Executive Committee. the proceedings are recorded by a court Expert Opinion Services. Expert testimony The PCC members devote considerable reporter. After both sides have made presen- must be informed, objective, impartial, time to the program, spending hours tations, cross-examination has occurred, and medically sound. Litigants, juries, reviewing each case and participating, usu- and the committee’s questions have been judges, and the public should be able to ally for a full day, in hearings held twice answered, the committee goes into execu- rely on that. 3 yearly in conjunction with the AANS and tive session to determine whether unprofes- CNS annual meetings. sional conduct has been established and, if The committee reviews the submissions so, what penalty is appropriate. If an adverse of both the complainant and respondent action (censure, suspension, or expulsion) For Further Information is recommended, the respondent has the opportunity to appeal to the AANS Board 3 AANS Rules for Neurosurgical of Directors and further to the general Medical/Legal Expert Opinion membership at the annual business meeting Services, page 37 AANS Professional Conduct Committee if necessary. 3 American College of Surgeons, W. Ben Blackett, MD, JD, chair To date there have been 80 complaints www.facs.org Russell M. Pelton, JD, parliamentarian filed and 65 of these have involved expert 3 American Medical Association, and legal counsel witness testimony. Sixty hearings have been www.ama-assn.org held, resulting in nine letters of censure, 22 3 Blackett, WB: AANS testimony rules Ulrich Batzdorf, MD suspensions and five expulsions. There have rewritten: New rules for neurosurgical med- been five repeat offenders. Martin B. Camins, MD ical/legal expert opinion services. AANS Not surprisingly the AANS Professional Steven L. Giannotta, MD Bulletin 13(1):33, 2005. www.AANS.org, Conduct Program has gained the attention Article ID 21843 Hal L. Hankinson, MD of the plaintiff bar. Although the AANS 3 Pelton, RM: Professing professional con- Roberto C. Heros, MD program has been challenged in state and federal courts, thus far it has withstood all duct: AANS raises the bar for expert testi- Philip R. Weinstein, MD challenges. A federal appeals court judge mony. AANS Bulletin 11(1):7–13, 2002. praised the program, stating that “this kind www.AANS.org, Article ID 9916

4 Vol. 15, No. 2 • 2006 • AANS Bulletin

N EWSLINEEWSLINE N NewsMembersTrendsLegislation

Medical Liability 3 IOM Issues Three Reports on Emergency Medical Care On June 14 the Institute of Medicine issued Reform Legislation Falls three reports related to the Future of Emergency Care in the U.S. project. The report of most rele- Short in U.S. Senate vance to neurosurgeons, Hospital-Based Emergency Care: At the Breaking Point, explores the chang- On May 8 the U.S. ing role of the hospital emergency department and describes the national epidemic of overcrowded Senate voted on two emergency departments and trauma centers. This report offers an assessment of the emergency care medical liability reform workforce, including specialists who provide on-call emergency and trauma care services. To help bills. Both bills failed to improve the availability of on-call physicians, the IOM recommends a number of remedies that gain the necessary sup- include improved reimbursement for emergency services, medical liability reform, regionalization of port to move forward in certain emergency specialty services, and creation of a new specialty called acute care surgery. The the legislative process. AANS opposes the establishment of an acute care surgical specialty if these specialists are intended See Washington Update, to perform neurosurgical procedures. The three IOM reports—Hospital-Based Emergency Care: At page 26. the Breaking Point, Emergency Medical Services at the Crossroads and Emergency Care for Children: Growing Pains—are available a www.iom.edu. Neurosurgical involvement in the emergency medical system is the subject of this issue’s cover section, beginning on page 8, and the editor’s Personal Perspective, page 7.

3 AANS, CNS and ASTRO Define SRS In April the AANS Board of Directors, the Executive Committee of the Congress of Neurological Surgeons and the Board of Directors of the American Society for Therapeutic Radiology and Oncology agreed on a contemporary definition of stereotactic radiosurgery. This position statement follows and also is published online at www.AANS.org, article ID 38198.

3 Stereotactic radiosurgery is a distinct discipline that utilizes externally generated ionizing radiation in certain cases to inactivate or eradicate (a) defined target(s) in the head and spine without the need to make an incision. The target is defined by high-resolution stereotactic imaging. To assure quality of patient care the procedure involves a multidisciplinary team consisting of a neurosurgeon, radi- ation oncologist, and medical physicist.

3 Stereotactic radiosurgery typically is performed in a single session, using a rigidly attached stereo- tactic guiding device, other immobilization technology and/or a stereotactic image-guidance sys- tem, but can be performed in a limited number of sessions, up to a maximum of five.

3 Technologies that are used to perform stereotactic radiosurgery include linear accelerators, particle beam accelerators, and multisource Cobalt 60 units. In order to enhance precision, various devices may incorporate robotics and real time imaging.

3 AANS and CNS Seek Medicare Payment Policy Change for SRS of Multiple Lesions Beginning with Medicare carrier Noridian Administrative Services, which had issued a proposed Medicare coverage policy related to stereotactic radiosurgery that would affect its coverage area of more than 10 states, the AANS and Congress of Neurological Surgeons are urging Medicare carriers to adopt the AANS, CNS and ASTRO definition of SRS and to ensure that additional payments for SRS are made when a neurosurgeon treats more than one lesion. The AANS and CNS comments to Noridian state that Current Procedural Terminology “code 61793 is valued for treating a single lesion, whether or not that treatment requires multiple isocenters or multiple sessions. Under CPT and Medicare policy for multiple procedures, code 61793 may be reported multiple times for multiple lesions, using 61793 alone for the first lesion and 61793 appended by modifier 59 or modifier 51. This code should not Send news briefs for be reported more than five times for any session. Any additional sessions (up to five) for the same Newsline to lesion(s) are inclusive of CPT 61793. If any lesion requires multiple isocenters and/or requires more [email protected]. complex targeting, then code 61793 should be reported appended by modifier 22.”

Vol. 15, No. 2 • 2006 • AANS Bulletin 5

P ERSONAL P ERSPECTIVE W ILLIAM T .COULDWELL, MD

swift transport of patients in need of neuro- The Case for Regionalization surgical emergency care. From a neurosur- IOM Report and AANS Survey Point to Proactive Strategy gical perspective, the development of coordinated, regionalized care is the funda- mental change which must occur. good deal of media attention herald- taken a circuitous route to reach our hospi- Emergency access to on-call specialists in ed the June 14 release of three tal, in part because the emergency system some regions was noted in the IOM report reports that conclude the Institute of functions under the premise that optimal as a problem which, the authors admitted, A Medicine’s two-year examination of neurosurgical care will be provided by stemmed from the disruptive lifestyle, poor the U.S. emergency medical system. The other institutions, when in actuality those compensation, and increased liability that is attendant headlines in newspapers across facilities do not always have the resources— associated with providing emergency surgi- the country—“Crisis Seen in Nation’s ER cal care. As part of a multipronged strategy Care” (Washington Post), “Emergency William T. Couldwell, for improvement, the report recommended Medical Care Listed in Critical Condition” MD, is editor of the regionalization of specialty services. (USA Today)—may sound hyperbolic, but AANS Bulletin. To achieve regionalization, appropriate the problems identified by the IOM are real He is professor and triage is necessary. The IOM called for Joseph J. Yager Chair of and quite sobering. the Department of effective communication and coordination The reports introduce the public to Neurosurgery at the among various components of the system, what neurosurgeons and others working University of Utah including 911 emergency call and dispatch, within the healthcare system day in and day School of Medicine. ambulances, EMS workers, and hospital out know firsthand: Emergency depart- emergency departments. In addition to ments are overcrowded, patients presenting equipment or personnel—to provide such increased state and federal funding for in the nation’s ERs often wait long periods care. What this means is that my facility facilities that bear a disproportionate of time before being seen, ambulance diver- functions as a de facto regional care center amount of the cost of care for the unin- sions are increasing, and the system as a for neurosurgery; what this means to sured, the report called for methods to whole is highly fragmented and variable. patients is that they often experience delays determine the performance of the different These problems are at least partially in getting appropriate treatment. system components and for public report- rooted in the increasing number of ER vis- Another perspective, that of a neurosur- ing. It also included a recommendation its (113.9 million in 2003, compared with geon practicing at a hospital in an Idaho that Congress establish a five-year demon- 90.3 million a decade earlier) at a time community of about 175,000 people, was stration program to fund individual states when the number of facilities with emer- discussed in the pages of the Winter 2004 in developing a coordinated, regionalized gency departments has been declining, said issue of the Bulletin. That scenario involved and accountable system which will be used the IOM. Concurrently the uninsured pop- the neurosurgeon and his partner covering to identify “best practices”on which to base ulation has been increasing, while there has emergency call 24/7 with one of them on larger scale development. been a decline in federal funding for emer- call every other night. When, citing unsus- Based on the AANS 2006 Workforce Sur- gency medical services since the early 1980s tainable negative impact on personal life vey of ER coverage and related issues, the that has resulted in haphazard develop- and elective practice, they stopped provid- results of which are reported in this issue’s ment of emergency medical systems across ing their hospital with emergency coverage, cover story, neurosurgeons have been pro- the United States. emergent neurosurgical cases from that viding emergency coverage, though more Further, close to 70 percent of urban area began to be transported to my facility. than three-quarters of them identified neu- hospitals diverted patients at some point Scenarios such as this one point to rosurgical emergency call coverage as a during 2004, resulting in transfer or proactive regionalization of neurosurgical problem in their practice areas. Clearly, we rerouting from an ER that was full or emergency care as an idea whose time has need to find ways to render the system man- lacked services to one farther away. Major come. Such a plan should not necessarily ageable; the regionalization of neurosurgical reasons for diversion included shortages mean that regional facilities would be aca- care will be the best solution for both patient of available intensive care unit beds and demic medical centers, but certainly that care and for neurosurgery as a specialty. on-call specialists. they would be strategically located, well- At my own institution, an academic equipped and appropriately staffed centers For Further Information medical center, countless patients with supported by adequate federal and state 3 See the cover section, beginning on emergent neurosurgical problems have funding as well as by well-coordinated and page 8.

Vol. 15, No. 2 • 2006 • AANS Bulletin 7

COMPLETING THE PICTURE AANS 2006 Workforce Survey Assesses Neurosurgical ER Coverage

MANDA J. SEAVER Completing the picture of neurosurgical emergency coverage in the United States is the aim of a new survey conducted by the American Association of Neurological Surgeons. The AANS 2006 Workforce Survey shows that while the overall participation of neurosurgeons in the nation’s emergency medical system remains strong, there is room for improvement in neurosurgical call coverage and, more broadly, in the emergency medical system itself. The emergency medical system has been the subject of intense scrutiny, most recently by the Institute of Medicine which released three reports June 14 that conjure an image of an unraveling system. The three reports—Emergency Care for Children: Growing Pains, Emergency Medical Services at the Crossroads, and Hospital-Based Emergency Care: At the Breaking Point—depict what the IOM char- acterizes as an “overburdened, underfunded, and highly fragment- ed” U.S. emergency medical system. The IOM reports are the product of the Committee on the CFuture of Emergency Care in the U.S. Health System, a group com- missioned in September 2003 to perform extensive study of emer- gency care issues. In announcing the reports, committee chair Gail L. Warden observed that “the system’s capacity is not keeping pace with the increasing demands being placed on it” and called for “a comprehensive effort to shore up America’s emergency medical care resources and fix problems that can threaten the health and lives of “Portion of a Hanging Showing a Figure of a Warrior.” See page 1 for details. people in the midst of a crisis.” Inadequate reimbursement, increased liability, and unintended Bulletin by AANS Executive Committee member James R. Bean, consequences of the Emergency Medical Treatment and Labor Act, MD, the survey also showed that “some neurosurgeons [were] all cited in the IOM report on hospital-based care as factors con- straining to provide emergency coverage, particularly those in pri- tributing to inadequate coverage by specialists in the ER, have been vate practice and in small group settings, and that some patients, among organized neurosurgery’s premier concerns in recent years. particularly trauma victims and children distant from a level 1 trau- These issues were also among the threads comprising the complex ma center, may be at risk for not receiving timely and appropriate fabric that characterizes the delivery of emergency neurosurgical neurosurgical emergency care.” care, described by Alex Valadka, MD, in the cover story of the Win- That neurosurgeons were interested in and concerned about ter 2004 Bulletin. Also in that issue, results of the 2004 AANS/CNS neurosurgical emergency coverage was demonstrated by the 2004 Neurosurgical ER and Trauma Services Survey were released. survey’s robust response rate of 32 percent, coupled with the more The 2004 ER survey was clear in its finding that a solid majority, than 350 comments offered and the more than half of respondents 83 percent, of neurosurgeons or their practices were providing full who volunteered themselves for follow-up discussion of neurosur- (24/7/365) emergency coverage. However, as summarized in the gical emergency care in their areas.

8 Vol. 15, No. 2 • 2006 • AANS Bulletin

E PICTURE l ER Coverage

Neurosurgeons Are Participating in the Emergency Care System As shown in Figure 4 on page 10, most on-call neurosurgeons, Rather than waning, neurosurgeons’ concern regarding appropriate, 59 percent, practiced in a community hospital setting, while 38 per- quality neurosurgical emergency care has intensified. The AANS cent practiced in an academic medical center and 6 percent selected Task Force on Neurosurgical Care and Physician Workforce Issues “other.” As expected, the majority of on-call neurosurgeons prac- commissioned the 2006 Workforce Survey to help AANS leadership ticed at level 1 or level 2 trauma centers, both of which are defined identify and quantify problems in neurosurgical emergency cover- by the American College of Surgeons Committee on Trauma as age and in other areas of the workforce. Although this survey was requiring neurosurgical coverage. Most on-call neurosurgeons also broader in scope than the 2004 survey, results of a few key questions covered call at two or more hospitals (57 percent) with another 43 regarding emergency neurosurgical care could be compared, though percent covering call at only one facility, and almost all respondents, some caveats apply. 95 percent, said that some or all of their hospitals require them to The AANS 2006 Workforce Survey was conducted online by Per- cover call. About 57 percent of on-call neurosurgeons took call two ception Solutions, an independent market research company. E-mail or three days per week,though nearly equal percentages took call invitations were delivered in January to 2,562 neurosurgeon members more or less frequently: 22 percent took call four or more days per of the AANS. The demographics of survey respondents tracked close- week, and 21 percent, one day per week or less. ly with those of AANS members as well as participants in the 2004 On-call neurosurgeons worked an average of 70 hours per week, survey, with the great majority of respondents with 56 hours devoted to direct patient care. ranging from 36 to 55 years of age, in private 2006 Administrative work absorbed eight hours per practice, and practicing in small groups of two week, and 6 hours were spent on research or 94% to five neurosurgeons or medium groups of six education, while four hours were allocated to to 20 neurosurgeons. Do you take ER call? unspecified “other” tasks. A total of 770 surveys were completed, The majority of survey respondents said 2004 resulting in a 30 percent return comparable to they provided all types of neurosurgical servic- that of the 2004 survey. Results are accurate 83% es. Of the neurosurgeons who took emergency plus or minus 5 percent or better, meaning call, 61 percent covered all neurosurgical serv- Do you or your practice provide full that the same survey conducted 100 times (24/7/365) emergency neurosurgi- ices in 2006, compared with 54 percent who did would yield the same results 95 times. cal call coverage for a hospital? so in 2004. Additional results are shown in The 2006 Workforce Survey reaffirmed Figure 3 on page 10. that the vast majority of neurosurgeons are Figure 1. Percentage of Neuro- In the 2006 survey, the service coverage surgeons Taking Emergency Call taking emergency call. As shown in Figure 1 question also was put to all neurosurgeons

above, 94 percent responded affirmatively to Percentages are rounded. Sources: 2006 Data, participating in the survey, inclusive of those the question, Do you take ER call? It is unclear AANS 2006 Workforce Survey; 2004 Data, who took emergency call and those who did whether the increase in neurosurgical emer- 2004 AANS/CNS Neurosurgical Emergency and not. When asked, Have you limited the type of Trauma Services Survey. gency call coverage of 11 percentage points procedures performed by your practice, 62 over the 2004 survey result is attributable to broader phrasing of the percent affirmed that they had not. The 38 percent who had lim- question in the 2006 survey or to some other factor or factors. ited their practices were asked to identify any procedures they had The 2006 survey also indicated a 17 percent increase in the completely eliminated. The greatest number, 57 percent, had elim- number of neurosurgeons who receive a stipend for emergency call inated pediatric cases, while 13 percent had eliminated trauma coverage: 50 percent in 2006 compared with 33 percent in 2004, as cases, and 11 percent had eliminated cranial cases. Only 5 percent shown in Figure 2 on page 10. The distribution of stipend amount had eliminated spinal cases, although research by Richard Wohns, remained fairly constant, with the areas of greatest change reported MD, published in the Bulletin, indicated that elective spinal cases in the $1,001 to $1,500 per diem range (8 percent reduction are the primary source of medical malpractice lawsuits. Another 55 between 2004 and 2006) and in the number of neurosurgeons who percent selected “other” and offered a variety of explanations, fre- have an arrangement for emergency call other than per diem pay- quently citing aneurysms, neurovascular cases (a lack of available ment (10 percent increase between 2004 and 2006). However, dif- interventionists was noted several times), subarachnoid hemor- ferences in question design between the 2006 and 2004 surveys rhages, and complex cranial and spinal cases as the types of cases may account for some variation in results. eliminated from practice.

Vol. 15, No. 2 • 2006 • AANS Bulletin 9

COMPLETING THE PICTURE

Compensation Services Covered 2006 2004 Cover all services 61% Receive a Stipend 50% 33% More than $3,000 per diem 3% 2% Cranial 48% $2,001–$3,000 per diem 7% 6% $1,501–$2,000 per diem 7% 8% Spinal 47% $1,001–$1,500 per diem 17% 25% $751–$1,000 per diem 19% 17% Trauma 46% $501–$750 per diem 7% 11% $500 or less per diem 13% 17% Pediatric 22% Not paid per diem; have another 26%* 16% compensation arrangement Other 3% *Some respondents commented that they included their arrangements of employment (such as “employed by hospital”) and salary (such as “part of 0 10 20 30 40 50 60 70 80 salary package”) in their responses. Percentages are rounded. PERCENT Sources: 2006 Data, AANS 2006 Workforce Survey; 2004 Data, Percentages are rounded. Participants could select more than one response. 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey Source: AANS 2006 Workforce Survey.

Figure 2. Compensation for Neurosurgical On-Call Services Figure 3. Services Covered by On-Call Neurosurgeons

FACILITY TYPE . AGE DISTRIBUTION . Academic Medical Center 38% . 35 or Younger 6% . . Community Hospital 59% . 36–45 37% Other 6% 46–55 36% 56–65 20% 66 or Older 2% . .

TRAUMA CENTER DESIGNATION YEAR NEUROSURGEONS EXPECT TO STOP TAKING EMERGENCY CALL . Level 1 Trauma Center 40% . . 2010 or Sooner* 22% . Level 2 Trauma Center 37% . 2011–2015 18% Level 3 Trauma Center 10% . 2016–2020 19% Other 18% . . 2021 or Later 19% . Don't Know* 22%

Figure 4. Where On-Call Neurosurgeons Are Practicing Figure 5. Age Distribution and Year Expected to Stop Taking Call Percentages are rounded. Participants could select more than one *Responses of those not currently taking call may have been included. Percentages response. Source: AANS 2006 Workforce Survey. are rounded. Source: AANS 2006 Workforce Survey.

Of the scant six percent of neurosurgeons who did not take For neurosurgeons who said they were planning to stop taking emergency call, 48 percent selected as their reason “other,” and the call, the most influential factor was retirement; the great majority of great majority of these respondents specified age-related exemptions those planning to retire said they had intended to do so anyway, but such as recent retirement or senior partner status. Other reasons this other factors reported were excessive on-call demands and high mal- group reported for not taking call included insufficient pay for practice insurance premiums. The second-ranked factor for those emergency services (17 percent), disruption of routine practice planning to discontinue call was lifestyle interference, followed by schedule (15 percent), lifestyle interference (13 percent), malpractice insufficient pay for emergency services, disruption of routine prac- insurer’s premium discount for eliminating trauma or other emer- tice schedule, and “other”unspecified factors.All of these factors out- gency services (6 percent), and malpractice insurer’s discontinuance ranked the insurer’s elimination of malpractice insurance coverage of coverage for emergency services (2 percent). for call services or insurance premium reduction in return for elim-

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KEY FINDINGS: AANS 2006 WORKFORCE SURVEY

Neurosurgeons Do: the hospitals for which they cover call. When asked if their group had been involved in developing a hospital’s plan for transfer of 94% Take Emergency Call patients, less than half (43 percent) responded affirmatively, and 19 percent said there was no transfer plan at any of the hospitals they 79% Take Emergency Call at Least Twice a Week cover. Only 9 percent of neurosurgeons, a number roughly equiva- 61% Cover All Services lent to the number of survey participants not taking call, said they would decline to participate in the planning process for handling Receive a Stipend or Have Another 50% offline events or patient transfers at their hospitals. Compensation Arrangement for Call Coverage What Is the Complete Picture? Neurosurgeons Say: What is an accurate depiction of neurosurgeons’ participation in 76% Emergency Call Coverage Is a Problem in the emergency care system? The 2006 AANS Workforce Survey Their Geographic Areas clearly shows that by far most neurosurgeons are answering when the nation’s ERs call, attending to people in need of neurosurgical Emergency Call System Works in the 52% emergency care. But despite evidence that the vast majority of neu- Best Interest of Patients rosurgeons are covering all types of emergency services and are 52% Emergency Call System Is Effective doing so chiefly in community-based ERs at level 1 or level 2 trau- ma centers, it is just as apparent that neurosurgeons share many of They Would Participate in Developing a 65% the concerns articulated by the IOM and others regarding the Hospital’s Plan for Transferring Patients or functioning of the U.S. emergency medical system and the provi- Going Offline sion of their vital services within it. Evidence that demonstrates exactly where the problems lie is less clear. While the survey’s initial findings provide a broad outline of ination of trauma or other emergency services. Only 2 percent of all neurosurgeons’ participation in the emergency medical system, survey respondents reported receiving malpractice insurance premi- additional analysis of survey data could fill in the detail and better um reductions for not taking call, but of that small group 71 percent complete the picture. For example, the responses of those who iden- received a substantial premium discount of 11 percent or more. tified call coverage as a problem could be examined for demograph- All survey participants also were asked when they expected to ic commonalities such as practice type or setting, or for geographic stop taking call. As shown in Figure 5, response distribution among correlations such as practice within a state that lacks effective med- the selections was fairly equal. The two top-ranking selections,“2010 ical liability reforms or a coordinated emergency medical system. or sooner” and “don’t know,” may include responses of those not Conversely, similar additional data analysis for the 24 percent of currently taking call. respondents who reported no problem with call coverage in their areas might lead to identification of specific factors that in turn Call Coverage, ER System Concern Neurosurgeons would generate strategies or a model that could be applied in other In addition to providing data that help to complete the picture of locales to alleviate problems with call coverage. neurosurgeons’ participation in the emergency medical system, the Additional meaningful data optimally would illuminate the path 2006 Workforce Survey offered insight into neurosurgeons’ percep- toward productive change and aid the many neurosurgeons who tions of how the system is working. The survey clearly shows that want to improve of the delivery of neurosurgical emergency servic- neurosurgeons think there is plenty of room for improvement in the es to those who need them. 3 emergency system and that they are willing to join in the effort. Manda J. Seaver is staff editor of the AANS Bulletin. Fully 76 percent of respondents identified call coverage as a prob- lem in their geographic areas, and most neurosurgeons, 60 percent, For More Information disagreed with the statement that the emergency system allows them 3 Seaver MJ: Baseline ER survey explores system’s cracks: 2004 enough time off call. Of even greater concern are the data that only AANS/CNS neurosurgical emergency and trauma services survey. about half of respondents believe the call system either works in the AANS Bulletin 13(4): 19–24, 2004. www.AANS.org, Article ID 26367 best interest of patients (52 percent) or is effective (52 percent). Less than one fifth of respondents (18 percent) reported that 3 Valadka AB: The ER: Who is answering call? In some hospitals, their practice group had been involved in development of a hospi- not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004. www.AANS.org, tal’s plan for going “offline,” meaning that ambulances are diverted Article ID 26358 from a hospital’s emergency department, and nearly one third (32 3 Wohns RN: Liability is rooted in elective spine cases. AANS percent) reported that a plan for going offline doesn’t exist at any of Bulletin, 14(2): 18–19, 2005. www.AANS.org, Article ID 37060

Vol. 15, No. 2 • 2006 • AANS Bulletin 11

WHAT WILL IMPROVE NEUROSURGICAL EMERGENCY COVERAGE?

MANDA J. SEAVER s the picture of neurosurgical emergency coverage is Patient Access to Emergency Surgical Care, a position paper by the becoming clearer, neurosurgeons and others involved American College of Surgeons released June 23. Regarding region- in the emergency medical system have recognized that alization, the ACS said it is “achieving some consensus on how to in at least some situations and geographic areas, deliv- apply the trauma system model so that a blueprint can be developed ery of neurosurgical emergency care could be for better regionalizing specialty care services that may be required improved. in an emergency situation.” The ACS also noted that support for AMeasures to improve availability of on-call specialists were pro- comprehensive medical liability reform is shared by “all medical and posed in Hospital-Based Emergency Care: At the Breaking Point, surgical specialty organizations” and expressed support for broad- one of three Institute of Medicine reports released June 14. The IOM based improved reimbursement—reform of the Medicare payment specifically called for the regionalization of certain emergency spe- system, for example—rather than specifically for emergency servic- cialty services; improved reimbursement for emergency services; es. The creation of an acute care surgery specialty was not men- medical liability reform; and the creation of a new acute care surgery tioned in the report. specialty. The American Association of Neurological Surgeons, The AANS’ ongoing advocacy for comprehensive federal medical together with the Congress of Neurological Surgeons, offered three liability reform is well documented in the pages of the AANS of these recommendations to the IOM in February 2005. The AANS Bulletin, as is the AANS’ position on improved reimbursement for opposes the creation of an acute care surgical specialty, which, as the emergency services, which specifies “reasonable compensation” for IOM described, would include neurosurgical and orthopedic proce- on-call neurosurgeons. The introduction of an acute care surgery dures “that can be safely performed without the direct intervention specialty and the concept of regionalization as it relates to emer- of these specialists.” gency specialty care have only recently been discussed, and these Some of these measures are reflected in A Growing Crisis in ideas are ripe for exploration.

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Acute Care Surgery? Longing for Cooperation gical emergency care” as well as the continuing efforts of the AANS That a new surgical specialty was under serious consideration by to gather information and develop a plan for improving the situation. several of surgery’s national organizations was brought to the atten- He acknowledged agreement among leadership that “neurosurgical tion of Bulletin readers in 2004 by Alex Valadka, MD, then chair of care is best delivered by trained neurosurgical providers,” a position the AANS/CNS Section on Neurotrauma and Critical Care. The which in April was sanctioned with the Board of Directors’ approval proposed new breed of specialist, who perhaps would be known as of the AANS Policy Statement on Patient Safety: an emergency surgeon or an acute surgeon, would perform non- trauma surgical emergencies as well as some emergent neurosurgi- The AANS affirms that patient safety is best achieved when cal procedures including craniotomies and insertion of intracranial surgical diseases affecting the nervous system are managed pressure monitors. After noting that neurosurgeons are the most by neurological surgeons. qualified physicians to help patients with injuries to or disorders of the nervous system, Dr. Valadka warned that “as a profession we The development of an acute care surgical specialty, at least to the must determine whether neurosurgeons will continue to play a extent that it would expand into emergency neurosurgery, would dominant role in neurosurgical emergencies, or if instead someone run contrary to the AANS position on patient safety. Dr. Wirth stat- else will answer when the ER calls.” ed that the “AANS has opposed this expansion for a number of com- In fall 2005 the AANS Task Force on Neurosurgical Care and Physi- pelling reasons, chief among them training and current evidence.” cian Workforce Issues was commissioned. By spring 2006 the develop- He also noted that “since most trauma surgeons work in level 1 trau- ment of an acute care surgical specialty again was addressed in the ma centers, additional training in neurosurgery—even if effective— Bulletin,this time by 2005–2006 AANS President Fremont Wirth, MD. is unlikely to benefit neurosurgical trauma patients because by Dr.Wirth discussed the “developing crisis in delivery of neurosur- definition neurosurgeons already are available at level 1 trauma cen-

Neurosurgeons Serving on the ACS Committee on Trauma Interview: ACS Medical Director of Trauma well as the immediate past On June 10, the American College chair of the ACS Committee of Surgeons approved the addition Programs J. Wayne Meredith, MD on Trauma. “But we do of another neurosurgeon to serve n June the AANS Bulletin asked ACS Medical Director of need to know enough to on the COT. Neurosurgeons Trauma Programs J. Wayne Meredith, MD, to comment on the determine when to call currently serving are: recent “acute care surgical specialty” discussion and other [a neurosurgeon].” P. David Adelson, MD, FACS I issues affecting the delivery of neurosurgical emergency care. Overall, Dr. Meredith James M. Ecklund, MD, FACS When specifically asked whether the Esposito and Moore arti- expressed a desire for a col- Domenic P. Esposito, MD, FACS cles represent the position of the college, Dr. Meredith pointed laborative spirit. “We need to Karen Margaret Johnston, out that the JACS is a peer-reviewed journal with an editorial restore cooperation in the MD, PhD, FACS board independent of the college’s leadership so that, as is true house of surgery,” he said. John Hugh McVicker, MD, FACS of the AANS Journal of Neurosurgery, publication of an article “Let’s figure out what these Shelly Diane Timmons, does not imply the parent organization’s endorsement unless the patients need and do that.” MD, FACS article specifically states otherwise. In support of this strategy, In describing the college’s position on acute care surgery, he he noted that on June 10 the Alex B. Valadka, MD, FACS exercised caution. college approved the addition “Right now there is no such thing as an acute care surgery of another neurosurgeon to the Committee on Trauma, a move specialist,” he said. “We do perceive a growing multifactorial that he hopes will lead to increased involvement of neurosur- problem with the availability of specialists to perform [neuro- geons in improving the surgical emergency] care, and we need to find solutions.” delivery of emergency care to patients. He said the committee’s He added that the ACS is not supporting an entity—an acute plan is to advocate for a system will lead to regionalization of care surgeon or general or emergency surgeon—that would trauma care. replace a neurosurgeon. “There are many obstacles—EMTALA, workforce, politics, lia- “Not a trauma surgeon in the country wants to do cran- bility—and we need to get to the resources and work together,” iotomies,” said Dr. Meredith, who is himself a trauma surgeon as he said. “There’s no way to manage without each other.”

Vol. 15, No. 2 • 2006 • AANS Bulletin 13

WHAT WILL IMPROVE NEUROSURGICAL EMERGENCY COVERAGE

ters.”He was, however, optimistic following an ACS-organized meet- article to what the authors call the “golden age” of trauma surgery in ing of specialty leaders that consensus could be reached. “Our col- the 1970s and 1980s, a period characterized by inspiring mentors and lective goal is to develop an effective, unified message to leadership abundant opportunity to perform challenging operative procedures. in the U.S. Congress that will facilitate a solution to the delivery of It was “Eraritjaritjaka” that prompted a response from Dr. Val- appropriate emergency care to our patients,”he stated. adka, Shelly Timmons, MD, and Richard Ellenbogen, MD. Their In the meantime, some trauma surgeons embraced the develop- editorial, submitted to the JACS in June, challenged the authors’ ment of an acute care surgical specialty, not only as a way to speed emphasis on “saving the specialty of trauma surgery” and focused care to patients in the ER, but also as a means for revival of their own instead on the provision of “optimal care of neurosurgical patients specialty. Two articles published in the April 2006 Journal of the in emergency departments.” They presented compelling evidence American College of Surgeons discussed the creation of an acute supportive of such care being managed by neurosurgeons and care surgical specialty. delivered via a regionalized system modeled on the military’s sys- Thomas Esposito, MD, and colleagues asserted in “Making the tem of triaged care. Case for a Paradigm Shift in Trauma Surgery” that the trauma sur- Valadka and colleagues recognized that neurosurgical emergency gery specialty is “in the throes of an identity crisis that threatens its care involves a great deal more than trauma and called for “a team future.”Their literature review of the causes and implications of this approach to repair what is broken.”The authors argued that “it is not identity crisis includes a table showing the Eastern Association for the neurosurgeon who needs to be supplanted or the trauma surgeon the Surgery of Trauma’s proposed major areas for inclusion in core who needs to be reinvented [but rather the] emergency care system curriculum and competencies for an acute care surgeon;“basic neu- which needs to be re-engineered!” They further acknowledged that rosurgical”appears under the heading “cognitive and technical prin- “thoughtful and equitable regionalization and interspecialty cooper- ciples of treating injuries.” ation are essential in any plan to optimize the individual components An editorial in the same JACS issue, “Acute Care Surgery: Erarit- and overall delivery of emergency care,” and stated that “neurosur- jaritjaka,” strongly advocated for the acute care surgery concept. “We geons…are eager to share in an open and honest dialogue.” submit that the only viable solution to the trauma surgery crisis is to The ACS discussed the acute care surgical specialty in two arti- recapture complex elective and emergent operative procedures and cles published in the July issue of the ACS Bulletin. Executive Direc- extend operative capabilities into other surgical trauma tor Thomas R. Russell, MD, called acute care surgery “one of the disciplines…and to some extent, orthopedics and neurosurgery,”stat- more controversial ideas under discussion.”He recognized the need ed Ernest Moore, MD, and colleagues. Eraritjaritjaka, an Aboriginal for thorough training as well as the input of all specialties in the expression that translates to longing for something lost, refers in the training curriculum “if we do pursue the development of this spe- cialty,” but focused much of his attention on consensus-building: “Ultimately, we must stay centered on achieving some sort of con- sensus about which approaches will ensure that surgical patients receive appropriate care by the right person at the right time and in AANS Policy Statement the right place.” The second article summarized practical advantages and dis- on Patient Safety advantages of the proposed specialty. For example, an “advan- tage” of the acute care surgeon’s expanded role is the increased (Statement approved by the AANS Board attractiveness of the specialty, which is expected to assist with the of Directors on April 22, 2006) recruitment and retention of trauma surgeons. How does this balance the “disadvantage” of the significant challenge of provid- The AANS affirms that patient safety ing this new specialist with adequate training? Author Gregory S. is best achieved when surgical diseases Cherr, MD, called “learning the subtleties of urgent neurosurgi- affecting the nervous system are cal and orthopedic intervention” a “daunting” task and wondered managed by neurological surgeons. “how this might be accomplished in a brief fellowship rotation.” Further exploration of the proposed specialty will be offered dur- This position statement (article ID 38148) and all ing a symposium with “open mic” to be presented at the 2006 AANS position statements are available in the Clinical Congress in October. online Library at www.AANS.org. While a longing for cooperation and a desire to care for neuro- surgical emergency patients appear to be the common ground with respect to the development of an acute care surgical specialty, the concept of regionalization enjoys comparatively widespread support.

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Regionalization of Emergency Specialty Services rosurgical providers as well as enhancing the availability of high Regionalization of emergency specialty services is proposed as a quality neurosurgical care for our patients.” solution to a variety of emergency system ills, among them the avail- Most recently, Valadka and colleagues offered support of the ability of on-call specialists. While there is a good deal of consensus regionalized emergency care concept as well as two possible models, on the concept, the details of implementing such a system remain to one based on the U.S. military’s medical system and the other on the be determined, although some models have been proposed. emergency system in the Pacific Northwest. They described the mil- The IOM report specifically called for “hospitals, physician organ- itary’s sophisticated and efficient triage system as allowing neurosur- izations and public health agencies to collaborate to regionalize crit- geons to be strategically located in well-equipped facilities and ical specialty care on-call services.” Directing patients to the nearest patients quickly delivered to them, or using telemedicine and telera- facility with the best resources to handle their needs will improve diology to provide neurosurgical expertise to those in remote loca- health outcomes, mitigate overcrowding, reduce costs, and ensure tions. They cited the Pacific Northwest for its “very well-developed specialty coverage at the regionalized facility, the report stated. emergency system…in which complex patients are rapidly stabilized The ACS report advocated building a system of regionalized care at community hospitals and then evacuated as needed to a level 1 or based on the trauma system model. The system not only would alle- level 2 trauma center.” viate overcrowded emergency departments, but also “would be par- Valadka and colleagues suggested that “regionalization, a plan ticularly appropriate for services provided by specialties with which eliminates redundancy, provides patient safety nets, and workforce numbers in the few hundreds or thousands, such as neu- lessens competition for limited resources, will ultimately improve rological and hand surgery.” quality and safety and also save money…it simply needs to be cham- Two recent AANS presidents have tackled this topic: Robert A. pioned at a national level by all surgeons.” Ratcheson, MD, in his 2005 Presidential Address, and Fremont P. Both the proposed specialty of acute care surgery and regional- Wirth, MD, in the last issue of the AANS Bulletin. ization of emergency specialty services are likely to be among the Dr. Ratcheson offered several reasons, in addition to improving topics addressed in the recommendations of the AANS Task Force on-call availability, for fostering regionalization: on Neurosurgical Care and Physician Workforce Issues. 3

[Regionalization] would necessarily promote the formation of Manda J. Seaver is staff editor of the AANS Bulletin. neurosurgical teams and enhanced teamwork. It should allow resources to be centralized to serve the needs of patients rather than the desires of hospitals. It may ameliorate the problem of physician fatigue and allow more efficient utilization and greater For More Information development of subspecialty skills. It can go a long way toward 3 AANS Position on Improving Access to Emergency Neurosurgical meeting society’s demands for reasonably rested, well-educated, Services, www.AANS.org, Article ID 9760 and up-to-date neurosurgeons who are constantly available, and it can be organized to ease the burden of trauma call, which is 3 Cherr GS: Acute care surgery: Enhancing outcomes or fragmenting exacerbated by the availability of too few individuals covering care? ACS Bulletin 91(7):40–43, 2006 multiple hospitals. It may allow lifestyle considerations to be 3 Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD: Making addressed in more satisfactory ways and encourage more women the case for a paradigm shift in trauma surgery. J Am Coll Surg to enter neurosurgery. I think this is a change that will be good 202(4):655–67, 2006 for neurosurgeons, and most importantly, for our patients. 3 A Growing Crisis in Patient Access to Emergency Surgical Care, www.facs.org/ahp/emergcarecrisis.pdf Dr. Wirth observed that “the crisis in emergency care with respect to neurosurgery has as much to do with distribution of neu- 3 Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute rosurgical trauma care as with a shortage of it.”He noted the many care surgery: Eraritjaritjaka. J Am Coll Surg 202(4):698–701, 2006 factors underlying the problems with delivery of care, some of which 3 Ratcheson RA: Fast forwarding: The evolution of neurosurgery. have been mentioned here—medical liability, lack of reimburse- The 2005 presidential address. J Neurosurg 103:585–590, 2005 ment—and some that have not: lack of neurosurgical unit intensive 3 Russell, TR: From my perspective. ACS Bulletin 91(7):4–5, 2006 care beds, lack of appropriate imaging or neurosurgical endovascu- 3 Valadka AB: The ER: Who is answering call? In some hospitals, lar capabilities, and lack of adequately trained personnel to assist in not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004. the complex care of neurosurgical patients. www.AANS.org, Article ID 26358 “It is likely that the [AANS Task Force on Neurosurgical Care and Physician Workforce Issues] will recommend some reorganization 3 Wirth FP: The moral of the story: Neurosurgery’s professionals of the system for providing neurosurgical care,” he stated. “Such an offer best neurosurgical emergency care. President’s Message. approach has the potential for improving the quality of life for neu- AANS Bulletin 15(1):3–4, 2006. www.AANS.org, Article ID 38188

Vol. 15, No. 2 • 2006 • AANS Bulletin 15

Sweet Success in San Francisco 74th Annual Meeting Initiates AANS’ Diamond Jubilee Year

BY MANDA J.SEAVER hen the 74th AANS Annual Meeting officially opened on Monday, April 24, Annual Meet- ing Chair James T. Rutka, MD, announced the expectation that the event would be “the most successful annual meeting in the Whistory of the AANS.” The final numbers bear out Dr. Rutka’s optimism. With medical attendees totaling 3,172, the San Fran- cisco meeting proved to be the most successful ever by this measure, and the grand total of 6,887 atten- dees puts the meeting in contention for top honors with the year 2000 meeting. The meeting’s success sets the bar high in keeping with great expectations for the AANS 75th anniversary, a celebration that began with the 2006 meeting, continues throughout the year, and culminates in the 75th Annual Meeting: Celebrating AANS’ Diamond Jubilee, to be held in Washington, D.C., April 14–19, 2007. Of course, stellar attendance is but one indica- tor of success. This meeting’s singular mix of sci- ence, social events, and the city’s hospitality coalesced in a a peer-review process to select scientific topics from all accepted particularly memorable occasion. annual meeting oral abstracts for release to the media. The meeting owes its success in large part to Dr. Rutka and to This year’s 13 annual meeting scientific press releases reflected the entire planning team, including Mitchel S. Berger, MD, scien- a wide range of neurosurgical topics, covering, for example, spinal tific program chair, and Timothy B. Mapstone, MD, scientific fusion and artificial discs, the use of cortical language mapping posters chair; Russell J. Andrews, MD, Nicholas M. Barbaro, MD, before glioma surgery, skull protection offered to children by bicy- Sue Ellen Barbaro, Deborah L. Benzil, MD, Lawrence S. Chin, MD, cle helmets, and deep brain stimulation. The scientific releases as E. Sander Connolly Jr., MD, Anthony L. D’Ambrosio, MD, Joseph well as the public interest releases associated with Neurosurgery A. Hlavin, PA-C, David F.Jimenez, MD, Eric A. Potts, MD, Andrea Awareness Week, held concurrently with the AANS Annual Meet- Strayer, CNRN, Vincent C. Traynelis, MD, and Eve C. Tsai, MD. ing, generated considerable media attention, with print and This meeting’s 38 practical clinics, 19 general scientific ses- broadcast media reaching an estimated worldwide audience of 636 sions, 77 breakfast seminars, 135 oral abstract presentations, more million and counting. Notable online publications covering the than 500 poster presentations, and 234 companies exhibiting the meeting included Yahoo!News, USA Today, Reuters, HealthScout, latest neurosurgical technology and products were introduced to HealthDay, HealthCentral, Excite and Forbes. Major newspapers a broader audience through media outreach. The AANS not only and magazines included The Wall Street Journal, The Cleveland promoted the meeting and the association itself, it also employed Plain Dealer, Star Tribune, Indianapolis Star, and Business Week.

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CME: A Main Attraction Discectomy—offer CME credit and also A major attraction of the meeting is the opportunity to earn con- are available in the Online Marketplace. tinuing medical education credit. Meeting registrants could earn 20.75 category 1 CME credits, and those attending ticketed edu- Memorable Moments cational programs such as breakfast seminars, practical clinics, the Following two days of intensive, hands-on Pain Section Satellite Symposium and the Japanese American practical clinics, the Sunday evening open- Friendship Symposium, additionally could earn up to 35 category ing reception marked the ceremonial start 1 CME credits. “Chinatown” of the 74th AANS Annual Meeting in an While the meeting has concluded, the opportunity to learn event that offered 3,000 guests the opportunity to stroll through the continues. Audio recordings on compact disc cover the plenary, streets of San Francisco without ever leaving the friendly confines of scientific, subspecialty section, and socioeconomic sessions. Titles the AANS headquarters hotel. Fisherman’s Wharf, Chinatown, and of the individual programs recorded are listed on the order form the Giants’stadium were among the attractions. The “sweet spot”and available in the AANS Online Marketplace at www.AANS.org. In a popular destination was Ghirardelli Square, appropriately located addition, DVD recordings of three programs—Cerebral Trauma on Rich Street (named, as were all these “San Francisco” streets, for State-of-the-Art Treatment, Head Trauma: Current Treatments an AANS president, in this case 1996–1997 President J. Charles Rich). and Controversies, and Minimally Invasive Microendoscopic Continued on page 18

AWARDS AND HONORS Cushing Medal– Distinguished David G. Kline, MD Service Award– Dr. Kline received the Lyal G. Leibrock, MD Cushing Medal, the high- “This afternoon I am est honor that is honored and sad bestowed by the AANS. because the AANS is “Few have given so gen- recognizing a neurosur- erously of themselves geon posthumously over time to the field of after his protracted bat- neurosurgery,” said Dr. Wirth in his introduc- tle with colon cancer,” said Dr. Wirth. He tion, in which he recognized Dr. Kline for noted Dr. Leibrock’s many years of service launching a peripheral nerves clinic. Dr. and his initiation of the Neurosurgical Kline, recounted his experience “rendering Leadership Development Conference. Judi care without electricity, air conditioning or ele- Leibrock, accepting the award on behalf of Judi Leibrock accepts the Distinguished Service vators” during the evacuation of intensive her husband, discussed his love of neuro- Award from Fremont P. Wirth, MD, in honor of her care unit patients during the harrowing period surgery and said, “This is wonderful, late husband, Lyal G. Leibrock, MD. during and after Hurricane Katrina. thank you.”

Humanitarian Award– Robert Florin Award– Cone Pevehouse Award– Gene E. Bolles, MD Dr. Douglas Kondziolka, MD Ming-Yuan Tseng, MD Bolles was honored in Dr. Kondziolka received Dr. Tseng received the recognition of his many the Florin Award for his Pevehouse Award for professional accomplish- paper “Improving the his paper “Survival ments to the develop- Informed Consent Analysis for 540 ment of neurosurgery Process for Surgery.” The Patients With Primary and for his extensive paper demonstrated that Spinal Intramedullary efforts in Mexico, Beliz a patient's recall of Gliomas in England and and Albania. “I am surprised, honored and informed consent information can be improved Wales: A Population-Based Study.” The study humbled to receive this award,” he said. He when a surgeon goes through the form with the identified old age, nonependymoma, and high described his volunteer work as educational patient followed later by a staff member asking grade tumors as negative prognostic factors and extremely rewarding and encouraged the same questions of the patient. “Patients for these patients’ survival. Dr. Tseng and “each and every one of you to become can be well informed, informed consent can be colleagues concluded that results from this involved in this kind of work.” He said that he documented in an efficient manner, and efforts population-based study are very helpful for and his family were leaving the following week to improve the informed consent process are comparison with other hospital-based studies to volunteer in Iraq. “It’s important to express valued by patients,” he said. and for public health purposes. to the rest of the world the humanness of Americans,” he said.

Vol. 15, No. 2 • 2006 • AANS Bulletin 17

SWEET SUCCESS IN SAN FRANCISCO

Continued from page 17 On Monday, two luminaries from different walks of life, Volker K.H. Sonntag, MD, and George Will, offered tales from their respec- tive experience.As the Rhoton Family Lecturer, Dr. Sonntag discussed the “Journey of Spinal Neurosurgery in the United States,” a journey that began in 1905 when Cushing removed an “inoperable” spinal lesion. He said that neurosurgical treatment of the entire spinal col- umn began to be emphasized in the 1980s, and tension that arose between neurosurgery and orthopedics in 1989 with the approval of spine fellowship training in orthopedics was not resolved until the specialties together faced the pedicle screw challenge in the 1990s. Observing that the Journal of Neurosurgery: Spine now is published monthly and that the Decade of the Spine spans 2001 to 2010, he teas- ingly concluded that “vascular neurosurgery is out and spinal neuro- surgery is in,”to general amusement and applause. Alioto's on Fisherman's Wharf was among the opening reception attractions on Sunday evening. The event marked the ceremonial start of the 74th AANS Annual Meeting, Cushing Orator George F.Will delivered an entertaining amalgam offering 3,000 guests the opportunity to stroll through the streets of San Francisco of economics, politics, American wit and wisdom, and baseball.“This without ever leaving the friendly confines of the headquarters hotel. is a country in which the American people have decided that the gov- ernment has a role in assuaging two ancient fears: illness and old age,” Quest, MD, president, Jon H. Robertson, MD, president-elect, he said. He discussed entitlements, “promises we have made to our- Arthur L. Day, MD, vice-president; James T. Rutka, MD, PhD, selves,”such as Social Security.“Fixing Social Security is easy: Raise the secretary; James R. Bean, MD, treasurer; and Fremont P.Wirth, MD, retirement age,”he said. Noting that “medicine is another matter,”he past president. discussed the growth of medicine from 6 percent of the U.S. gross Rounding out the Board of Directors are directors at large domestic product in 1960 to the point at which medical centers now William T. Couldwell, MD, PhD, Robert E. Harbaugh, MD, Christo- often are the largest employers in cities like Cleveland and Houston. pher M. Loftus, MD, Warren R. Selman, MD, Troy M. Tippett, MD; “Prosperity produced by a dynamic economy creates economic regional directors Jeffrey W. Cozzens, MD, R. Patrick Jacob, MD, hypochondria,” he said, a concept which he described as Americans Stephen T. Onesti, MD, and Edie E. Zusman, MD; historian Eugene driving “Lincoln Navigators, barely making it from one gas station to S. Flamm, MD; ex-officio members Rick Abbott, MD, P.David Adel- another,sipping designer water that costs more than a gallon of gaso- son, MD, Charles L. Branch Jr., MD, Lawrence S. Chin, MD, Fernan- line, and talking on their cell phones discussing how arduous life in do G. Diaz, MD, PhD, Andres M. Lozano, MD, Richard K. Osenbach, America has become.” MD, Setti S. Rengachary, MD, B. Gregory Thompson Jr., MD, and The business meeting of the AANS and the American Association Ronald E.Warnick, MD; and liaisons Richard G. Ellenbogen, MD, H. of Neurosurgeons concluded the day with the election of 2006–2007 Derek Fewer, MD, and Isabelle M. Germano, MD. AANS leadership: Executive Committee members are Donald O. The scientific papers presented Tuesday morning were punctuat- ed with presentations by A. John Popp, MD, and Martin W. Weiss, MD. Representing Doctors for Medical Liability Reform, Dr. Popp related the recent progress of medical liability reform in Congress. “When I talk to neurosurgeons about this, I sense their frustration,” he said. He discussed the establishment of AANSPAC, neurosurgery’s new political action committee that is funding the campaign for fed- eral tort reform, and he stressed the importance of each neurosur- geon’s commitment to this effort. Pointing to his jacket, he said,“This lapel cost a thousand dollars because I’m wearing an AASNPAC founders’ pin, and I hope that as I walk though the hall today I will see many more.” Representing the Neurosurgery Research and Education Founda- tion, Dr. Weiss described the NREF’s impressive 25-year track record of finding ways to fund the research projects of neurosurgeons through donations and through corporate partnerships. “Research and development, corporate or scientific, is the foundation of the

Fremont P. Wirth, MD, delivers the Presidential Address.

18 Vol. 15, No. 2 • 2006 • AANS Bulletin

Developing Science oster Chair Timothy Mapstone, MD, and the Scientific Program Committee select- P ed more than 500 abstract submissions for poster presentation at the 74th AANS Annual Meeting. The top three posters in each of the following categories were recognized, and first place awardees and their topics are listed below. 3 Cerebrovascular Shaye I. Moskowitz, MD, “Statin Use Increases the Risk of Vasospasm Following Aneurysmal Subarachnoid Hemorrhage” 3 General Interest Pankaj A. Gore, MD, “Normobaric Oxygen Therapy Strategies in the Treatment of Postcraniotomy Pneumocephalus”

3 History William C. Bergman, MD, “Walter 3 Pain Aneela Darbar, MD, “Efficacy of 3 Stereotactic and Functional Abbas F. Dandy and His Approaches to the Third Gamma Knife Radiosurgery For Trigeminal Sadikot, MD, “Probabilistic Maps of Ventricle Circa 1933” Neuralgia Associated With Multiple Sclerosis” Subthalamic Electrodes in an MRI-Atlas 3 Pediatrics Richard J. Edwards, MD, Integrated Reference Space Correlated with “The Development of a Telemetric Clinical Outcome” Intracranial Pressure Sensor 3 Trauma and Critical Care Lori Shutter, MD, for Long-term Monitoring of “Unhelmeted Motorcyclists—Higher Mortality, Intracranial Pressure” Morbidity and Costs” 3 Spine and Peripheral Nerves 3 Tumor Hidenobu Ochiai, MD, “Targeted Denis J. DiAngelo, PhD, Therapy for Glioblastoma Multiforme Neoplastic “Biomechanical Comparison of the Meningitis With Intrathecal Delivery of an Charite and Prodisc-L Lumbar Disc Oncolytic Recombinant Poliovirus” Prostheses”

Above, Rintaro Hashizume, MD, PhD, points to research results shown on his poster “Intranasal Delivery of Specific Telomerase Inhibitor GRN163 in Human Glioblastoma Xenografts.” At left, Ajay Niranjan, MCh, discusses his poster “Biochemical Assessment After Radiosurgery for Growth Hormone Secreting Pituitary Adenomas.”

future,” he said. Noting that participation in just the Young Neuro- neurosurgical practice as the possible encroachment of proposed surgeons Committee’s Silent Auction, held in the exhibit hall during specialists in acute care surgery. He explained that these specialists the meeting, funds one NREF award, he encouraged broader, enthu- would be expected to perform among their duties emergency neuro- siastic support of the NREF. surgical procedures, contrary to the idea that “patients are safest when neurosurgeons provide neurosurgical care.” He discussed the Presidential Address results of the AANS 2006 Workforce Survey, which demonstrated Fremont P.Wirth, MD, identified five main issues with which neuro- that most neurosurgeons are providing on-call services.Acknowledg- surgery today must contend: (1) education; (2) defining the bound- ing that there may be a better system for providing neurosurgical aries of neurosurgical practice (3) responding to changing demands emergency care, he said that ideas for improving the delivery of such of society (4) influencing increase in reimbursement; and (5) med- care were being explored. ical liability reform. He called education the fundamental issue for Dr. Wirth also described organized neurosurgery’s efforts for neurosurgery as well as a primary mission of the AANS, which is bent medical liability reform and other issues on the national agenda as upon providing “modern, efficient, responsive educational programs moving forward in cooperation with colleagues in other specialties. for neurosurgeons.” He warned that advocacy efforts such as these can be protracted and Dr. Wirth defined the most recent challenge to the scope of Continued on page 20

Vol. 15, No. 2 • 2006 • AANS Bulletin 19

SWEET SUCCESS IN SAN FRANCISCO

Continued from page 19 that apathy toward continuing versity of California, San Francisco has planned a stem cell train- involvement in these matters is ing program. a worthy opponent. “We must The Thursday socioeconomic session was highlighted by pointed step up to the plate,” he said. discussion of and audience commentary on the Centers for Medicare “It’s going to take time, effort and Medicaid Services’ pay-for-performance project. Jeffrey Flick, the and money. Individual neuro- CMS administrator for region IX, presented rationale for the program surgeons can have an impact.” and said that the 262 hospitals already participating in CMS P4P have On Wednesday, communi- demonstrated that “just measuring and publishing improves quality.” cation, science and politics He said that the CMS is “looking for your help to make sure we have were the focus of two lectur- this right” and encouraged physicians to participate in the CMS’ P4P ers. Mark Bernstein, MD, the demonstration program.“I believe that physicians are likely to be paid Theodore Kurze lecturer, hon- just for reporting as early as next year,”he said. ored the raconteur in Dr. Robert E. Harbaugh, MD, chair of the Quality Improvement Kurze by discussing the im- Workgroup of the AANS/CNS Washington Committee, expressed (l–r) Donald O. Quest, MD, Julia Grubb, portance of neurosurgeons neurosurgery’s concerns involving establishment of appropriate P4P Peggy Ratcheson, Robert L. Grubb, MD, making their voices heard measurements.“All measures are focused on management of chron- Ilona Quest, and Robert A. Ratcheson, MD, gather around the street sign honoring more widely through publica- ic disease, so application to surgical patients is a concern,” he said. Dr. Ratcheson, the 2004–2005 AANS tion in nonbiomedical venues. Acknowledging that there is “widespread, bipartisan support in all of president, at the opening reception. Dr. Bernstein noted that Washington”for P4P and that the CMS is very committed to the pro- Harvey Cushing, a Pulitzer gram as a way to save money, Dr. Harbaugh suggested that neuro- Prize winner, could serve as surgery should participate but should develop its own quality inspiration.“Narrative stories reach people,”he said.“It’s never too measures based on prospectively collected outcomes data. late to try.” Hunt-Wilson Lecturer Arnold Kriegstein, MD, Presentations by master neurosurgeons Kevin T.Foley, MD, spine; reviewed the science and politics currently affecting neural stem Patrick J. Kelley, MD, tumor; Michael T. Lawton, MD, vascular; cell research. He said that current stem cell research in the Unit- Johannes Schramm, MD, epilepsy; and Albert L. Rhoton, MD, cere- ed States is moving forward at the state level, led by New Jersey, brovascular, concluded the meeting. 3 Illinois, Maryland, Connecticut, and California, and that the Uni- Manda J. Seaver is staff editor of the AANS Bulletin.

2006 International Awardees uring the AANS Annual Meeting in San Francisco, the following 2006 International Award recipients were D announced. The International Abstract Award was presented to Ming-Yuan Tseng, MD, of the United Kingdom, for “Biological Effects of Acute Pravastatin Therapy On Cerebral Vasospasm, Delayed Ischemic Deficits, and Outcome in Patients Following Aneurysmal Subarachnoid Hemorrhage: A Randomized Controlled Trial.” The International Travel Scholarship recipient was Emad K. Hammood, BSN, of Iraq for “Surgical Management of Brain Hydatid (l–r) James T. Rutka, MD, and Muh-Lii Liang, MD, both of Canada, and Dar-ming D. Lai, MD, of Taipei, are pictured at the international attendee reception on Wednesday evening. Cyst in the North of Iraq.” The association also announced the first two recipients of the first effects of spinal decompression and stabilization, and time of AANS International Visiting Surgeons Fellowships. They are Mirsad surgical treatment on patient outcomes. Hodzic, MD, of Bosnia and Herzegovina, and Rene Fernando Paz, MD, Additionally, the recipient of the FIENS/Integra Fellowship was of Honduras. announced at the AANS Annual Meeting. He is Sushil Shilpakur, Dr. Hodzic, whose fellowship will be at the University of New York MBBS, of Nepal, who is studying neuroendoscopy during his fellow- at Buffalo, is specifically interested in developing new knowledge in ship at the CURE Children’s Hospital of Uganda. minimally invasive neurosurgery in children. With the exception of the FIENS/Integra Fellowship, these awards Dr. Paz will complete his fellowship at the University of Colorado are managed by the AANS International Outreach Committee. All Health Sciences Center. His research study will involve the awards will be offered again in 2007.

20 Vol. 15, No. 2 • 2006 • AANS Bulletin

P RACTICEM ANAGEMENT N ICK G REEN

Easy Money: Find the Hidden PPOs When Insurers Share Savings, You Don’t Have to Suffer

n this era of reimbursement cutbacks The solution may be either to hire someone Increased Payment Rates from Auto Insurers and rising overhead, it is becoming to do EOB audits (a position that usually increasingly difficult to improve the net will pay for itself, especially in large prac- 90 income of a practice. Yet, there is a rela- tices), have a supervisor perform the I 80 tively easy way to accomplish this with a lit- audits, or contract a consultant. 83.8% tle research and a willingness to drop one or 3 Analyze Financial Reports A second way 70 more insurance plans. This method is to to find hidden PPOs is to perform analysis 72.0% find and eliminate the “hidden PPOs.” that can help determine the possible extent 60

A hidden PPO is an insurance company of underpayment. First run reports that 50 56.4% that discounts your charges without your provide payments and adjustments for consent. This can happen when insurance charge-based payers—auto insurers, for 40 companies with which you have signed example. Run these reports for the last three 30 contracts for a set fee schedule then pass to five years. For each year, add the payments these rates on to other insurance companies and adjustments. Divide the payments for 20 with which they have contractual relation- each year by the totals for each year calculat- ships, but you do not. This dubious dis- ed previously. You may be able to see trends 10

counting technique has been used at an of decreasing percentages of payment or 0 increasing rate in recent years. absolute levels of payments. 2003 2004 2005 Sept YTD

Untangling Dubious Discounts A tough decision to drop an insurer in 2003 came after There are at least two ways to discover if The deterioration was traced financial reports revealed a decline in the insurer’s pay- you are the victim of hidden PPOs. ment rate. Since then, the rates have climbed back. 3 Audit EOBs The simplest method is to to one PPO that represented audit the explanation of benefits forms that only 3.5 percent of our age of the savings from our charges. you receive from insurance companies— business.The insurance After a one-month failed negotiation especially the EOBs of those companies that process, our practice decided to drop this are paying charges or a percentage of companies with which this PPO effective Jan. 1, 2004. This was a very charges rather than those remitting based PPO had contracts actually difficult decision to reach within our own on contractually set fees. You may find that paid the PPO a percentage of group. Some physicians were extremely you are not being paid the correct amount reluctant to say no to any business and also and that in many cases you are being paid the savings from our charges. doubted whether we would really see any significantly less. Upon contacting the increased reimbursement. As shown in the insurance company (Company B), its rep- chart, since that time we have seen our resentative may inform you that “we priced Once the Problem Is Identified, Take Action payment rates from auto insurers return the bill at the rate you contracted with For our practice, I run payer-mix reports nearly to the 85 percent level, increasing Company A, and according to your con- on cash payments instead of just charges. our practice’s annual reimbursement by tract, we can apply that rate because of our This method found that the actual payment more than $650,000. contract with Company A.” percentages for our auto insurance charge- This is not to say that your results will Your practice’s billers, particularly if based payers had dropped from about match this dramatic outcome. However, they are rewarded on a days-in-receivable 85 percent of charges to about 55 percent finding hidden PPOs may well be the easi- basis, may not have delved into the under- over a five-year period. This deterioration est way to significantly improve practice lying problem; to move the account off the was traced to one PPO that represented net income available today. 3

books, their interest may be in just posting only 3.5 percent of our business. The insur- Nick Green is past president of NERVES, www.nerves the payment and writing off the remainder ance companies with which this PPO had admin.com, and practice administrator for Michigan of the charge to a contractual adjustment. contracts actually paid the PPO a percent- Head and Spine Institute PC in Southfield, Mich.

Vol. 15, No. 2 • 2006 • AANS Bulletin 21

Inspirations and Epiphanies

my residency in neurosurgery at Case Western Reserve University. WHAT WOULD YOU TITLE YOUR STORY? Finishing my training in 1965, I returned to Mexico and from then hether standing at neurosurgery’s threshold (Great on have had a most enjoyable and quite successful private practice. Expectations), juggling a thousand responsibilities My advice to a medical student: If you are thinking about neuro- at midcareer (Who Moved My Cheese?) or enjoying surgery, do it. the fruits of a long career (Life of [Boswell], or pos- Javier Verdura Riva Palacio, MD sibly The Expanding Universe), you have a story to Oaxtepec, Mexico tell.W What would you title it? Who or what inspired you to enter this profession? What from your experience would you share with a medical student? What do you still love about your daily work? decided to become a neurosurgeon as a first During the AANS 75th anniversary year, when neurosurgery’s year medical student after hearing Stephen origins and organizers will be recognized and remembered, I Mahaley at the University of North Carolina accounts of inspiration and epiphany by today’s neurosurgeons deliver a lecture about third ventricular tumors. are being published in the AANS Bulletin. Send your account He was just great and I couldn’t imagine a more (300-word maximum) by e-mail to [email protected]. You will interesting career or a more inspiring role model. Stephen Maheley, MD receive an automatic confirmation of receipt, and you will be My decision became firm after watching him do contacted if your item is selected for publication in an upcoming a temporal lobectomy for tumor. During the setup of the case we all issue of the Bulletin. watched the Duke–UNC basketball game, which he had transmit- ted into the OR on closed-circuit TV. He also was the track neuro- surgeon at the Darlington Raceway where he had a special parking n 1954 I was beginning my third year of med- place for his black Porsche. ical school in Mexico, where I was born, when Dr.Mahaley was as inspirational a figure as I ever saw, and he stim- I I decided it was time to choose a field of spe- ulated many young UNC medical students to enter neurosurgery. cialization. At that early stage of my career I only Phillip S. Dickey, MD knew that there were medical and surgical spe- New Haven, Conn. cialties. I decided to embrace a surgical specialty, Leo M. Davidoff, MD but which one? It seemed natural to me to choose the most difficult specialty, but ecoming a neurological surgeon was some- again, which one? I started to ask around. The overwhelming answer thing I never anticipated either during col- from my fellow students, my professors and hospital personnel was B lege or medical school. But when I assisted neurosurgery, which in most opinions was not only the most diffi- a neurosurgeon during the third year of my gen- cult but also the most daring, glamorous and challenging of all med- eral surgery residency, my love of the specialty ical and surgical specialties. Armed with this information, I began to was immediate. Edgar Kahn, MD ponder other aspects of neurological surgery. For one, there were but It was John (Jack) T. Bakody who introduced a handful of trained neurosurgeons, which meant more work and me to the “queen of the medical specialties,”and I less competition. For another, if a patient survived an appendecto- assisted him frequently in addition to my general my, that was expected and therefore it was not a big deal. But if a surgery responsibilities. My application was patient survived and did well after a craniotomy, that was almost a accepted at the University of Michigan, but I was miracle. Finally, and perhaps least importantly, were financial con- drafted and served in Vietnam as C.O. of the 62nd siderations. I learned that the fee for a craniotomy was 10 times surgical mobile unit. After service in the army, I Keasley Welch, MD higher than the fee for an appendectomy. was able to train with Edgar Kahn and Keasley In 1955 I started an “apprenticeship” with Juan Cardenas, who Welch and to complete the neurosurgical program at New York Uni- received his training from Leo M. Davidoff in New York and was the versity under Joseph Ransohoff. first neurosurgeon in Latin America certified by the American Board Throughout my training and career, my love affair with the spe- of Neurological Surgeons. He was my inspiration. Finally, I started cialty grew. Although I admit that at times the path was difficult, I

22 Vol. 15, No. 2 • 2006 • AANS Bulletin

d Epiphanies

have no regrets. There is for me no other specialty in medicine that a life is brought back from the doorstep of death via timely evac- compares to neurological surgery for its challenges, rigorous intel- uation of an epidural hematoma are extremely fulfilling. So is alle- lectual honest analysis, consummate operative skill and compas- viating the pain and suffering of patients from pinched nerves and sionate care of patients. I cherish the moments with the program improving their quality of life. directors and residents, and the professional camaraderie and satis- Vivekanand Palavali, MD faction of being a team leader able to successfully improve the qual- Flint, Mich. ity of life of patients. Severe, disabling health problems abruptly precluded my con- hat initially drew me to neurosurgery was the notion that tinuation of this beautiful and demanding specialty. Despite this, as a doctor and surgeon one would be dealing directly I love neurological surgery and the privileged, marvelous and W with the brain, which I thought was a very privileged unique opportunity to glimpse in wonder at the inner man, as cre- position to be in. I was also attracted to the complex organization ated by the Higher Being. of the nervous system, which unlike many other body systems, Michel W. Andre Kildare, MD, FACS allows precise localization of the lesion from a history and physi- Marysville, Calif. cal examination. Finally, I was attracted to the technical challenge of brain surgery. was 17 years old and in medical school. Neurological surgery is a challenging and I’ll never forget the excitement I experi- demanding specialty by many criteria: hours I enced when I saw it for the first time: the expended, physical stamina required, and human brain! The 1,500 grams of soft tis- emotional toll exacted. Neurosurgeons have sue is what imparts Homo sapiens their to balance their jobs with the other impor- unique essence and distinguishes them tant areas of their lives: family, physical fit- from every other animal on the planet. A ness, friends, and spirituality. Furthermore, billion neurons, spreading their dendrites there are very few opportunities for “mid- and axons throughout the body, create con- course” career corrections once one has sciousness and contemplation and are become fully engaged in neurosurgical prac- responsible for the birth of civilization that tice. Neurosurgery’s tradition as a discipline gave us the Roman coliseum, Mona Lisa, Taj whose practitioners are intellectually restless Mahal, Darwin’s theory of evolution and a and rarely satisfied with old maxims or cur- plethora of religions and philosophies. So rent statistics holds true to the present time. much function of the body is controlled by For all its difficulties, when done well so small a mass, intricate, complex and neurological surgery gives one a great sense highly organized. of personal satisfaction and also is capable of I was drawn by its aura of mystery and making great differences in the lives of our wonder. I knew then that I wanted to deal patients. It is undergoing fascinating changes with this incredible structure that requires in the way we treat patients, largely due to handling with utmost reverence, patience, unwavering hand, thor- new technologies. We are currently undergoing radical subspecial- ough knowledge, and a penchant for meticulous detail—all necessary ization, with pediatric, spinal and functional neurosurgery being the attributes for a brain surgeon. I decided to take up the challenge. most obvious and well-developed examples. Thirty years later my excitement upon first seeing the brain, All neurosurgeons have to balance decisiveness and assertiveness instead of waning, is magnified because I look at and operate on with approachability and excellent patient communication skills. brains that are alive, pulsating synchronously with the heartbeat. Aspiring neurosurgeons should be self-motivated, ambitious, obses- Any mishap could result in the patient’s devastating debilitation or sive for detail and deeply analytical. They should be willing to learn death, which explains one’s healthy apprehension while perform- and able to perform well under pressure and handle stress. ing delicate brain surgery. But the rewards of emotional and pro- Sanjay Mongia, MD fessional satisfaction when an aneurysm is successfully clipped or Mumbai, India

Vol. 15, No. 2 • 2006 • AANS Bulletin 23

R ESIDENTS’ F ORUM L AWRENCE S. C HIN, MD

The Basics of Practice Management You Can Clip an Aneurysm, but Can You Compute Cost Per RVU?

ost per RVU (that’s relative value tion for research must also be approved; one person, but a dissatisfied patient tells unit) can be determined by dividing one strategy is to have patients sign a con- 13 people.” Find out what the patients total practice expenses by total sent form at initial consultation that think; send out surveys, and make sure that C RVUs, yielding a number that can allows their information to be used for the practice’s phones are answered by a live be compared annually as an indicator of a research purposes. person. Listen to patients’ concerns and practice’s performance. If you didn’t know Knowing how to code a surgical proce- respond to them quickly. that, you are not alone. Neurosurgical dure properly is important for every neuro- Probably the best advice is to avoid residency programs do a great job of surgeon because even when someone else micromanaging the practice. Let the prac- teaching how to diagnose and operate, but handles coding, the neurosurgeon is tice manager handle the details, but know they typically do a poor job of preparing responsible for the accuracy of submitted what he or she is doing because ultimately residents for the practical aspects of bills. All residents should attend a billing the neurosurgeon is responsible. managing a neurosurgical practice, which course such as those offered by the AANS in reality is a small business. This article before starting practice. The most common Resources for the Real World offers some basics of practice management Current Procedural Terminology codes, In acknowledgement of the complex prac- for the new-to-practice neurosurgeon, which describe the operation, and ICD-9 tice environment faced by today’s neuro- with focus on four primary areas: com- codes, which provide the diagnosis or the surgical residents, resources that better pliance, billing, office management, and symptoms, should be learned. Medicare prepare residents for the transition are patient relations. publishes quarterly updates that detail under development. At least one training With the passage of the Health Insur- which codes may be added on (for more program, the Medical College of Georgia ance Portability and Accountability Act, reimbursement) and when “unbundling” in Augusta, requires a Web-based course ensuring compliance is one of the most —breaking down a procedure into smaller that acquaints its residents with basics of important functions of an office manager. parts for greater reimbursement—is disal- practice management. The AANS recent- In addition to HIPAA, there are federal, lowed.An average practice of five neurosur- ly offered the course Neurosurgery in the state, and local regulations regarding the geons performing 1,400 cases and seeing Real World, which covered coding and flow of information between patients and patients in 6,000 office visits per year will reimbursement, government regulations, doctors, doctors and doctors, and doctors need two coders and two collectors. At least contract negotiations, practice develop- and the insurance carriers (including gov- one of the coders should be certified, a ment and professional liability. In addi- ernment payers). Medicare regulations process that requires at least two years’ tion, print resources such as Starting a generally are followed by most insurance experience and annual recertification. Medical Practice and Managing the Med- plans, but specifics for a particular region A medium-to-large practice will need a ical Practice are available from the AANS can be found by accessing the Web site of practice manager. A bachelor’s degree is a Online Marketplace, www.AANS.org. the regional Medicare intermediary. For minimum requirement, and often this per- Perhaps the greatest resource for neuro- example, Trailblazers is the intermediary son will have an MBA or other master’s surgeons entering practice is the AANS responsible for handling all Medicare degree, or other appropriate credentials Young Neurosurgeons Committee. The claims in Baltimore. such as a CPA. A practice manager’s YNC provides information at www.AANS The most visible aspect of HIPAA in an responsibilities include hiring and evaluat- .org > Young Neurosurgeons and develops office setting relates to patient privacy. In ing staff, promotions, preparing the budg- programs like the Real World course that general, relating more than one unique et and payroll, cash management, and respond to the needs of early career neuro- piece of identifying information should be maintaining supplies. The practice manag- surgeons while opening the door to avoided. For example, patients may be er as well as coders and collectors should be involvement in the AANS. 3 identified by name, but not also with their included in a practice’s incentive program Lawrence S. Chin, MD, is chair of the Department of doctor’s name or diagnosis. Release of to reward them for going the extra mile. Neurosurgery at Boston University School of patient information is allowed to referring Patient satisfaction is the ultimate goal Medicine and chair of the AANS Young Neurosurgeons Committee. Gloria Jones, office man- physicians only; all others must have of a neurosurgical practice. An office man- ager at University of Maryland Neurosurgical patient consent. Use of patient informa- agement axiom is “A happy patient tells Associates, contributed to this article.

24 Vol. 15, No. 2 • 2006 • AANS Bulletin

W ASHINGTONU PDATE K ATIE O. ORRICO,JD

Tort Reform Falls Short in Senate DMLR Campaign Presses Forward

minority of U.S. senators used pro- applies the same reform provisions as S. 22, activist database and grassroots network. As cedural devices to prevent two med- but for obstetrics and gynecological services of early June, DMLR has reached approxi- ical liability reform bills from only. This motion also failed, but by a vote mately 65 million listeners through several A reaching the Senate floor for an up of 49 to 44 with seven not present. Of the “radio tours” held since the campaign rede- or down vote on May 8. three additional senators voting, one was a ployed last October. Neurosurgeons Troy First, the Medical Care Access Protection Republican and two were Democrats. Tippett, MD, from Pensacola, Fla., and John Act of 2006, S. 22, was effectively blocked Despite the Senate filibuster, some in Caruso, MD, from Hagerstown, Md., partic- when its supporters were unable to gain the Congress have vowed to continue the fight ipated in these radio interview programs. necessary 60 votes to break a Democrat-led in support of comprehensive medical liabil- DMLR has collected more than 40,000 sig- filibuster. The MCAP is modeled after ity reform legislation. The talk on Capitol natures for its petition drive, and more than recent Texas reform legislation and includes, Hill is that the House of Representatives 15,000 letters have been sent to Congress among other things, a $250,000 cap on may take up this issue again sometime this (over 5,000 in the week immediately before noneconomic damages against physicians, summer and the Senate may revisit medical the Senate vote). The grassroots network is limits on attorneys’ fees, and expert witness liability reform before the November cam- nearly 150,000 strong, and it continues to reforms. The motion to proceed (required paign season gets into full swing. Organized expand every day. before action on the underlying bill could be neurosurgery, through its participation in In light of the recent unsuccessful votes considered) on S. 22 was defeated by a vote Doctors for Medical Liability Reform, will in the U.S. Senate, DMLR is redoubling its of 48 to 42.All Democrats who voted, joined continue to press Congress for action. grassroots outreach efforts and is working by three Republicans, opposed the measure. hard to recruit more patients to join the Regrettably, 10 senators were not present, DMLR Campaign Builds Momentum campaign to stop medical lawsuit abuse. among them four senators who had previ- for Tort Reform The success of the program depends on ously supported reform legislation. DMLR’s Protect Patients Now national cam- neurosurgeons helping to spread the word Immediately following the first vote, the paign for medical liability reform continues about the medical liability crisis and Senate considered a motion to proceed to to build impressive momentum. Using cre- DMLR’s Protect Patients Now campaign. It debate the Healthy Mothers and Healthy ative animations, Web advertisements, and is vital that neurosurgeons stay the course Babies Access to Care Act, S. 23, which radio and print media, DMLR is building its and stay involved in the DMLR campaign. Members of the U.S. Senate need to hear from patients as well as doctors on this vitally important health care issue. One easy The Fight to Pass Reform—By the Numbers way to help is by introducing patients to 65 million The number of people who have heard DMLR’s medical liability reform issues and solutions through the DMLR’s Patient Outreach Kit. message on the radio. The kit includes: 150,000 The number of people who have joined DMLR’s 3 a packet of informational brochures grassroots network. that have a tear-off portion allowing patients to sign and mail a petition in 40,000 The number of individuals who have signed DMLR’s support of reform; petition for reform. 3 a poster, which dramatically illustrates the crisis; 15,000 The number of letters that have been sent to Congress. 3 a pad of tear-off postcards that are attached to the poster and can be filled 800 The number of physicians who have requested DMLR’s in and mailed back to DMLR; and patient outreach materials. 3 wearable “Stop Medical Lawsuit Abuse” buttons.

26 Vol. 15, No. 2 • 2006 • AANS Bulletin

continue to stay involved until we succeed The talk on Capitol Hill is that the House of at passing reform legislation. 3 Representatives may take up this issue again Katie O. Orrico, JD, is director of the AANS/CNS Washington Office, (202) 628-2072, sometime this summer and the Senate may revisit [email protected]. medical liability reform before the November campaign For Further Information 3 How They Voted: S. 22, Medical season gets into full swing. Care Access Protection Act of 2006, and S. 23 Healthy Mothers and Healthy Babies Access to Care Act, These materials are free of charge and abuse. DMLR also will continue to keep www.senate.gov > Votes > will be shipped directly to your office once neurosurgeons informed and involved Roll Call Tables 2006 (109th, 2nd) > the order is placed. Neurosurgeons are en- through regular e-mail messages. In addi- Votes 00115 and 00116 couraged to get an outreach kit and help tion, neurosurgeons are encouraged to spread the word about the crisis and our watch for new information and campaign 3 DMLR’s Patient Outreach Kit, www.pro campaign for reform. updates on the Protect Patients Now Web tectpatientsnow.org > Physicians > With your help, DMLR will continue to site, www.protectpatientsnow.org. Remem- Patient Outreach Kit build its grassroots network, educate ber, this is a marathon, not a sprint, and all 3 Texas Teaches That Tort Reform patients, and put a stop to medical lawsuit neurosurgeons must get involved and Works, page 34

Vol. 15, No. 2 • 2006 • AANS Bulletin 27

C ODING C ORNER G REGORY J. PRZYBYLSKI,MD

of spinal instrumentation (22840-22844), and performance of a fusion at the same or Concurrent Spinal Procedures adjacent levels (22612, 22614, 22630, 22632). The CMS has used National Cor- Coding Frequently Changes for Established Procedures, Too rect Coding Initiative edits for years to pre- clude payment for an exploration of fusion he increase in spinal fusion proce- necessary to perform the fusion. It may be with arthrodesis, despite introductory lan- dures during the past decade has difficult when coding to differentiate the guage in CPT that specifically identifies drawn scrutiny from the Centers for incidental decompression that occurs dur- arthrodesis and instrumentation as sepa- T Medicare and Medicaid Services and ing the laminectomy and discectomy rate physician work. Although an explo- third party payers, resulting in coverage approach for the interbody fusion from the ration of fusion and arthrodesis at the limitations for some of these procedures. additional decompression that may be war- same level should be considered inclusive, Recent CMS coverage decisions for estab- ranted because of neurological symptoms arthrodesis at adjacent levels is separately lished, concurrent spinal procedures will be from compressive lesions. Correct coding identifiable and the arthrodesis code examined in this Coding Corner. for interbody fusion is further complicated should be appended with the –59 modifi- when a unilateral approach using a trans- er. If spinal instrumentation is removed Coding for Decompression and foraminal technique is performed because and replaced at the same levels, only code Arthrodesis for Spondylolisthesis code 22630 describes a bilateral procedure. 22849 should be used, rather than a A common procedure for lumbar spondy- In either instance, if a decompression proce- removal code and an insertion code. lolisthesis involves decompression of the dure is performed beyond what is required When spinal instrumentation is re- nerve roots and a lumbar arthrodesis. A for the interbody exposure, then the decom- moved and then replaced with instrumen- variety of procedures exist for decompres- pression should be appended with the –59 tation extended to additional levels, one sion including laminectomy for lateral modifier (unusual procedural services) to must balance the lesser work of replacing recess stenosis (63047) or for Gill fragment acknowledge this as separately identifiable fixation in sites that have been prepared removal (63012), and discectomy for pos- additional work, and it is critical for the neu- previously with the new work of exposing terolateral herniation (63030), for far later- rosurgeon to document the separate loca- and placing fixation at new levels. An al disc herniation (63056), or for tion of compression that is being treated. insertion code that describes the entire re-exploration of a disc herniation (63042). Another recent limitation imposed by span of instrumentation (both revised and Several years ago, the Current Procedur- the CMS is for concurrent performance of new) would reflect the physician work al Terminology Editorial Panel approved an a posterior arthrodesis and a posterior lum- under most circumstances because the editorial change to posterior lumbar inter- bar interbody fusion. The authors of the work of removal and replacement at an body arthrodesis (22630) that includes lumbar fusion guidelines, published in June individual level is similar to work of prepa- laminectomy and discectomy work other 2005, concluded that complications and ration and insertion at a new level. The than that needed for decompression. How- costs were higher and without an observed neurosurgeon should be aware that the ever, the National Correct Coding Initiative benefit when a posterior fusion is per- removal and reinsertion of instrumenta- of the CMS excluded coding of 22630 con- formed in addition to an interbody fusion. tion codes are 90-day global codes to currently with the decompression codes This year, CMS payment policy precludes which the multiple procedure modifier under ordinary circumstances. payment for a posterior fusion when an –51 applies, whereas the insertion codes The vignette describing posterior lumbar interbody fusion is performed. The various are ZZZ global codes and are not subject to interbody arthrodesis identifies a patient surgical societies representing spinal sur- a 50 percent payment reduction when with mechanical back pain after prior dis- gery are reviewing the guidelines and their used with other stand-alone codes. cectomy and failed posterolateral fusion implications before preparing a response to The area of spinal coding and reim- who undergoes a laminectomy, discectomy the CMS decision. bursement is frequently changing. There- and interbody arthrodesis. Since the fore, it behooves neurosurgeons to keep described patient does not have radiculopa- Coding for Revision Spinal Surgery abreast of these changes annually. 3 thy, a decompression above and beyond Additional difficulties in proper coding are Gregory J. Przybylski, MD, is professor and director of what is required to perform the posterior encountered when revision spinal surgery neurosurgery at JFK Medical Center in Edison, N.J. He interbody fusion is not included in the is performed. For example, a revision of a is chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing vignette. However, the vignette does prior fusion may include procedures such Physicians Advisory Council, and he chairs and describe mobilization of nerve roots and as exploration of a fusion (22830), removal instructs coding courses for the AANS and the North dural sac as well as dissection of scar tissue (22852), reinsertion (22849), or placement American Spine Society.

28 Vol. 15, No. 2 • 2006 • AANS Bulletin

P ATIENTS AFETY P ATRICK W. MC C ORMICK,MD

Whom Does Credentialing Protect? Medical Professionalism Meets Hospital Board Protectionism

fter neurosurgeon Steve Cathey Despite the alignment of the JCAHO invested in the Arkansas Surgical Patrick W. goals with the professional medical code of Hospital—a private, for-profit 16- McCormick, MD, conduct as well as AMA policies opposing A bed specialty hospital designed for FACS, MBA, economic credentialing, the legal system has orthopedic and neurosurgical spine care— is a partner in allowed healthcare delivery organizations to Neurosurgical Network his wife, gynecologist Janet Cathey, was use credentialing to address market con- Inc., Toledo, Ohio. threatened with revocation of privileges at cerns over patient interests. Baptist Health Hospital in Little Rock. Some hospitals have adopted policies to According to American Medical News, this limit or effectively prohibit perceived com- action was possible because Baptist Health petitive behavior by credentialed physi- System’s board had “adopted a policy that Thus, hospital credentialing and privileg- cians. Targeted physician behaviors include mandates denial of initial or renewed staff ing are a medical staff function. As such, failing to sign loyalty oaths, perform a privileges to any practitioner who, directly physicians who participate in this process defined percentage of procedures at a hos- or indirectly, acquires or holds an owner- are guided by the American Medical Associ- pital, or admit a specific percentage of their ship or investment interest in a competing ation Code of Medical Ethics, Opinion 4.07: patients to a hospital; referring patients out hospital” and had extended the restriction of an integrated system; accepting staff to the immediate family members of any- The mutual objective of both the gov- privileges or leadership positions at a com- one who invested in a competing hospital. erning board and the medical staff is peting hospital; and having financial in- Such economic-based criteria, however, to improve the quality and efficiency terest in a competing healthcare delivery are not among the goals for medical staff of patient care in the hospital. Deci- entity. These “competitive behaviors” have credentialing and privileging as defined by sions regarding hospital privileges resulted in denial or revocation of physi- the Joint Commission on Accreditation of should be based upon the training, cian hospital privileges. Healthcare Organizations. Instead, the experience, and demonstrated com- JCAHO goals center on quality patient care petence of candidates, taking into Legal Challenges to Economic and safety and specifically state that the consideration the availability of facili- Credentialing purpose of medical staff credentialing and ties and the overall medical needs of Hospital policies involving economic cre- privileging is to determine competency of the community, the hospital, and dentialing have been met by legal chal- physicians, assess physical and mental abil- especially patients.... Physicians who lenges on several grounds. ity of physicians to discharge patient care are involved in the granting, denying, In Mahan v. Avera St. Luke’s, the South responsibilities and perform ongoing or termination of hospital privileges Dakota Supreme Court stressed that the assessment of the safety and quality of care have an ethical responsibility to be “continued economic viability of the hos- provided by physicians. guided primarily by concern for the pital” is sufficient reason to deny privi- JCAHO further asserts that the credi- welfare and best interests of patients leges to physician applicants, and that bility of the credentialing process requires in discharging this responsibility. such denials may be based on “any rea- cooperation between the hospital govern- sonable basis,” including “the common ing body and medical staff through its The inclusion of this opinion in the Code good of the public and the hospital.”This appointed designees. The medical staff of Medical Ethics underscores the integral decision allows the credentialing process leadership designees make recommenda- role credentialing fulfills in the professional for physician hospital privileges to be tions to the hospital governing body social contract to ensure patient access to used to erect barriers to competition, regarding a physician’s appropriateness for appropriate, safe and quality care. The AMA, impeding function of competitive market credentials and privileges. The hospital as it notes in a recently adopted Council on forces and raising anticompetitive behav- governing body must act on these recom- Medical Service report, additionally has sev- ior concerns. Challenges to such behavior mendations and report back to the med- eral existing policies that oppose loss or under Section 1 of the Sherman Act on ical staff regarding its decisions and the restriction of privileges based solely on eco- balance have failed to prevail because it is underlying rationale. nomic factors. difficult to demonstrate a conspiracy. This

30 Vol. 15, No. 2 • 2006 • AANS Bulletin

is due in part to the prevailing judicial economic considerations above patient philosophy that the stakeholders in the Physicians should interests. This is due in part to a common hospital credentialing process (that is, the but questionable judicial philosophy that medical staff and hospital governance) advocate for a hospital for-profit governance principles are appro- are a single entity. credentialing process that priate in the nonprofit sector. Broad man- Claims of willful acquisition or mainte- agement discretion under the business nance of monopoly power under Section 2 establishes privileges judgment rule may well be inappropriate in of the Sherman Act also have been unsuc- based on patient interests. the nonprofit sector because of lack of pub- cessful in providing relief to physician lic reporting, transparency of decision plaintiffs. Such claims have been complicat- making, and public accountability. ed by the fact that exclusion of physicians Overall, the courts have supported the from a medical staff via the credentialing instances, the economic impact of physi- use of credentialing to shield hospitals process could diminish rather than enhance cian admissions, treatment plans, and pro- from market competition and protect hospital revenues. The impact of corollary cedure performance is seen as a sufficient established revenue. The impact of the claims of intimidation and adhesion con- basis to deny or revoke hospital privileges, legal system has been to place patient tracting to control market competition is and the courts have upheld such decisions. quality and safety as a necessary but insuf- yet to be vetted in the judicial process. In general, economic criteria used to adju- ficient basis for physician hospital privi- The courts have been less permissive dicate credentialing must be explicitly leges in opposition to the professional when hospital privileges are denied based characterized in the organization’s bylaws. ethical code which guides physicians who on claims of conflict of interest, such as The bulk of legal arguments have centered are willing to represent the medical staff in staff privileges at competing organizations, on contract law, and in general, the courts the credentialing process. ownership in competing entities, or failure have deferred to “reasonable” management to attain admission or procedure volumes. discretion for hospital governance. Credentialing Should Protect Patients In Potters Medical Center v. City Hospital Public policy law also has helped shape The divergence of professional ethical Association, the court found that restrict- the legal debate regarding the appropriate opinion and the legal adjudication of hos- ing a physician’s ability to practice at com- denial of hospital privileges to physicians. pital credentialing for physician privileges peting facilities for reasons of conflict of A hospital’s nonprofit status is statutorily calls for physicians involved in the medical interest may constitute monopolization. In defined in the Internal Revenue Service staff credentialing process to effect change. Miller v. Indiana Hospital, the court found Ruling 69.545. This rule outlines the nec- Physicians should advocate for a hospi- that hospital privileges were unreasonably essary preconditions for a hospital to claim tal credentialing process that establishes terminated when a surgeon opened a com- nonprofit status and explicitly requires privileges based on patient interests and in peting healthcare delivery facility. such a hospital to maintain a medical staff accordance with the Code of Medical A common defense theme for hospitals that is open to all qualified physicians. In Ethics, which clearly places patient interests when accused by physicians of anticom- the event of an investigation, the burden of above market and financial considerations. petitive behavior based on conflict-of- proof falls to the hospital to demonstrate Perhaps this is best accomplished by physi- interest rationale for denial or revocation that the underlying purpose of the restric- cian advocacy for public access to the hos- of privileges is that of “cherry picking” tive credentialing policies and decisions is pital institutional bylaws and medical staff patients for the physician-owned facility beneficial to the community and consis- bylaws. Physicians further can support to the detriment of the hospital. In Blue tent with a nonprofit mission. Because it is revisions to these documents as necessary Cross v. Kitsap Physician Service, the difficult for a hospital to develop substan- to maintain credentialing on the basis of court substantially weakened this claim tive, demonstrable arguments for commu- physician competency and quality. Model when it found that financial interests are a nity benefit that override a statutory medical staff bylaws to accomplish these fundamental motivation in a free market obligation to credential all qualified physi- goals are available through the AMA. and necessary for rational healthcare cians, physician challenges to the nonprof- These physician actions would restore delivery in such a market. it status of hospital organizations are the credentialing to its proper position as a In addition to insulating hospitals from most effective approach to challenging safeguard to society for accessible and competitive market forces, the courts have credentialing policies. excellent healthcare rather than a mecha- supported credentialing for physician hos- However, the courts have been sym- nism that shields hospitals from competi- pital privileges as a mechanism to protect pathetic to hospital boards that cite a fidu- tive market forces. 3 and enhance hospital revenues. In these ciary rationale to place organizational,

Vol. 15, No. 2 • 2006 • AANS Bulletin 31

T IMELINE: NeurosurgeryThroughHistory

Is It Really Brain Surgery? During World War I Surgeon General William Gorgas called for 8,000 nurses, as the MICHAEL SCHULDER,MD poster at right testifies. He s it only neurosurgeons who can per- also needed 100 neurosur- geons, at a time when there form neurosurgical procedures? If there weren’t that many in the are places where patients suffer delayed United States. Ernest Sachs treatment because of the need to trans- Sr. (pictured below) was I among the neurosurgeons fer them to a medical facility with neuro- who created three programs surgical coverage, might not the answer be where general surgeons were to train a new cadre of “generalist” trauma trained for the Army’s neuro- or “acute care” surgeons? surgical positions. (Poster: Library of Congress, Prints & It may be useful to consider these ques- Photographs Division, WWI tions in light of the environment that gave Posters, LC-USZC4-7781.) rise to neurosurgery as a specialty. Gilbert Horrax described this period in his book Neurosurgery: An Historical Sketch. In the early years of the 20th century, general sur- geons “unfamiliar as yet with any special knowledge of how to handle brain tissue,

were attempting at infrequent intervals to Ernest Sachs Sr. Eben Alexander Jr. Donald Matson Joseph Ransohoff Bertram Selverstone do something to which they were entirely Training general surgeons in neurosurgery during World War II involved a six-week introductory course by civilian neuro- unaccustomed.”It became apparent that “to surgeons followed by two to three months at an Army neurosurgical center. Prominent neurosurgeons who arose out of attain the desired end someone would have this training included Eben Alexander Jr., Donald Matson, Joseph Ransohoff, and Bertram Selverstone. to devote his entire time to working out a new technic [sic] for operations upon the central nervous system.” world (remember, this was a specialty that three months at an Army neurosurgical cen- Horrax proceeded to document Harvey was 12 years old at the time), Surgeon Gen- ter, as described by Eben Alexander Jr. in the Cushing’s thoughts on the subject in 1905: eral William Gorgas replied, “That doesn’t AANS Journal of Neurosurgery. Some promi- interest me! It’s up to you to furnish the nent neurosurgical careers arose out of this …many of [his colleagues in surgery] men!” In response, three centers were training, including those of Dr. Alexander have expressed themselves emphati- cally against any form of operative established, in New York, Chicago, and St. himself, Donald Matson, Joseph Ransohoff, specialization…I do not see how such Louis, where experienced general surgeons and Bertram Selverstone. particularization can be avoided if we learned the essentials of neurosurgery in We would be foolish to pretend that wish more surely and progressively to six- to 12-week courses. The Army got its appropriately intense training cannot teach advance our manipulative therapy. “neurosurgeons,”and as far as Sachs knew, other surgeons the necessary rudiments of Are practice of hand and concentra- “none of them went into neurological sur- neurosurgery. But we are not at war, at least tion of thought to go for nothing? gery as a specialty after the war.” not the kind mandating complete mobiliza- History more or less repeated itself a tion and massive deployments as in the Wartime brought a new urgency to the generation later. In 1941 the United States world wars. Would we really be satisfied in question of who should perform neurolog- entered World War II, shortly after the turning the clock back so far that the rudi- ical surgery. In his memoir Fifty Years of American Board of Neurological Surgery ments of head trauma management would Neurosurgery, Ernest Sachs Sr. described came into being. There were only 30 or so suffice as appropriate, quality care for our the situation as the United States entered Americans who were qualified in neuro- patients today? Shouldn’t we insist that neu- World War I. Cushing was already in surgery and ready for active military duty. rosurgeons are those best equipped to man- Europe in 1917 when nearly every other Again, plans were made to turn “medical age diseases affecting the nervous system? American neurosurgeon was summoned officers trained in general surgery” into Indeed, are practice of hand and concentra- to Washington. The U.S. Army planned to combat-ready neurosurgeons. The training tion of thought to go for nothing? 3

create 100 hospitals and wanted a neuro- this time was slightly more elaborate, with Michael Schulder, MD, is professor and vice-chair in surgeon in each one. When informed that a six-week introductory course taught by the Department of Neurological Surgery at New there were not 100 neurosurgeons in the civilian neurosurgeons followed by two to Jersey Medical School in Newark.

32 Vol. 15, No. 2 • 2006 • AANS Bulletin

E DUCATION J ONI L. SHULMAN

Collaboration Benefits Education Endovascular Course for Residents Generates Enthusiastic Response

n April 1, the AANS hosted a unique these corporate sponsors, the course educational opportunity for senior provided an opportunity to interact with neurosurgical residents. The course, residents on a variety of levels. Industry O Endovascular Techniques for Resi- representatives participated side by side dents, was held at the Medical Education with residents and displayed their newest and Resource Institute in Memphis, Tenn. technologies as well as provided instruction While as a state-of-the-art facility MERI on how to use the equipment. contributed to the course’s success, it was “The number of work stations [in the the dedication of expert faculty and the animal lab] was ideal, giving everyone the financial support and equipment dona- opportunity for hands-on experience with tions of corporate sponsors that made the each product and procedure,” commented course possible and available at no cost to Roberto Refeca of the Regulatory Affairs the 14 residents selected for participation. Charles J. Prestigiacomo, MD, demonstrates a proce- Department of Cordis Neurovascular, Inc. The endovascular course was the brain- dure during Endovascular Techniques for Residents, a “Where necessary, the residents were able new AANS course held April 1 at MERI in Memphis. child of Jon H. Robertson, MD,AANS pres- to repeat procedures as they desired ident-elect and Development Committee Comments provided by participants because resources were not restricted.” chair. He selected Robert H. Rosenwasser, indicated that the program was outstand- The generous corporate financial sup- MD, to serve as course director based on his ing.“Learning how to manipulate catheters port made it feasible for the AANS to pro- reputation and extensive expertise in the and wires and experiencing how it feels in a vide neurosurgical residents considering ever-growing endovascular neurosurgery real brain was so helpful along with learn- fellowship opportunities in endovascular field. Dr. Rosenwasser designed the course ing how to use the stent and deploy it,” techniques with a specialized learning with topical instruction and instrumenta- noted Sheila Smitherman, senior resident at opportunity that the AANS would be tion that would appeal to senior residents Baylor. “Overall, the lab was superb.” unable to provide on its own. In order to interested in advanced training in endo- Warren Roberts, senior resident at Port- participate in the endovascular course, the vascular procedures, including arterial and land University, summarized the course as corporate sponsors agreed to become venous femoral access; therapies for “[an] excellent presentation of topics [that members of the AANS Pinnacle Partners aneurysms and arteriovenous malforma- are] extremely important in the training of Program. Each company invested an addi- tions; use of mechanical devices to treat neurosurgeons.”Residents also overwhelm- tional $25,000 beyond the cost of the strokes; carotid angioplasty; and stenting. ingly expressed appreciation for the oppor- course for future funding of neurosurgical Dr. Rosenwasser chose course faculty tunity to meet with the endovascular education and research opportunities. who provided additional endovascular thought leaders and learn concepts from “Generous corporate support provides expertise, including B. Gregory Thompson, renowned experts in the field. advanced educational instruction that aug- MD, Elad I. Levy, MD, Erol Veznedaroglu, “This course was designed to be an ments resident learning,” said John A. Wil- MD, and Charles J. Prestigiacomo, MD. introduction for neurosurgical residents son, MD, chair of the AANS Education and Residents attended a morning of didac- to endovascular techniques,” said Dr. Practice Management Committee. “I look tic instruction that included presentations Robertson. “It represents a wonderful forward to working closely with the Devel- on hemorrhagic and ischemic disease and educational experience which will influ- opment Committee on similar initiatives.” then performed endovascular techniques ence those in training to consider a career The AANS continues to invest in educa- using balloons and catheters on live hogs. A in endovascular neurosurgery.” tional offerings for residents. Two addition- simulator provided by Cordis gave residents What made this course so unique was al courses have been scheduled for 2006, an opportunity to develop endovascular that it forged a perfect marriage between including a minimally invasive spine course skills using the same equipment they will use corporations and education. Support for in August at MERI and a socioeconomic on actual patients, but in an environment this course was secured from corporate course for senior residents in September. 3 that provides instructive feedback as they partners Boston Scientific, Micrus Endo- Joni L. Shulman is AANS associate executive director, progress on the learning curve. vascular and Cordis Neurovascular Inc. For education and meetings.

Vol. 15, No. 2 • 2006 • AANS Bulletin 33

M EDICOLEGALU PDATE D AVID F. J IMENEZ,MD

Texas Teaches That Tort Reform Works Will Other States Learn the Lesson?

eurosurgeons are well aware of the the board. This was followed nine months tacted by more than two dozen companies significant financial impact that later by another 5 percent rate reduction. for information on entering the malprac- skyrocketing medical liability insur- Between February 2005 and March 2006, tice insurance market, and an insurer who N ance premiums can have on their additional rate decreases were announced had announced plans to pull out of the practices, and organized neurosurgery has by numerous other Texas professional lia- Texas market began expanding and writing been at the forefront of efforts to institute bility insurance underwriters, including new business. medical tort reform at both the federal and American Physicians Insurance Company The reforms have wrought additional state levels.Yet a long-standing debate con- (9 percent–14 percent), The Joint Under- beneficial changes in Texas healthcare, tinues on the real impact of tort reform on writing Association (10 percent), Medical among them: malpractice insurance premiums. Some Protective (2 percent), Texas Medical Lia- 3 From May 2003 through July 2005 there argue that there is no correlation between bility (an additional 5 percent) and The was an increase of approximately 3,000 the capping of noneconomic damage Doctors Company (18 percent). new doctors establishing practices in Texas, awards and the annual insurance premi- In 2005, Bernard Black and colleagues many of whom serve in high-risk specialty ums and argue further that the premiums reported that the total number of medical medicine. (Texas Medical Association, set by the insurance industry have nothing malpractice claims for 2002 was 6,929 March 23, 2006). to do with jury verdicts and awards. compared with a high of 8,943 claims filed However, medical tort reform enacted the preceding year. In 2003, the year in 3 Some Texas communities (Corpus in Texas on Sept. 12, 2003, refutes that idea which tort reform passed, there was a Christi, Beaumont, the Rio Grande Valley, and supports the position that appropriate transition drop in claims to 5,967 as Webb County) are experiencing surges in reforms will reduce medical malpractice reported to the Texas Department of physician recruitment (American Medical premiums and increase patients’ access to Insurance by the four largest medical mal- Association, May 9, 2005). care. In fact, Texas House Bill 4 and its con- practice insuring companies in Texas; fig- 3 Texas physicians are now able to shop stitutional amendment, Proposition 12, ures from these companies represent for medical malpractice insurance since the have served to reduce high rates of medical claims for approximately 60 percent of number of new and start-up medical malpractice insurance by granting the Texas physicians, according to Kenneth malpractice insurers increased from four Texas Legislature the authority to limit McDaniel of the Texas Department of pre-reform to roughly 20 new entities. noneconomic medical civil liability dam- Insurance Professional Liability Commer- (Beaumont Enterprise, Feb. 22, 2005). ages to no more than $250,000 in medical cial Property/Casualty Division. Addition- malpractice lawsuits. The cap was estab- al decreases in claim rates also are being Texas teaches that appropriate medical lished at $250,000 for all doctors (no mat- observed using the same TDI data set, tort reform does indeed work. It lowers ter how many are named in a lawsuit) and indicating a reduction in medical mal- medical malpractice premiums and $250,000 per healthcare institution (up to practice claims in 2004 to 2,359 and in increases the number of available doctors, two institutions). All actual medical 2005 to 2,259. The overall number of thus increasing patients’ access to care. An expenses, lost past and future income and claims in 2005 was roughly just one third important caveat, however, is that Texas other expenses that can be translated into of the number reported in 2002, the year voters passed a constitutional amendment an actual dollar amount (such as maid serv- immediately prior to reform enactment. that makes it highly unlikely for the state’s ice, transportation) are still recoverable. This dramatic difference is echoed by high court to overturn the cap. The ques- The reforms, which were intended to Texas Department of Insurance data which tion now is whether other states will learn help reduce frivolous medical malpractice shows that medical malpractice lawsuit fil- Texas’ very valuable lesson. 3 lawsuits and to decrease escalating medical ings decreased by half by 2006. Addition- David F. Jimenez, MD, FACS, is professor liability insurance rates, began to pay divi- ally, the agency reported its action to deny and chair of the Department of Neurosurgery dends soon after enactment. As early as rate increases that did not take into account at the University of Texas Health Science Center, San Antonio. Jan. 1, 2004, Texas Medical Liability Trust, the reduced exposure to frivolous claims. the largest medical malpractice insurer in The agency further reported that within Texas, reduced its rates by 12 percent across months of reform passage, it had been con-

34 Vol. 15, No. 2 • 2006 • AANS Bulletin

L ETTERS

Editor: successful defense of a malpractice suit is often affected by how I read this particular article [“To Prevail, First Prepare,”AANS well the physician, defense counsel and the insurer’s claim counsel Bulletin, 15(1):22, 2006; www.AANS.org, article ID 38174] work together. Ideally, these three parties should act in partner- with interest. However, I believe that item 10 in the article, ship to pursue resolution of a claim. However, due to the varying Trust your lawyer, is a generalized statement that should be concerns and interests that each party has, and the failure to com- carefully considered. municate, the relationship often fails to approach that ideal. In my experience in the past 30-plus years, I have found that It is no secret that being sued for malpractice is a traumatic most defense attorneys do not expedite matters in court. Even experience that often elicits emotional responses ranging from though many medical liability cases are dropped or dismissed by a outrage to resignation. These emotions often influence how a judge as frivolous, these lawsuits drain the money from insurance physician prefers that a case be defended. In some cases, a physi- companies, and most of the money, unfortunately, goes to our cian might desire a fast settlement of the claim, period. In oth- own defense lawyers. For example, instead of taking 90 or 120 days ers, the physician’s goal might be to seek vindication through to get an expert’s report, the process is deliberately delayed because complete litigation of the claim. the attorneys make no money if the case is disposed of quickly. The insurer’s goal is to resolve the claim in a cost-efficient This is not to say that all defense attorneys are the same, but one manner. Unfortunately, this goal has the potential to create a can say that there is little financial incentive to expedite cases. conflict of interest between the insurer and the insured physi- Also, your defense attorney should provide you with insight cian. For example, while the physician might want a claim set- into the plaintiff attorney you are dealing with because they are tled as quickly as possible, the insurer, based on its assessment not all the same. A very good attorney will tell you what to expect of the exposure, might not be willing to accede to the plaintiff’s and how to respond to questioning. early settlement demands. I must add that we must make every effort nationwide to Conflicts between the insurer and the insured place defense resolve this medical liability crisis. counsel in an uncomfortable position. It is without question that defense counsel’s paramount duty is owed to the insured. How- David A. Yazdan, MD, FACS ever, defense counsel is obligated to report to the insurer, which Brick, N.J. is paying defense counsel’s bills, to provide objective advice con- cerning what is necessary and appropriate for a defense and to The Author Responds: assess exposure and the reasonableness of a potential settlement, My best advice is, Don’t sweat the small stuff. Concentrate and regardless of whether such advice might displease either the remain focused on the medical aspects of your case. Leave the insurer or the insured. “lawyering” to the lawyer and “the lawyer’s bill” with your insur- The single most important factor in developing and maintain- ance company. That’s why you pay insurance. He must justify his ing a productive relationship between the physician, the insurer fees to the insurance company. You have more than enough to and defense counsel is communication. Defense counsel must worry about. make the physician and the insurer feel that they are informed Remember the operant word is “trust.”If you don’t trust your and involved in the management of the defense. Similarly, the lawyer, get another lawyer! Keep the lines of communication physician and the insurer need to continuously advise defense open. If you have questions and concerns about your case, call counsel about their respective views concerning the case. A break- your lawyer and don’t worry about “running up the tab.”Your down in communication between the physician, the insurer and professional integrity and personal assets are on the line. Don’t be defense counsel only serves to benefit one party: the plaintiff. penny-wise. Ask him about opposing counsel if he has not prepped you in that regard. Michael A. Chabraja, JD With regard to solving the medical liability crisis: Not in our Chicago, Ill. lifetime.

Stanley W. Fronczak MD, JD, FACS COMMUNICATE YOUR THOUGHTS Share your point of view regarding malpractice litigation, reim- Oak Brook, Ill. bursement, ER coverage or other issues in neurosurgery with the editor at [email protected]. Letters are assumed to be for A Defense Attorney’s Perspective: publication unless otherwise specified. Correspondence select- This letter to the editor illustrates the need for effective communi- ed for publication may be edited for length, style and clarity. cation between the three parties involved in defending a malprac- tice claim: the physician, the insurer and defense counsel. A

Vol. 15, No. 2 • 2006 • AANS Bulletin 35

G OVERNANCE W. BEN BLACKETT,MD,JD,AND RUSSELL M. PELTON,JD

Two Disciplinary Actions Announced AANS Board Approves Four PCC Recommendations

t its meeting April 21 in San Francis- patient the next morning on rounds, he nursing staff to check vital signs and neu- co, the AANS Board of Directors found him to be densely paraparetic/para- rological function as ordered by the admit- approved the recommendation of plegic. The ordered neurological checks ting neurologist did not fall below the A the Professional Conduct Commit- had not been documented and apparently acceptable standard of nursing care. Dr. tee that four members be disciplined for had not been performed during the night. Buster further testified that the surgical unprofessional conduct while testifying as An emergency MRI of the thoracic and procedure was inappropriate and that the expert witnesses in medical malpractice lumbar spine demonstrated a large left- defendant neurosurgeon could have been lawsuits. Two of those disciplinary actions, sided disc herniation with cord compres- “up to 50 percent responsible” for the an expulsion and a six-month suspension of sion at T8–9. A neurosurgeon was then patient’s resulting neurological deficit. membership, are being appealed to the gen- consulted and performed an emergency During the Professional Conduct Com- eral membership of the AANS. The two dis- decompression with left posterolateral mittee hearing, Dr. Buster stated that he ciplinary actions that are not being excision of the herniated disc at T8–9. The had not thoroughly reviewed the nursing appealed are summarized below. patient gradually improved from his essen- records prior to testifying in his deposition tially paraplegic state to a paraparesis with and that “looking back on it now” the stan- Edwin R. Buster, MD neurogenic bladder. dard of proper nursing care was not met. In the underlying malpractice litigation, a The patient sued the hospital, the nurse The Professional Conduct Committee 53-year-old man who experienced sudden who had been on duty the night of the concluded that Dr. Buster’s testimony as a nontraumatic onset of back pain, sense of patient’s deterioration, and the neurosur- defense expert witness for the hospital leg heaviness, and leg pain was admitted to geon. The neurosurgical expert witness for consisted of improper advocacy in denying a hospital through the emergency room in the plaintiff testified to the hospital’s neg- negligence by the hospital and in misrep- January of 2000. The admitting neurolo- ligence but was not at all critical of the sur- resenting the range of surgical standards gist ordered that vital signs and neurolog- gery for removal of the thoracic disc for excising thoracic disc herniations in an ical evaluations be obtained every four herniation. Dr. Buster, the defense medical attempt to shift responsibility for the neu- hours by the nursing staff during the night. expert for the hospital, testified in his dis- rological deficits from the hospital to the When the neurologist examined his covery deposition that the failure of the treating neurological surgeon. The AANS Board of Directors agreed with the PCC’s findings and voted to suspend Dr. Buster’s membership in the AANS for one year. ABOUT THE AANS PROFESSIONAL CONDUCT PROGRAM The AANS Professional Conduct Committee evaluates complaints by one or more AANS William H. Bloom, MD members about another member or members and makes recommendations to the Board The underlying lawsuit in this case involved of Directors. Established in 1982, the PCC has served as a model for other professional a 44-year-old man who complained of a associations to structure and adopt similar professional conduct programs. In June of history of right arm pain with numbness in 2001, the AANS Professional Conduct Committee’s work was examined by the 7th Circuit his right index and middle fingers. The Court of Appeals in a landmark case for professional associations, Austin v. AANS. This problem reportedly began when he awak- opinion strongly supported the AANS Professional Conduct Program and the importance ened one morning with scapular pain that to a professional association of having an internal mechanism for self-regulation. The was soon followed by right arm pain. A CT program also received an honor roll designation from the American Society of Association scan showed foraminal narrowing with Executives in 2002. spondylosis and some spinal stenosis. The AANS rules for expert witness testimony are reprinted on page 37. These rules, Approximately one month later the patient the AANS Code of Ethics and more information related to association governance are reported having experienced some “electric available online at www.aans.org/about in the Governance and Leadership area. shock” sensations in his left arm. Surgery was carried out in the lateral position with bilateral laminectomies at C4, C5, C6 and C7. The operative note describes decom-

36 Vol. 15, No. 2 • 2006 • AANS Bulletin

pression of the right C5, C6 and C7 nerve signal indicated a surgical cord contusion therefore improperly gave unequivocal tes- roots and the left C6 and C7 nerve roots. despite having disclaimed personal expert- timony that nothing other than operative Postoperatively the patient experienced ise in the interpretation of abnormal MRI contusion could have caused the postoper- pain in his left hand, and his right deltoid signals. In his deposition, Dr. Bloom was ative MRI findings. The Professional Con- was very weak. The deltoid strength recov- excessively vague, unclear, and forgetful duct Committee concluded that Dr. Bloom ered spontaneously, but the left-hand pain about what he reviewed or did not review. demonstrated inadequate subject matter persisted. A cervical MRI done postopera- He did not recall whether he saw all of the knowledge and/or improper advocacy in tively showed an abnormal signal in the left MRI films or any of the CT films. parts of his testimony. The AANS Board of paracentral region of the cord at about The Professional Conduct Committee Directors concurred and since Dr. Bloom’s C5–6. The patient was treated with some concluded that, despite some problems with membership in the AANS had previously sympathetic blocks that did not relieve the documentation, surgical indications and been suspended in another matter, the pain, and he underwent implantation of a confusion about some aspects of the surgi- board voted to extend that suspension by cervical epidural stimulator. The patient cal procedure on the part of the treating one year from whatever point Dr. Bloom filed his lawsuit shortly after learning about neurosurgeon, Dr. Bloom failed to suffi- might otherwise be entitled to reapply for the abnormal signal shown in the MRI. ciently review and familiarize himself with active AANS membership. 3 Dr. Bloom, the plaintiff’s medical the relevant medical records. Because Dr. W. Ben Blackett, MD, JD, is chair of the expert, testified in his deposition that the Bloom disclaimed any expertise in the AANS Professional Conduct Committee, and postoperative abnormal cervical cord MRI interpretation of abnormal MRI signals, he Russell M. Pelton, JD, is AANS general counsel.

AANS Rules for Neurosurgical Medical/Legal Expert Opinion Services Revised March 22, 2006

Preamble 5. The neurosurgical expert witness shall not be evasive for the The American legal system often calls for expert medical testimony. purpose of favoring one litigant over another. The neurosurgical Proper functioning of this system requires that when such testimony expert shall answer all properly framed questions pertaining to his is needed, it be truly expert, impartial and available to all litigants. or her opinions on the subject matter thereof. To that end, the following rules have been adopted by the American Association of Neurological Surgeons. These rules apply to all AANS B. Subject Matter Knowledge members providing expert opinion services to attorneys, litigants, or 1. The neurosurgical expert witness shall have sufficient knowledge the judiciary in the context of civil or criminal matters and include of and experience in the specific subject(s) of his or her written written expert opinions as well as sworn testimony. expert opinion or sworn oral testimony to warrant designation as an expert. A. Impartial Testimony 2. The neurosurgical expert witness shall review all pertinent avail- 1. The neurosurgical expert witness shall be an impartial educator able medical information about a particular patient prior to ren- for attorneys, jurors and the court on the subject of neurosurgical dering an opinion about the appropriateness of medical or surgical practice. management of that patient. 2. The neurosurgical expert witness shall represent and testify as to 3. The neurosurgical expert witness shall be very familiar with the practice behavior of a prudent neurological surgeon giving dif- prior and current concepts of standard neurosurgical practices ferent viewpoints if such there are. before giving testimony or providing written opinion about such 3. The neurosurgical expert witness shall identify as such any per- practice standards. sonal opinions that vary significantly from generally accepted neu- rosurgical practice. C. Compensation 4. The neurosurgical expert witness shall recognize and correctly 1. The neurosurgical expert witness shall not accept a contingency represent the full standard of neurosurgical care and shall with rea- fee for providing expert medical opinion services. sonable accuracy state whether a particular action was clearly with- 2. Charges for medical expert opinion services shall be reasonable in, clearly outside of, or close to the margins of the standard of and commensurate with the time and effort given to preparing neurosurgical care. and providing those services.

Vol. 15, No. 2 • 2006 • AANS Bulletin 37

A DVANCINGN EURORESEARCH M ICHELE S. G REGORY

The 2006 Research Fellows include: Ming Two NREF Milestones (David) Cheng, MD (University of North Carolina), Lewis Chun Hou, MD (Stanford 25 Years, Record Number of Awards Are Reasons to Cheer University), Eric M. Jackson, MD (Univer- sity of Pennsylvania),Adrian W.Laxton, MD he Neurosurgery Research and Edu- tices and programs, hospitals and the gen- (University of Toronto), Daniel A. Lim, MD, cation Foundation is celebrating two eral public,” noted Martin H. Weiss, MD, PhD (UCSF), Neil R. Malhotra, MD (Uni- milestones in 2006. The first is the FACS, chair of the NREF Executive Council. versity of Pennsylvania), Wael Musleh, MD, T NREF’s silver anniversary. In 1981 “However, we are consistently exploring PhD (University of Chicago), and Lyman Robert Ojemann, MD, Robert King, MD, other partnerships in an effort to fund as Whitlach, MD, PhD (Duke University). Sidney Goldring, MD, and William Buch- much great science as we can.” The 2006 Young Clinician Investigators heit, MD, with the help of a number of Partnerships with industry, founda- include: John A. Boockvar, MD (Cornell other AANS members, formed the NREF tions and voluntary health associations Medical College), Alfredo Quinones-Hino- to: provide private, nongovernmental fund- have enabled the NREF to maximize its josa, MD (Johns Hopkins University), ing for neurosciences research; to ensure funding without compromising its Michael D. Taylor, MD, PhD (Hospital for continued viability and expansion of the integrity. In 2004, the AANS Develop- Sick Children, Toronto), and G. Edward field based on fundamental research in the ment Committee, under the leadership Vates, MD (University of Rochester). basic sciences and clinical enterprises; to of Jon H. Robertson, MD, developed the augment support for research by the neuro- Guidelines for Corporate Relations doc- Cutting-Edge Research surgical community; and to stimulate life- ument. The guidelines define appropri- Two examples of the cutting-edge research long learning by neurosurgeons. During the ate relationships between the AANS and the NREF is funding this year are the proj- past 25 years, the NREF has awarded near- NREF and their corporate partners such ects of Dr. Lim and Dr. Boockvar. Dr. Lim’s ly $4.5 million dollars in one- and two-year as DePuy Spine, Kyphon Inc., Medtron- research has established an in vitro SVZ grants to 113 residents and junior neuro- ic Neurological, and W. Lorenz Surgical. stem cell culture system which will allow surgical faculty members. According to Dr. Weiss, such partner- him to determine the role that the Mll gene Alone, the NREF’s 25th anniversary is a ships enable the NREF to allocate more plays in stem cell self-renewal, differentia- cause for celebration; however, an equally funding for research grants each year tion, cellular migration, and cell survival. important milestone also was achieved this while building ethical relationships with Dr. Boockvar’s research seeks to identify year. For the first time the NREF awarded a industry. the mechanism by which EGFR signaling double-digit number of grants, 12 total. In 2006 the AANS and NREF will enhances human progenitor cell invasive- Eight applicants received research fellow- cosponsor an annual research grant from ness for the purpose of improving the ships and four received young clinician funds raised through the AANS Pinnacle treatment of glioblastoma multiforme. investigator awards. Partners in Neurosurgery corporate giv- It is hoped that the exciting potential of Robert Grossman, MD, chair of the ing program.“The Pinnacle Partners pro- projects like these will stimulate continued NREF’s Scientific Advisory Committee, gram provides an opportunity for growth in financial support from neurosur- thinks that some of the most innovative and industry to financially support neurosur- geons, as well as partnerships with industry interesting investigations occurring in neu- gical research and education through the and other funding sources. The extent to rosurgical labs today are funded by the NREF in a responsible and ethical man- which the entire neurosurgical community NREF. “The scientific quality of the grant ner,” said Dr. Robertson. “A company’s recognizes the importance of research and applications has increased each year and participation in the Pinnacle Partners development to the future of the specialty meets our highest expectations,”he stated. program generates recognition that and the patients it serves will determine the Thanks to generous support of the reflects its commitment to the future of outlook for the NREF research grant pro- Corporate Associates program by AANS neurosurgery and the public good.” gram over the next 25 years. members, hospitals, neurosurgery depart- The 2006 NREF awardees come from 11 For information about the NREF or to ments, the general public, and our corpo- different neurosurgery programs. The make a donation, visit www.aans.org/ rate partners, the NREF has committed research grants encompass neurosurgical research or contact the AANS Develop- $500,000 in research support for 2006, an areas of pediatric brain tumors, spine trau- ment department at (847) 378-0500. 3 increase of $100,000 from last year. ma, deep brain stimulation, aneurysms, Michele S. Gregory is AANS director of development. “The NREF continues to secure support epilepsy, pain biomaterials and stem from neurosurgeons, neurosurgical prac- cell research.

38 Vol. 15, No. 2 • 2006 • AANS Bulletin

Neurosurgery - Roanoke, Virginia Southern Oregon -Affiliated with Carilion Medical Center, largest hospital in Neurosurgery Opportunity Southwest Virginia, Level I Trauma Center, 880-beds. Dedicated neuro ICU, seven residency programs, and medical Join a well-established group of four neuro- school affiliations with University of Virginia and Via College of Osteopathic Medicine surgeons and five neurologists in southern Oregon. -State of the art neurosurgical equipment, including biplanar Income guarantee with a partnership track. flouroscopic image guidance, Stealth and CyberKnife. Medford is a community of approximately 75,000 -Comprehensive, established neurosurgical practice. with a medical service area of 750,000. There -Hospital-employed group practice, with collaborative are two hospitals that share a joint medical staff approach and cross coverage. and the neurosurgeons provide coverage at both -Competitive salary and benefits, paid malpractice insurance. hospitals, but this is not a hospital-based practice. -A five time "All America City", one of the top rated small The medical community is sophisticated and cities in the US, nestled in the gorgeous Blue Ridge Mountains reputable, and the clinic, medical facilities and of Southwest Virginia. equipment are state-of-the-art. The draw to this -Metropolitan population of 250,000, referral market area and this opportunity is the ability to recognize population of 1.5 million. an unprecedented balance of personal and -Region offers affordable housing, recreational, cultural, and professional opportunities. Mild weather and four seasons. professional quality of life in a very desirable location. For detailed information about the opportunity, or to submit a Contact: cover letter and CV please contact Andrea Henson, Physician Anne Folger, Executive Director, Recruiter, Carilion Health System [email protected] 540-224-5241 office, 540-985-5329 fax. www.carilion.com Health Future – A unique healthcare consortium owned byOregon hospitals and healthcare systems Email: [email protected] Phone: 541/618-7240

DENVER, COLORADO Luther Midelfort Seeking Neurosurgeon Mayo Health System Wonderful opportunity to practice state of the art Luther Midelfort – Mayo Health System in Eau Neurosurgery in “base camp for the Rockies,” Denver, Claire, Wisconsin, has an opening for a BC/BE Colorado. Enjoy an academic practice with three other (upon arrival) neurosurgeon with a broad range of neurosurgeons and two orthopedic spine surgeons, skills. Call of 1:3 is shared equally. Draw area while living in a cultural center at the foot of the world’s of 300,000. Our neurosurgeons practice “state of greatest mountains for skiing, hiking, fishing, golf and the art” medicine, have equal earning potential a true outdoor lifestyle. Over 300 days of sunshine from the beginning, have their office in the only yearly! Support staff includes two hospital physician hospital they cover, and share a close working assistants and two office physician assistants, and relationship with their neurosurgery colleagues at a dedicated Neurosurgical scrub technician. The Mayo Clinic. Eau Claire is a university city of Neurosurgery service provides exclusive coverage for 63,000 with a metro area of 90,000, 90 minutes over 430,000 insured patients. This yields an excellent east of Minneapolis. You may expect a safe mix of elective cranial and spine cases, with relatively family environment, a city that serves as the little trauma care. Surgical residency program includes regional hub for the arts and shopping, and intern on the neurosurgical service with 24-hour schools that are in the top 10% of preferred in-house coverage. Competitive pay scale and none schools nationally. For more information contact: of the business hassles of running a private practice. If interested please contact Eileen Christie Blink, Director Jones-Charlett, Colorado Permanente Medical Group, Physician Recruitment (303)344-7838. Or fax your CV with a cover letter to Phone: 1-800-573-2580 Physician Recruitment at 303-344-7818 or e-mail to Fax: 715-838-6192 [email protected]. EOE E-mail: [email protected]

Vol. 15, No. 2 • 2006 • AANS Bulletin 39

B OOKSHELF G ARY V ANDER A RK, MD

Too Much Like Ourselves? Neurosurgeons Author Two New Books

Another Day in the Frontal “Today, were it not for an army base that Lobe: A Brain Surgeon Exposes bears his name, we would never hear of Life on the Inside, by Katrina Firlik’s book is in the Firlik, 2006, Random House, Leonard Wood.” For neurosurgeons, that 271 pp., $24.95. may not be true. Those of us who have read tradition of Rudy Giuliani Cushing biographies by John Fulton and and Erin Brockovich. more recently by Michael Bliss know Leonard Wood: Rough Rider, Leonard Wood as a famous patient. McCal- Books that glorify the Surgeon, Architect of American lum sets the record straight as to Wood’s Imperialism, by Jack McCallum, medical history, but does much more in American dream come 2006, New York University allowing us to know the doctor who Press, 355 pp., $34.95. true have always found became a soldier. Leonard Wood was born Oct. 9, 1860, in an audience…. Pocasset, Mass., and died in the operating eurosurgeons are writing books! room at Boston’s Peter Bent Brigham Hos- Hot off the presses are two new pital at 1:50 a.m., Aug. 6, 1927. The 1880s training was funding and taking responsibil- titles by Jack McCallum, MD, and were the decade in which American medi- ity for Walter Reed’s yellow fever experi- N Katrina Firlik, MD. McCallum, cine transformed itself from a cult to a sci- ments and authorizing William Gorgas to who is on the neurosurgery faculty at Bay- ence, and Harvard Medical School, where use the finding to virtually eradicate yellow lor and also teaches history at the Texas Wood framed as a physician, was the nexus fever and malaria from Cuba. Christian University, has written a schol- of that revolution. But Wood enlisted as a The later chapters of Wood’s life as mil- arly biography of Leonard Wood; Firlik, a military surgeon and became a soldier itary commander and governor general of recent neurosurgical graduate from the more than a doctor. His medical back- the Philippines were not as successful. University of Pittsburg, has published the ground, however, had profound influence Wood had a dark side and at times his dis- story of her neurosurgical residency with on his legacy as an administrator. dain descended to cruelty and even mur- the attention-getting moniker of Another Wood’s first military experience was der. Wood at his best was altruistic, Day in the Frontal Lobe. chasing Geronimo, and he won the Medal intelligent, creative, self-confident and Firlik’s book is in the tradition of Rudy of Honor just as Frederick Jackson Turner indefatigable. On the other had, he was Giuliani and Erin Brockovich. Books that declared the American frontier closed. He intolerably self-righteous and his insatiable glorify the American dream come true have spent a year as Georgia Tech’s first football appetite for power culminated in his always found an audience, and Random coach before moving to Washington where unsuccessful run for the U.S. presidency. House is betting that people will want to he developed a lifelong friendship with the McCallum offers an interesting conclu- read the story of a woman from Harvey assistant secretary of the U.S. Navy, sion in the epilogue of his book:“In the end Cushing’s hometown who has made it in Theodore Roosevelt. … Wood never quite discovered how to the male-dominated world of brain surgery. Leonard Wood’s conversion from physi- fulfill himself or to satisfy others in the Firlik has a gift for making neuro- cian to professional soldier was completed exertion of his own remarkable powers. surgery sound intriguing. The book begins when Roosevelt convinced President Perhaps we have forgotten him because he with this attention grabber: “The brain is McKinley that a cowboy regiment should was too much like ourselves.” soft. Some of my colleagues compare its join the Spanish War. The Rough Riders Ah, there’s the rub. consistency to toothpaste, but that’s not were a combination of Wood’s western con- Here you have two new books by fellow quite right. Tofu—the soft variety, for those tacts plus Roosevelt’s assortment of Ivy neurosurgeons. Both of these books will knowledgeable about tofu—may be a more League ex-athletes. When the war ended, serve as mirrors, and both will help us to accurate comparison.” Neurosurgeons will Wood accomplished great things as a natu- understand ourselves better. 3 probably not find this book as fascinating ral administrator and a zealous autocrat. Gary Vander Ark, MD, is director of the Neurosurgery as some of our patients might. Within one year, he was military governor of Residency Program at the University of Colorado. He is McCallum says of Leonard Wood, Cuba. The crowning achievement of all his the 2001 recipient of the AANS Humanitarian Award.

40 Vol. 15, No. 2 • 2006 • AANS Bulletin

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Chief Operating Officer AANS Bulletin: Department of Neurosurgery A Top Member University of Minnesota Medical School The Department of Neurosurgery at the University of Minnesota Benefit and a seeks a Chief Operating Officer to provide oversight of all aspects of billing, coding and collection for services provided by faculty and Leading Predictor extenders of the Neurosurgery Clinical Staff Unit. of Satisfaction This position is accountable for the efficiency of the Neurosurgery outpatient clinic functions in concert with the clinic leadership, With AANS Membership faculty and staff and provides integrational support of the CSU staff with clinic staff in order to optimize patient care and patient satisfaction. Department oversight will include involvement in The AANS Bulletin is the primary source of news that affects the managing hiring, promotion, discipline, payroll, work hours, vacation practice of neurosurgery: practice management, legislation, coding and sick leave, in order to adequately staff the daily operations of the and reimbursement, professional development and education, and Neurosurgery department and CSU. more. Readers are invited to participate in the Bulletin: Qualifications include a Bachelor’s degree with a minimum of 4-6 years of progressively responsible experience, and with specific Neurosurgical Professionals experience in a senior management position in the clinic administration • Write a letter to the editor. of a physician’s practice. Supervision of personnel in the areas of • Submit an article or article idea. billing and collection of provider fees, third party agreements, and • Submit socioeconomic research papers for peer review. physician support. Knowledge of coding and billing, financial reporting, • Provide news briefs to News.org. and staff management in a physician-oriented clinical setting is essential. • Submit a neurosurgical meeting to the online calendar. Interested candidates may send a resume and letter of interest to:

Corporations Rob Super, Search Committee Chair • Advertise in the Bulletin. University of Minnesota • Sponsor the Bulletin MMC 391, 420 Delaware Street SE (an exclusive opportunity). Minneapolis, MN 55455 e-mail: [email protected] Learn more at www.aans.org/bulletin. The University of Minnesota is an equal opportunity employer and educator

Vol. 15, No. 2 • 2006 • AANS Bulletin 41

NN EWSEWS.. ORGORG AANS/CNS SectionsCommitteesAssociationsSocieties

AANS Humanitarian AANS Releases New Mission and Vision During CNS, formalized this concern in a resolution sub- Awardees 75th Anniversary Year On April 21, the AANS mitted in May to the American Medical Association Nominations for the 2007 Board of Directors approved a new mission and House of Delegates. The resolution “to develop award are due Oct. 15. vision for the organization: standards for MRI equipment and interpretation 2006 for the purpose of improving patient safety” asked: Gene Bolles, MD AANS Mission The American Association of Neurological Sur- “That our American Medical Association convene a 2005 geons (AANS) is the organization that speaks meeting(s) with representatives from MRI manu- Tetsuo Tatsumi, MD, FACS for all of neurosurgery. The AANS is dedicated facturers, radiology and other interested medical 2004 to advancing the specialty of neurological sur- specialties, and imaging facilities, with the goals of: Charles L. Branch Sr., MD gery in order to promote the highest quality of (1) agreeing to standards in electronic imaging for- 2003 patient care. mats (e.g., left to right, axial, coronal, sagittal); (2) No award AANS Vision developing standards of data manipulation and 2002 localization consistent throughout all units for best Edgar M. Housepian, MD The American Association of Neurological Sur- geons will ensure that neurosurgeons are recog- interpretation of the data; and (3) ensuring that 2001 nized as the preeminent providers of quality care each electronic format is equipped with the capabil- Gary D. Vander Ark, MD to patients with surgical disorders that affect the ity of loading and launching its contained images 2000 nervous system. on the physician’s computer.” Merwyn Bagan, MD, MPH The American Association of Neurological Sur- 1999 2007 Humanitarian Award Nominations Due Oct. 15 Thomas B. Flynn, MD geons will work to expand the scope of neurosur- gical care as new technologies and treatments of Voting members of the AANS are invited to submit 1998 neurological disorders become available. nominations for the 2007 Humanitarian Award by Lee Finney, MD Oct. 15. The award will be presented at the 2007 The American Association of Neurological Sur- 1997 AANS Annual Meeting in Washington, D.C., April geons will be the organization speaking for neu- Robert J. White, MD 14–19, 2007. The Humanitarian Award honors a rosurgery through its communications and 1996 member of the AANS whose activities outside of interactions with the public, media, government, No award medicine bring great benefit to society. Nominees medical communities, and third party payers. 1995 can be living members from any category of AANS Melvin L. Cheatham, MD The American Association of Neurological Sur- membership who give selflessly of time or talents to 1994 geons will be its members’ principal resource for a charitable or public activity; who are deserving of E. Fletcher Eyster, MD professional interaction, practice information and recognition by the AANS; and whose actions education. 1993 enhance neurosurgery’s image. Activities may be Manuel Velasco-Suarez, MD The American Association of Neurological Sur- international, national, regional or local in nature 1992 geons will promote and support appropriate clin- and benefit humanity collectively or individually William H. Mosberg Jr., MD ical and basic science to expand the scope of without providing remuneration to the recipient. 1991 neurosurgical practice. Additional details and the nomination form are George B. Udvarhelyi, MD available at www.aans.org/shared_pdfs/nomination_ 1990 AANS Seeks Standardization of Radiological Images %20form.pdf, or contact Susan E. Funk at A. Roy Tyrer Jr., MD Presented on CD At the suggestion of an AANS [email protected] or (847) 378-0507. 1989 member during the AANS Annual Meeting in Hugo V. Rizzoli, MD April, the AANS asked the American College of AANS Streamlines Disclosure Process for Speakers 1988 Radiology to consider development of standards Speakers at AANS educational meetings are required Gaston Acosta-Rua, MD for production of radiological images on CD. annually to disclose their financial relationships with 1987 AANS President Donald O. Quest, MD, communi- commercial interests. Individuals can now meet the Courtland H. Davis Jr., MD cated neurosurgeons’ concern about this issue in a requirement by completing the online Disclosure May 10 letter to ACR Board of Chancellors Chair Statement once. After it is submitted, the informa- James P. Borgstede, MD. The AANS, joined by the tion will remain available online, where it must be

42 Vol. 15, No. 2 • 2006 • AANS Bulletin

NERVES Releases Results of Second Annual Neurosurgical Practice Survey

Submitted by Hiroshi Nakano, chair of the demonstrating its value to any neurosurgical show this trend. However, this may also sim- NERVES Survey Committee practice that aims to improve operational ply be an aberration in the data collection he Second Annual NERVES and financial results by benchmarking itself process, due to increased numbers of prac- (Neurosurgery Executives’ Resource against peer practices. tices reporting for this survey. T Value and Education Society) Socio- A comparison of 2005 survey results with 3 Malpractice costs continue to rise. Economic Survey was released to participat- those of the 2004 survey highlighted several While in certain parts of the country, malprac- ing neurosurgical practices in April 2006. emerging trends that should be watched in tice premiums are reportedly stabilizing after The overall response rate from NERVES the future, including the following. several years of large increases, the NERVES member practices was 28 percent. The par- 3 Practices are looking for additional survey reported a 21 percent increase in ticipation of practices in this 2005 survey sources of revenue. As neurosurgery contin- average malpractice premiums nationally. increased by 27 percent over participation in ues to face the challenges of falling reim- Two data points do not make a trend. But the inaugural 2004 survey, and the number bursement, increasing practice costs, and the availability of practice data through the of neurosurgeons represented in the survey competition from other specialties, the survey NERVES survey is beginning to provide results increased by 23 percent. results showed that an increasing number of answers that have long been sought by neuro- The consulting group of Heaton and Eadie practices are expanding their lines of service surgeons and their professional practice provided survey design, data collection and (36 percent reported in 2005 compared with administrators. The NERVES organization is reporting services for the second straight 15 percent in 2004), including the addition of providing a valuable resource for addressing year. The survey was based on 2004 data. ancillary services and surgery centers. the socioeconomic issues facing neurosurgery Survey methodology and overall results from 3 Neurosurgery incomes are rising. today. The quality of the data and the value to the first NERVES Socio-Economic Survey Despite the concerns of falling reimburse- neurosurgery will improve as participation were published in the Fall 2005 issue of ment, the median income for a neurosur- improves. We would ask neurosurgeons to the AANS Bulletin in an article that provided geon increased by approximately 16 percent encourage their administrators to participate in results of the 2004 survey and highlighted in 2005. Perhaps this is a result of the the survey by joining NERVES. 3 several areas important to the practice increasing interest and success of ancillary of neurosurgery. revenue streams or practices are becoming Additional information about NERVES is The data collected through the survey is better managed. Future surveys should help available at www.nervesadmin.com.

updated yearly or as necessary to report status the AANS, Controversies confronts many of the top- Softball Tournament changes. The Disclosure Statement and additional ics fueling neurosurgical discussions, with detailed Has Raised $100,000 information are accessible at www.MyAANS.org by coverage of treatments for ischemic diseases such as for Pediatric Brain selecting “Disclosure” from the navigation bar. extracranial and intracranial atherosclerosis. Many Tumor Research Questions about this new process can be directed to of the organizational issues of integrating subspe- On June 10 in New York’s the AANS at (888) 566-2267. cialties and training subspecialists are discussed. The Central Park, teams 336-page book contains 240 illustrations, figures, representing eight of Abstract Deadline for the 2007 AANS Annual and radiological images and offers 15 continuing the nation’s medical Meeting Is Sept. 15 Abstract submissions for the medical education credits. Information is available centers competed in the 2007 AANS Annual Meeting: Celebrating the in the AANS Online Marketplace, www.AANS.org. Third Annual Neurosurgery AANS’ Diamond Jubilee are being accepted until Charity Softball Tournament Sept. 15. The Call for Abstracts brochure containing AANS Members Serving on Committees Get New benefiting Columbia Univ- instructions on the submission process and access Information Management Tool Members now can ersity’s Pediatric Brain to the online Abstract Center are available at access information about their committees at www Tumor Research Fund. www.aans.org/annual/2007/abstract.asp. .MyAANS.org, including a committee roster with Top finishers were the contact information, an archive of past minutes and University of Pennsylvania, New Book Tackles Tough Topics Controversies in other materials, and upcoming meeting information Columbia University and Neurological Surgery, a new book by Michael T. for each committee on which an individual serves. Mt. Sinai School of Lawton, Daryl R. Gress, and Randall T. Higashida, The information is accessible after logging in to Medicine. The next event provides insight into trends and controversial www.MyAANS.org and selecting “Committees” from is planned for June 9, issues regarding state-of-the-art techniques in the navigation bar. Those who want to volunteer for 2007 (www.KidsBrain neurosurgery, interventional neuroradiology and a particular committee can do so in this area as well Research.org). endovascular surgery. Copublished by Thieme and by selecting “Edit” next to Volunteer for Committee.

Vol. 15, No. 2 • 2006 • AANS Bulletin 43

OFFICERS E VENTS Donald O. Quest, MD, president Calendar of Neurosurgical Events Jon H. Robertson, MD, president-elect Arthur L. Day, MD, vice-president James T. Rutka, MD, PhD, secretary Aspen Symposium on Brain Tumor XXXII Meeting of the Latin AANS/CNS Section on Pediatric James R. Bean, MD, treasurer Immunotherapy American Federation of Neurological Surgery+ Fremont P. Wirth, MD, past president Aug. 7–9, 2006 Neurosurgical Societies Nov. 28–Dec. 1, 2006 DIRECTORS AT LARGE Aspen, Colo. Oct. 21–26, 2006 Denver, Colo. William T. Couldwell, MD, PhD [email protected] Buenos Aires, Argentina www.neurosurgery.org/ Robert E. Harbaugh, MD www.clan2006.com.ar pediatric Christopher M. Loftus, MD 2nd International Conference on Warren R. Selman, MD Intracranial Atherosclerosis Research Updates in Neurobiology 19th Annual Contemporary Update + Troy M. Tippett, MD Aug. 11–12, 2006 for Neurosurgeons on Disorders of the Spine San Francisco, Calif. Oct. 21–28, 2006 Jan. 13–19, 2007 REGIONAL DIRECTORS www.cme.ucsf.edu Woods Hole, Mass. Whistler, Canada Jeffrey W. Cozzens, MD www.societyns.org www.cme.hsc.usf.edu/dots + R. Patrick Jacob, MD Tennessee Neurosurgical Society Aug. 19–20, 2006 Stephen T. Onesti, MD Neurocritical Care 2006: Southern Neurosurgical Society Chattanooga, Tenn. + Edie E. Zusman, MD Synchronicity Annual Meeting (423) 265-2233 Nov. 2–5, 2006 March 15–18, 2007 HISTORIAN Baltimore, Md. Sea Island, Ga. Eugene S. Flamm, MD Hydrocephalus 2006 www.neurocriticalcare.org www.southernneurosurgery.org EX-OFFICIO Sept. 6–9, 2006 Rick Abbott, MD Goteborg, Sweden 3rd International Symposium 75th AANS Annual Meeting P. David Adelson, MD www.hydrocephalus2006.com on Microneurosurgical April 14–19, 2007 Charles L. Branch Jr., MD Anatomy Washington, D.C. Lawrence S. Chin, MD Spinal Surgery in Elderly Patients Nov. 5–8, 2006 www.aans.org Fernando G. Diaz, MD, PhD Sept. 7–9, 2006 Antalya, Turkey Andres M. Lozano, MD Frankfurt, Germany www.isma2006.org Richard K. Osenbach, MD www.bgu-frankfurt.de + These meetings are jointly spon- Setti S. Rengachary, MD 67th Annual American sored or cosponsored by the American B. Gregory Thompson Jr., MD 8th Annual Interventional Academy of Physical Association of Neurological Surgeons. Ronald E. Warnick, MD Neuroradiology Symposium Medicine and Rehabilitation Sept. 8–9, 2006 LIAISONS Annual Assembly The frequently updated Meetings Richard G. Ellenbogen, MD Toronto, Canada Nov. 9–12, 2006 Calendar and continuing medical edu- H. Derek Fewer, MD www.cme.utoronto.ca Honolulu, Hawaii cation information are available at Isabelle M. Germano, MD www.aapmr.org www.aans.org/education. Egyptian Society of Neurological AANS EXECUTIVE OFFICE Surgeons: Minimally Invasive 5550 Meadowbrook Drive Neurosurgery Rolling Meadows, IL 60008 Sept. 13–15, 2006 Phone: (847) 378-0500 Alexandria, Egypt AANS Courses (888) 566-AANS www.esns.org.eg Fax: (847) 378-0600 For information or to register call (888) 566-AANS E-mail: [email protected] + Western Neurosurgical Society or visit www.aans.org/education. Web site: www.AANS.org Sept. 16–19, 2006 Thomas A. Marshall, executive director Blaine, Wash. 3 Managing Coding & Reimbursement Challenges Ronald W. Engelbreit, CPA, www.westnsurg.org deputy executive director in Neurosurgery Susan M. Eget, associate executive 56th Annual Meeting of the Congress Power Coding Sept. 8–9, 2006 Chicago, Ill. director-governance of Neurological Surgeons “Coding for the Pros” Nov. 3–4, 2006 Los Angeles, Calif. Joni L. Shulman, associate executive Oct. 7–12, 2006 Prerequisite: AANS coding course taken within two years. director-education & meetings Chicago, Ill. DEPARTMENTS www.neurosurgeon.org 3 Neurosurgery Review by Case Management: Communications, Betsy van Die Development, Michele S. Gregory American Neurological Association Oral Board Preparation Information Services, Anthony P. Macalindong Annual Meeting Nov. 5–6, 2006 ...... Houston, Texas Marketing, Kathleen T. Craig Oct. 8–11, 2006 May 20–22, 2007 ...... Houston, Texas Meeting Services, Patty L. Anderson Chicago, Ill. Member Services, Chris A. Philips www.aneuroa.org Nov. 4–6, 2007 ...... Houston, Texas AANS/CNS WASHINGTON OFFICE 725 15th Street, NW, Suite 800 American Academy of Neurological 3 Neurosurgical Practice Management: Improving + Washington, DC 20005 Surgery the Financial Health of Your Practice Oct. 18–22, 2006 Phone: (202) 628-2072 Sept. 10, 2006 ...... Chicago, Ill. Fax: (202) 628-5264 Greensboro, Ga. Web site: www.aans.org/legislative/ (602) 406-3159 aans/washington_c.asp

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