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A M E R I C A N A S S O C I AT I O N O F N E U R O L O G I C A L S U R G E O N S

The Soc ioeconomic and P ro fess iona l Magaz ine fo r AANS Members • Vo lume 15 Number 2 • 2006

COMPLETING THE PICTURE

AssessingNeurosurgical ER

CoverageCoverageWhom Does

Credentialing Protect? 30

Texas Teaches ThatTort Reform Works, 34

AANS Board Approves Professional Conduct

Recommendations, 36

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

C O N T E N T SC O N T E N T SV O L U M E 1 5 N O . 2

ON THE COVER

8 | Completing the Picture: AANS 2006 WorkforceSurvey Assesses Neurosurgical ER CoverageA new survey finds that the vast majority of neuro-surgeons are participating in the emergency care system, but most also report problems with call coverage in their practice areas.

Manda J. Seaver

12 | What Will Improve Neurosurgical Emergency Coverage?In the wake of the IOM report on emergency care,surgery’s views on the proposed specialty of acute care surgery and regionalization are explored.

Manda J. Seaver

PRESIDENT’S MESSAGE

3 | Professional Conduct: Witness TestimonyObligations of membership include adherence to the AANS Code of Ethics.

Donald O. Quest, MD

FEATURES16 | Sweet Success in San FranciscoThe 74th Annual Meeting initiates the AANS’ diamondjubilee year.

Manda J. Seaver

22 | Inspirations and EpiphaniesJuan Cardenas, Stephen Mahaley, Edgar Kahn,Keasley Welch, and the Mona Lisa are among neurosurgeons’ inspirations.

NEWS AND EVENTS

5 | NewslineThe AANS, CNS and ASTRO define stereotactic radiosurgery.

42 | News.orgNERVES releases 2005 practice survey results.

44 | Calendar of Neurosurgical EventsAANS/CNS Section on Pediatric Neurological Surgeryannual meeting will be held Nov. 29–Dec. 1.

OPINION

35 | LettersA reader questions the motivations of defense attorneys.

7 | Personal PerspectiveThe case for regionalization of neurosurgical emergencyservices grows stronger.

William T. Couldwell, MD

Continued on page 2

Egyptian, Coptic,“Portion of a HangingShowing a Figure of aWarrior,” 5th/6th century, linen and wool,plain weave with weftpile and embroideredlinen pile in back andstem stitches, 136.5 x 88.3 cm, Grace R. Smith TextileEndowment,1982.1578, The ArtInstitute of Chicago.Photography © The ArtInstitute of Chicago.

AANS MISSIONThe American Association of Neurological Surgeons (AANS) is the organization that speaks for all of neurosurgery.The AANS is dedicated to advancing the specialty ofneurological surgery in order to promote the highest quality of patient care.

AANS BULLETIN The official publication of the American Association ofNeurological Surgeons, the Bulletin features news about theAANS and the field of neurosurgery, with a special emphasis onsocioeconomic topics.

William T. Couldwell, MD, editorPatrick W. McCormick, MD, associate editorManda J. Seaver, staff editor

BULLETIN ADVISORY BOARD Deborah L. Benzil, MD

Frederick A. Boop, MD

Lawrence S. Chin, MD

Fernando G. Diaz, MD, PhD

David F. Jimenez, MD

Katie O. Orrico, JD

Mick J. Perez-Cruet, MD

A. John Popp, MD

DEPARTMENT EDITORS AND CORRESPONDENTSFrederick Boop, Newsline; Lawrence Chin, MD, Education;Fernando Diaz, MD, PhD, CSNS Report; David Jimenez,Patient Safety; Katie O. Orrico, JD, Washington Update; MickPerez-Cruet, MD, NS Innovations; Gregory J. Przybylski, MD,Coding Corner; Michael Schulder, MD, Timeline;Gary Vander Ark, Bookshelf; K.Michael Webb, MD, Residents’

Forum; Monica Wehby, MD, and Michael Chabraja, JD,Risk Management

WRITING GUIDELINESwww.aans.org/bulletin

ARTICLE SUBMISSIONS AND IDEAS Articles or article ideas concerning socioeconomic topicsrelated to neurosurgery can be submitted to the Bulletin,[email protected]. Objective, nonpromotional articles thatare in accordance with the writing guidelines, are original,and have not been published previously may be consideredfor publication.

The AANS reserves the right to edit articles for compliancewith publication standards and available space and to publish them in the vehicle it deems most appropriate.Articles accepted for publication become the property of theAANS unless another written arrangement has been agreedupon between the author(s) and the AANS.

PEER-REVIEWED RESEARCHThe Bulletin seeks submissions of rigorously researched,hypothesis-driven articles concerning socioeconomic topicsrelated to neurosurgery. Selected articles are reviewed by peer-review panelists. Papers must comport with the writing guide-lines at www.aans.org/bulletin.

Peer-Review Panel led by Deborah L. Benzil, MDWilliam E. Bingaman Jr., MD; Frederick A. Boop, MD; Fernan-do G. Diaz, MD; Domenic Esposito, MD; David F. Jimenez,MD; Mark E. Linskey, MD; Mick Perez-Cruet, MD; Richard N.Wohns, MD

LETTERSSend your comments on articles you’ve read in these pages or on a topic related to the practice of neurosurgery to [email protected]. Correspondence may be published

Gregory J. Przybylski, MD

Gail Rosseau, MD

Michael Schulder, MD

Gary D. Vander Ark, MD

K. Michael Webb, MD

Monica C. Wehby, MD

Richard N. Wohns, MD

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

in a future issue edited for length, clarity and style.Correspondence is assumed to be for publication unless otherwise specified.

Bulletin OnlineThe current issue and searchable archives since 1995 are avail-able at www.aans.org/bulletin.

PUBLICATION INFORMATION The AANS Bulletin, ISSN 1072-0456, is published four timesa year by the AANS, 5550 Meadowbrook Drive, RollingMeadows, Ill., 60008, and distributed without charge to theneurosurgical community. Unless specifically stated other-wise, the opinions expressed and statements made in thispublication are the authors’ and do not imply endorsementby the AANS.

© 2006 by the American Association of Neurological Surgeons,a 501(c)(6) organization, all rights reserved. Contents may notbe reproduced, stored in a retrieval system, or transmitted inany form by any means without prior written permission ofthe publisher.

ADVERTISING SALES Richard Devanna, Cunningham Associates, (201) 767-4170,or [email protected] card, www.aans.org/bulletin.

DEPARTMENTS

38 | Advancing NeuroresearchTwo NREF milestones give reason to cheer.

Michele S. Gregory

40 | BookshelfCharacter is at the core of two new books by neurosurgeons.

Gary Vander Ark, MD

28 | Coding CornerCoding for concurrent spinal procedures is explored.

Gregory J. Przybylski, MD

33 | EducationA new endovascular course for residents illustrateshow collaboration benefits education.

Joni L. Shulman

36 | GovernanceAANS Board of Directors approves four ProfessionalConduct Committee recommendations.

W. Ben Blackett, MD, JD, and Russell M. Pelton, JD

34 | Medicolegal UpdateTexas teaches that tort reform works.

David F. Jimenez, MD

30 | Patient SafetyWhom does credentialing protect?

Patrick W. McCormick, MD

21 | Practice ManagementWhen insurers share savings, you don’t have to suffer.

Nick Green

24 | Residents’ ForumYou can clip an aneurysm, but can you compute cost per RVU?


32 | TimelineTwo world wars had an “acute” impact on neurosurgi-cal training.

Michael Schulder, MD

26 | Washington UpdateTort reform falls short in the Senate, but the DMLRcampaign presses forward.

Katie O. Orrico, JD

C O N T E N T SC O N T E N T S


P R E S I D E N T ’ S M E S S A G E D O N A L D O . Q U E S T , M D

Membership in the AANS is volun-tary and not a prerequisite to thepractice of neurosurgery. Never-theless there are obligations of

membership, and one of these is adherenceto the AANS Code of Ethics.

The AANS Code of Ethics addresses, inpart, expert witness testimony. Such testi-mony as part of the practice of medicine isindeed an obligation of members of themedical profession. The AANS is joined inthis view by many prominent medical soci-eties, among them the American MedicalAssociation and the American College ofSurgeons. The AANS, the AMA and theACS all provide their members with guid-ance on how to act professionally andethically in the legal arena. While documen-tation of this guidance is readily availablefrom each of these organizations, a briefreview of salient points follows.

The ACS Statements of Principles, mostrecently updated in 2004, avers that “expertwitnesses are expected to be impartial andshould not adopt a position as an advocateor partisan in the legal proceedings.” Theexpert also should be “familiar with thestandard of care provided at the time of thealleged occurrence and should be activelyengaged in practice of the specialty or thesubject matter of the case at the time thetestimony or opinion is provided.”The ACSadditionally asks its members to sign andabide by the Expert Witness Affirmation,which sets forth 10 principles for expertwitness testimony that include conductinga thorough, fair, and impartial review of thefacts, and providing testimony that is objec-tive, scientifically based and helpful to a justresolution of the case.

The AMA offers guidance on medicaltestimony in its Code of Medical Ethics,which affirms that a physician’s participa-tion in the legal system is “an ethical obli-gation.” In 2004 the AMA issued a reporton medical testimony that addresses thephysician’s ethical obligation to provide

either prosecution or defense: “Althoughthe testifying physicians’ services may havebeen sought primarily by one party, [physi-cians] testify to educate the court as awhole.” The report further calls for impar-tial testimony that must not be false or mis-leading and for physicians providing experttestimony to have “recent and substantiveexperience or knowledge in the area inwhich they testify.”

The report’s conclusion reinforces theconcept of professional conduct throughadjudication of ethical infractions via aprogram that employs due process:

“Organized medicine…[has] impor-tant roles to play in promoting the ethical conduct of physician witnessactivities. With careful attention to dueprocess…organizations can help main-tain high standards for medical wit-nesses by assessing claims of false ormisleading testimony and issuing disciplinary sanctions as appropriate.”

The AANS Code of Ethics states in partthat “expert testimony should reflect notonly the opinions of the individual but alsodescribe where such opinions vary fromcommon practice; the expert should beengaged in active practice of surgery or beable to demonstrate enough familiaritywith present practice to warrant designa-tion as an expert, and should champion thetruth [rather than] the cause of one partyor other.”

The AANS also developed the Rulesfor Neurosurgical Medical/Legal ExpertOpinion Services document, which callsupon the neurosurgeon “to be an impar-tial educator for attorneys, jurors, and thecourt…not to be evasive for the purposeof favoring one litigant over another…and to review all pertinent availablemedical information prior to renderingan opinion.”

Complaints of ethics code violationsare evaluated by the Professional ConductCommittee through the ProfessionalConduct Program. The program was ini-tiated 25 years ago, and its procedureshave undergone some modifications overtime. The program’s premise is that mem-bership in a professional organizationrequires conduct which meets a high pro-fessional standard.

Professional Conduct: Witness Testimony

Donald O. Quest, MD,

is the 2006–2007

AANS president.

evidence in court, the general qualifica-tions necessary for those who testify, andthe importance of honest testimony. Thisreport states that “expert witnesses shouldavoid inflammatory accusations…andmust not merely offer speculations butrather be able to substantiate claims onthe basis of experience, published re-search, consensus statements or evidence-based guidelines….”

The AMA report also stresses that testi-mony is to be impartial and has a highergoal than that of supporting the claims of

Continued on page 4

When the ProfessionalConduct Program was initi-ated, guidelines for expertwitness testimony weredeveloped to ensure a standard of quality andimpartiality on both sides ofprofessional liability cases.


When the Professional Conduct Pro-gram was initiated, guidelines for expertwitness testimony were developed toensure a standard of quality and impar-tiality on both sides of professional liabil-ity cases. Violation of these guidelinescould be a cause for a member to bring acharge of unprofessional conduct againstanother member.

The AANS bylaws detail the process thatensues when a charge of unprofessionalconduct is brought by one AANS memberagainst another. It is the duty of the AANSProfessional Conduct Committee toaddress complaints on an impartial basis, toconduct hearings where appropriate withdue process protection for all partiesinvolved, and to make unbiased recommen-dations to the AANS Board of Directors.Members of the committee, experiencedand well-respected senior neurosurgeons,are appointed by the AANS president withratification by the Executive Committee.The PCC members devote considerabletime to the program, spending hoursreviewing each case and participating, usu-ally for a full day, in hearings held twiceyearly in conjunction with the AANS andCNS annual meetings.

The committee reviews the submissionsof both the complainant and respondent

and makes a decision as to whether or notunprofessional conduct is apparent. Either ahearing is scheduled or the case is dismissed(and 35 percent of the cases brought beforethe committee are dismissed). The com-plainant and respondent may each havecounsel in attendance at the hearings, andthe proceedings are recorded by a courtreporter. After both sides have made presen-tations, cross-examination has occurred,and the committee’s questions have beenanswered, the committee goes into execu-tive session to determine whether unprofes-sional conduct has been established and, ifso, what penalty is appropriate. If an adverseaction (censure, suspension, or expulsion)is recommended, the respondent has theopportunity to appeal to the AANS Boardof Directors and further to the generalmembership at the annual business meetingif necessary.

To date there have been 80 complaintsfiled and 65 of these have involved expertwitness testimony. Sixty hearings have beenheld, resulting in nine letters of censure, 22suspensions and five expulsions. There havebeen five repeat offenders.

Not surprisingly the AANS ProfessionalConduct Program has gained the attentionof the plaintiff bar. Although the AANSprogram has been challenged in state andfederal courts, thus far it has withstood allchallenges. A federal appeals court judgepraised the program, stating that “this kind

of professional self-regulation furthers,rather than impedes, the cause of justice”and acknowledging that “judges need thehelp of professional associations in screen-ing experts.” A number of other medicalsocieties have used the AANS ProfessionalConduct Program as a model for their own.

The goal of the AANS Professional Con-duct Program in hearing these complaintsis not to discourage members from testify-ing on behalf of either plaintiffs or defen-dants but rather to promote the integrity oftestimony on both sides of the litigationprocess. Medical malpractice occurs, andwhen it results in litigation expert witness-es are necessary to plaintiffs and defendantsso that justice can prevail.

It is essential that AANS members par-ticipate in the judicial process as expertwitnesses, and it is incumbent on everymember who testifies as an expert to befamiliar with the AANS Code of Ethics andRules for Neurosurgical Medical/LegalExpert Opinion Services. Expert testimonymust be informed, objective, impartial,and medically sound. Litigants, juries,judges, and the public should be able torely on that. 3

For Further Information

3 AANS Rules for Neurosurgical

Medical/Legal Expert Opinion

Services, page 37

3 American College of Surgeons,

www.facs.org

3 American Medical Association,

www.ama-assn.org

3 Blackett, WB: AANS testimony rules

rewritten: New rules for neurosurgical med-

ical/legal expert opinion services. AANS

Bulletin 13(1):33, 2005. www.AANS.org,

Article ID 21843

3 Pelton, RM: Professing professional con-

duct: AANS raises the bar for expert testi-

mony. AANS Bulletin 11(1):7–13, 2002.

www.AANS.org, Article ID 9916

P R E S I D E N T ’ S M E S S A G E

Continued from page 3

AANS Professional Conduct Committee

W. Ben Blackett, MD, JD, chair

Russell M. Pelton, JD, parliamentarian

and legal counsel

Ulrich Batzdorf, MD

Martin B. Camins, MD

Steven L. Giannotta, MD

Hal L. Hankinson, MD

Roberto C. Heros, MD

Philip R. Weinstein, MD

The AANS Rules forNeurosurgical Medical/Legal Expert OpinionServices document callsupon the neurosurgeon “to be an impartial educator for attorneys,jurors, and the court….”


3 IOM Issues Three Reports on Emergency Medical Care On June 14 the Institute of Medicine issuedthree reports related to the Future of Emergency Care in the U.S. project. The report of most rele-vance to neurosurgeons, Hospital-Based Emergency Care: At the Breaking Point, explores the chang-ing role of the hospital emergency department and describes the national epidemic of overcrowdedemergency departments and trauma centers. This report offers an assessment of the emergency careworkforce, including specialists who provide on-call emergency and trauma care services. To helpimprove the availability of on-call physicians, the IOM recommends a number of remedies thatinclude improved reimbursement for emergency services, medical liability reform, regionalization ofcertain emergency specialty services, and creation of a new specialty called acute care surgery. TheAANS opposes the establishment of an acute care surgical specialty if these specialists are intendedto perform neurosurgical procedures. The three IOM reports—Hospital-Based Emergency Care: Atthe 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 medicalsystem is the subject of this issue’s cover section, beginning on page 8, and the editor’s PersonalPerspective, page 7.

3 AANS, CNS and ASTRO Define SRS In April the AANS Board of Directors, the Executive Committee ofthe Congress of Neurological Surgeons and the Board of Directors of the American Society forTherapeutic 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 radiationin certain cases to inactivate or eradicate (a) defined target(s) in the head and spine without the needto make an incision. The target is defined by high-resolution stereotactic imaging. To assure qualityof 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, particlebeam accelerators, and multisource Cobalt 60 units. In order to enhance precision, various devicesmay incorporate robotics and real time imaging.

3 AANS and CNS Seek Medicare Payment Policy Change for SRS of Multiple Lesions Beginning withMedicare carrier Noridian Administrative Services, which had issued a proposed Medicare coveragepolicy 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 whena neurosurgeon treats more than one lesion. The AANS and CNS comments to Noridian state thatCurrent Procedural Terminology “code 61793 is valued for treating a single lesion, whether or notthat treatment requires multiple isocenters or multiple sessions. Under CPT and Medicare policy formultiple procedures, code 61793 may be reported multiple times for multiple lesions, using 61793alone for the first lesion and 61793 appended by modifier 59 or modifier 51. This code should notbe reported more than five times for any session. Any additional sessions (up to five) for the samelesion(s) are inclusive of CPT 61793. If any lesion requires multiple isocenters and/or requires morecomplex targeting, then code 61793 should be reported appended by modifier 22.”

Medical Liability Reform Legislation FallsShort in U.S. Senate

On May 8 the U.S.

Senate voted on two

medical liability reform

bills. Both bills failed to

gain the necessary sup-

port to move forward in

the legislative process.

See Washington Update,

page 26.

Send news briefs for

Newsline to

[email protected].

N e w s M e m b e r s T r e n d s L e g i s l a t i o n

N E W S L I N EN E W S L I N E


P E R S O N A L P E R S P E C T I V E W I L L I A M T . C O U L D W E L L , M D

Agood deal of media attention herald-ed the June 14 release of threereports that conclude the Institute ofMedicine’s two-year examination of

the U.S. emergency medical system. Theattendant headlines in newspapers acrossthe country—“Crisis Seen in Nation’s ERCare” (Washington Post), “EmergencyMedical Care Listed in Critical Condition”(USA Today)—may sound hyperbolic, butthe problems identified by the IOM are realand quite sobering.

The reports introduce the public towhat neurosurgeons and others workingwithin the healthcare system day in and dayout know firsthand: Emergency depart-ments are overcrowded, patients presentingin the nation’s ERs often wait long periodsof time before being seen, ambulance diver-sions are increasing, and the system as awhole is highly fragmented and variable.

These problems are at least partiallyrooted in the increasing number of ER vis-its (113.9 million in 2003, compared with90.3 million a decade earlier) at a timewhen the number of facilities with emer-gency departments has been declining, saidthe IOM. Concurrently the uninsured pop-ulation has been increasing, while there hasbeen a decline in federal funding for emer-gency medical services since the early 1980sthat has resulted in haphazard develop-ment of emergency medical systems acrossthe United States.

Further, close to 70 percent of urbanhospitals diverted patients at some pointduring 2004, resulting in transfer orrerouting from an ER that was full orlacked services to one farther away. Majorreasons for diversion included shortagesof available intensive care unit beds andon-call specialists.

At my own institution, an academicmedical center, countless patients withemergent neurosurgical problems have

taken a circuitous route to reach our hospi-tal, in part because the emergency systemfunctions under the premise that optimalneurosurgical care will be provided byother institutions, when in actuality thosefacilities do not always have the resources—

The Case for RegionalizationIOM Report and AANS Survey Point to Proactive Strategy

William T. Couldwell,MD, is editor of the

AANS Bulletin.He is professor and

Joseph J. Yager Chair ofthe Department of

Neurosurgery at theUniversity of UtahSchool of Medicine.

equipment or personnel—to provide suchcare. What this means is that my facilityfunctions as a de facto regional care centerfor neurosurgery; what this means topatients is that they often experience delaysin getting appropriate treatment.

Another perspective, that of a neurosur-geon practicing at a hospital in an Idahocommunity of about 175,000 people, wasdiscussed in the pages of the Winter 2004issue of the Bulletin. That scenario involvedthe neurosurgeon and his partner coveringemergency call 24/7 with one of them oncall every other night. When, citing unsus-tainable negative impact on personal lifeand elective practice, they stopped provid-ing their hospital with emergency coverage,emergent neurosurgical cases from thatarea began to be transported to my facility.

Scenarios such as this one point toproactive regionalization of neurosurgicalemergency care as an idea whose time hascome. Such a plan should not necessarilymean that regional facilities would be aca-demic medical centers, but certainly thatthey would be strategically located, well-equipped and appropriately staffed centerssupported by adequate federal and statefunding as well as by well-coordinated and

swift transport of patients in need of neuro-surgical emergency care. From a neurosur-gical perspective, the development ofcoordinated, regionalized care is the funda-mental change which must occur.

Emergency access to on-call specialists insome regions was noted in the IOM reportas a problem which, the authors admitted,stemmed from the disruptive lifestyle, poorcompensation, and increased liability that isassociated with providing emergency surgi-cal care. As part of a multipronged strategyfor improvement, the report recommendedregionalization of specialty services.

To achieve regionalization, appropriatetriage is necessary. The IOM called foreffective communication and coordinationamong various components of the system,including 911 emergency call and dispatch,ambulances, EMS workers, and hospitalemergency departments. In addition toincreased state and federal funding forfacilities that bear a disproportionateamount of the cost of care for the unin-sured, the report called for methods todetermine the performance of the differentsystem components and for public report-ing. It also included a recommendationthat Congress establish a five-year demon-stration program to fund individual statesin developing a coordinated, regionalizedand accountable system which will be usedto identify “best practices”on which to baselarger scale development.

Based on the AANS 2006 Workforce Sur-vey of ER coverage and related issues, theresults of which are reported in this issue’scover story, neurosurgeons have been pro-viding emergency coverage, though morethan three-quarters of them identified neu-rosurgical emergency call coverage as aproblem in their practice areas. Clearly, weneed to find ways to render the system man-ageable; the regionalization of neurosurgicalcare will be the best solution for both patientcare and for neurosurgery as a specialty.


3 See the cover section, beginning on

page 8.

C8 Vol. 15, No. 2 • 2006 • AANS Bulletin

Bulletin by AANS Executive Committee member James R. Bean,MD, the survey also showed that “some neurosurgeons [were]straining to provide emergency coverage, particularly those in pri-vate practice and in small group settings, and that some patients,particularly trauma victims and children distant from a level 1 trau-ma center, may be at risk for not receiving timely and appropriateneurosurgical emergency care.”

That neurosurgeons were interested in and concerned aboutneurosurgical emergency coverage was demonstrated by the 2004survey’s robust response rate of 32 percent, coupled with the morethan 350 comments offered and the more than half of respondentswho volunteered themselves for follow-up discussion of neurosur-gical emergency care in their areas.

Completing the picture of neurosurgical emergency coverage in theUnited States is the aim of a new survey conducted by the AmericanAssociation of Neurological Surgeons. The AANS 2006 WorkforceSurvey shows that while the overall participation of neurosurgeonsin the nation’s emergency medical system remains strong, there isroom for improvement in neurosurgical call coverage and, morebroadly, in the emergency medical system itself.

The emergency medical system has been the subject of intensescrutiny, most recently by the Institute of Medicine which releasedthree 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-BasedEmergency 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 theFuture 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 GailL. Warden observed that “the system’s capacity is not keeping pacewith the increasing demands being placed on it” and called for “acomprehensive effort to shore up America’s emergency medical careresources and fix problems that can threaten the health and lives ofpeople in the midst of a crisis.”

Inadequate reimbursement, increased liability, and unintendedconsequences of the Emergency Medical Treatment and Labor Act,all cited in the IOM report on hospital-based care as factors con-tributing to inadequate coverage by specialists in the ER, have beenamong organized neurosurgery’s premier concerns in recent years.These issues were also among the threads comprising the complexfabric that characterizes the delivery of emergency neurosurgicalcare, described by Alex Valadka, MD, in the cover story of the Win-ter 2004 Bulletin. Also in that issue, results of the 2004 AANS/CNSNeurosurgical ER and Trauma Services Survey were released.

The 2004 ER survey was clear in its finding that a solid majority,83 percent, of neurosurgeons or their practices were providing full(24/7/365) emergency coverage. However, as summarized in the

COMPLETING THE PICTUREAANS 2006 Workforce Survey Assesses Neurosurgical ER Coverage

MANDA J. SEAVER

“Portion of a Hanging Showing a Figure of a Warrior.” See page 1 for details.


As shown in Figure 4 on page 10, most on-call neurosurgeons,59 percent, practiced in a community hospital setting, while 38 per-cent practiced in an academic medical center and 6 percent selected“other.” As expected, the majority of on-call neurosurgeons prac-ticed at level 1 or level 2 trauma centers, both of which are definedby the American College of Surgeons Committee on Trauma asrequiring neurosurgical coverage. Most on-call neurosurgeons alsocovered call at two or more hospitals (57 percent) with another 43percent covering call at only one facility, and almost all respondents,95 percent, said that some or all of their hospitals require them tocover call. About 57 percent of on-call neurosurgeons took call twoor three days per week, though nearly equal percentages took callmore or less frequently: 22 percent took call four or more days perweek, and 21 percent, one day per week or less.

On-call neurosurgeons worked an average of 70 hours per week,with 56 hours devoted to direct patient care.Administrative work absorbed eight hours perweek, and 6 hours were spent on research oreducation, while four hours were allocated tounspecified “other” tasks.

The majority of survey respondents saidthey provided all types of neurosurgical servic-es. Of the neurosurgeons who took emergencycall, 61 percent covered all neurosurgical serv-ices in 2006, compared with 54 percent who didso in 2004. Additional results are shown inFigure 3 on page 10.

In the 2006 survey, the service coveragequestion also was put to all neurosurgeonsparticipating in the survey, inclusive of thosewho took emergency call and those who didnot. When asked, Have you limited the type ofprocedures performed by your practice, 62

percent affirmed that they had not. The 38 percent who had lim-ited their practices were asked to identify any procedures they hadcompletely eliminated. The greatest number, 57 percent, had elim-inated pediatric cases, while 13 percent had eliminated traumacases, and 11 percent had eliminated cranial cases. Only 5 percenthad eliminated spinal cases, although research by Richard Wohns,MD, published in the Bulletin, indicated that elective spinal casesare the primary source of medical malpractice lawsuits. Another 55percent selected “other” and offered a variety of explanations, fre-quently citing aneurysms, neurovascular cases (a lack of availableinterventionists was noted several times), subarachnoid hemor-rhages, and complex cranial and spinal cases as the types of caseseliminated from practice.

Neurosurgeons Are Participating in the Emergency Care SystemRather than waning, neurosurgeons’ concern regarding appropriate,quality neurosurgical emergency care has intensified. The AANSTask Force on Neurosurgical Care and Physician Workforce Issuescommissioned the 2006 Workforce Survey to help AANS leadershipidentify and quantify problems in neurosurgical emergency cover-age and in other areas of the workforce. Although this survey wasbroader in scope than the 2004 survey, results of a few key questionsregarding emergency neurosurgical care could be compared, thoughsome caveats apply.

The AANS 2006 Workforce Survey was conducted online by Per-ception Solutions, an independent market research company. E-mailinvitations were delivered in January to 2,562 neurosurgeon membersof the AANS. The demographics of survey respondents tracked close-ly with those of AANS members as well as participants in the 2004survey, with the great majority of respondentsranging from 36 to 55 years of age, in privatepractice, and practicing in small groups of twoto five neurosurgeons or medium groups of sixto 20 neurosurgeons.

A total of 770 surveys were completed,resulting in a 30 percent return comparable tothat of the 2004 survey. Results are accurateplus or minus 5 percent or better, meaningthat the same survey conducted 100 timeswould yield the same results 95 times.

The 2006 Workforce Survey reaffirmedthat the vast majority of neurosurgeons aretaking emergency call. As shown in Figure 1above, 94 percent responded affirmatively tothe question, Do you take ER call? It is unclearwhether the increase in neurosurgical emer-gency call coverage of 11 percentage pointsover the 2004 survey result is attributable to broader phrasing of thequestion in the 2006 survey or to some other factor or factors.

The 2006 survey also indicated a 17 percent increase in thenumber of neurosurgeons who receive a stipend for emergency callcoverage: 50 percent in 2006 compared with 33 percent in 2004, asshown in Figure 2 on page 10. The distribution of stipend amountremained fairly constant, with the areas of greatest change reportedin the $1,001 to $1,500 per diem range (8 percent reductionbetween 2004 and 2006) and in the number of neurosurgeons whohave an arrangement for emergency call other than per diem pay-ment (10 percent increase between 2004 and 2006). However, dif-ferences in question design between the 2006 and 2004 surveysmay account for some variation in results.

E PICTUREl ER Coverage

Figure 1. Percentage of Neuro-surgeons Taking Emergency Call

Do you take ER call?

Do you or your practice provide full(24/7/365) emergency neurosurgi-cal call coverage for a hospital?

94%

2006

2004

83%

Percentages are rounded. Sources: 2006 Data,AANS 2006 Workforce Survey; 2004 Data, 2004 AANS/CNS Neurosurgical Emergency andTrauma Services Survey.


Of the scant six percent of neurosurgeons who did not takeemergency call, 48 percent selected as their reason “other,” and thegreat majority of these respondents specified age-related exemptionssuch as recent retirement or senior partner status. Other reasons thisgroup reported for not taking call included insufficient pay foremergency services (17 percent), disruption of routine practiceschedule (15 percent), lifestyle interference (13 percent), malpracticeinsurer’s premium discount for eliminating trauma or other emer-gency services (6 percent), and malpractice insurer’s discontinuanceof coverage for emergency services (2 percent).

Figure 2. Compensation for Neurosurgical On-Call Services

Compensation

Figure 4. Where On-Call Neurosurgeons Are Practicing Figure 5. Age Distribution and Year Expected to Stop Taking Call

Figure 3. Services Covered by On-Call Neurosurgeons

COMPLETING THE PICTURE

Receive a Stipend 50% 33%

More than $3,000 per diem 3% 2%

$2,001–$3,000 per diem 7% 6%

$1,501–$2,000 per diem 7% 8%

$1,001–$1,500 per diem 17% 25%

$751–$1,000 per diem 19% 17%

$501–$750 per diem 7% 11%

$500 or less per diem 13% 17%

Not paid per diem; have another 26%* 16%compensation arrangement

Services Covered

Cover all services 61%

Cranial 48%

Spinal 47%

Trauma 46%

Pediatric 22%

Other 3%

Percentages are rounded. Participants could select more than one response.Source: AANS 2006 Workforce Survey.

*Some respondents commented that they included their arrangements of employment (such as “employed by hospital”) and salary (such as “part of salary package”) in their responses. Percentages are rounded.

Sources: 2006 Data, AANS 2006 Workforce Survey; 2004 Data, 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey

Percentages are rounded. Participants could select more than oneresponse. Source: AANS 2006 Workforce Survey.

*Responses of those not currently taking call may have been included. Percentagesare rounded. Source: AANS 2006 Workforce Survey.

0 10 20 30 40 50 60 70 80

FACILITY TYPE

Academic Medical Center 38%

Community Hospital 59%

Other 6%

AGE DISTRIBUTION

35 or Younger 6%

36–45 37%

46–55 36%

56–65 20%

66 or Older 2%

YEAR NEUROSURGEONS EXPECT TO STOP TAKING EMERGENCY CALL

2010 or Sooner* 22%

2011–2015 18%

2016–2020 19%

2021 or Later 19%

Don't Know* 22%

TRAUMA CENTER DESIGNATION

Level 1 Trauma Center 40%



Other 18%

For neurosurgeons who said they were planning to stop takingcall, the most influential factor was retirement; the great majority ofthose planning to retire said they had intended to do so anyway, butother factors reported were excessive on-call demands and high mal-practice insurance premiums. The second-ranked factor for thoseplanning to discontinue call was lifestyle interference, followed byinsufficient pay for emergency services, disruption of routine prac-tice schedule, and “other”unspecified factors.All of these factors out-ranked the insurer’s elimination of malpractice insurance coveragefor call services or insurance premium reduction in return for elim-

. .

.. .

.

..

.

.

.

..

. ..

.

P E R C E N T

2006 2004


the hospitals for which they cover call. When asked if their grouphad been involved in developing a hospital’s plan for transfer ofpatients, less than half (43 percent) responded affirmatively, and 19percent said there was no transfer plan at any of the hospitals theycover. Only 9 percent of neurosurgeons, a number roughly equiva-lent to the number of survey participants not taking call, said theywould decline to participate in the planning process for handlingoffline events or patient transfers at their hospitals.

What Is the Complete Picture?What is an accurate depiction of neurosurgeons’ participation inthe emergency care system? The 2006 AANS Workforce Surveyclearly shows that by far most neurosurgeons are answering whenthe nation’s ERs call, attending to people in need of neurosurgicalemergency care. But despite evidence that the vast majority of neu-rosurgeons are covering all types of emergency services and aredoing so chiefly in community-based ERs at level 1 or level 2 trau-ma centers, it is just as apparent that neurosurgeons share many ofthe concerns articulated by the IOM and others regarding thefunctioning of the U.S. emergency medical system and the provi-sion of their vital services within it.

Evidence that demonstrates exactly where the problems lie is lessclear. While the survey’s initial findings provide a broad outline ofneurosurgeons’ participation in the emergency medical system,additional analysis of survey data could fill in the detail and bettercomplete the picture. For example, the responses of those who iden-tified call coverage as a problem could be examined for demograph-ic commonalities such as practice type or setting, or for geographiccorrelations such as practice within a state that lacks effective med-ical liability reforms or a coordinated emergency medical system.Conversely, similar additional data analysis for the 24 percent ofrespondents who reported no problem with call coverage in theirareas might lead to identification of specific factors that in turnwould generate strategies or a model that could be applied in otherlocales to alleviate problems with call coverage.

Additional meaningful data optimally would illuminate the pathtoward productive change and aid the many neurosurgeons whowant to improve of the delivery of neurosurgical emergency servic-es to those who need them. 3

Manda J. Seaver is staff editor of the AANS Bulletin.

KEY FINDINGS: AANS 2006 WORKFORCE SURVEY

Neurosurgeons Do:

94% Take Emergency Call

79% Take Emergency Call at Least Twice a Week

61% Cover All Services

50% Receive a Stipend or Have Another Compensation Arrangement for Call Coverage

Neurosurgeons Say:

76% Emergency Call Coverage Is a Problem in Their Geographic Areas

52% Emergency Call System Works in the Best Interest of Patients

52% Emergency Call System Is Effective

65% They Would Participate in Developing a Hospital’s Plan for Transferring Patients or Going Offline

For More Information

3 Seaver MJ: Baseline ER survey explores system’s cracks: 2004

AANS/CNS neurosurgical emergency and trauma services survey.

AANS Bulletin 13(4): 19–24, 2004. www.AANS.org, Article ID 26367

3 Valadka AB: The ER: Who is answering call? In some hospitals,

not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004. www.AANS.org,

Article ID 26358

3 Wohns RN: Liability is rooted in elective spine cases. AANS

Bulletin, 14(2): 18–19, 2005. www.AANS.org, Article ID 37060

ination of trauma or other emergency services. Only 2 percent of allsurvey respondents reported receiving malpractice insurance premi-um reductions for not taking call, but of that small group 71 percentreceived a substantial premium discount of 11 percent or more.

All survey participants also were asked when they expected tostop taking call. As shown in Figure 5, response distribution amongthe selections was fairly equal. The two top-ranking selections,“2010or sooner” and “don’t know,” may include responses of those notcurrently taking call.

Call Coverage, ER System Concern NeurosurgeonsIn addition to providing data that help to complete the picture ofneurosurgeons’ participation in the emergency medical system, the2006 Workforce Survey offered insight into neurosurgeons’ percep-tions of how the system is working. The survey clearly shows thatneurosurgeons think there is plenty of room for improvement in theemergency system and that they are willing to join in the effort.

Fully 76 percent of respondents identified call coverage as a prob-lem in their geographic areas, and most neurosurgeons, 60 percent,disagreed with the statement that the emergency system allows themenough time off call. Of even greater concern are the data that onlyabout half of respondents believe the call system either works in thebest interest of patients (52 percent) or is effective (52 percent).

Less than one fifth of respondents (18 percent) reported thattheir practice group had been involved in development of a hospi-tal’s plan for going “offline,” meaning that ambulances are divertedfrom a hospital’s emergency department, and nearly one third (32percent) reported that a plan for going offline doesn’t exist at any of


As the picture of neurosurgical emergency coverage isbecoming clearer, neurosurgeons and others involvedin the emergency medical system have recognized thatin at least some situations and geographic areas, deliv-ery of neurosurgical emergency care could beimproved.

Measures to improve availability of on-call specialists were pro-posed in Hospital-Based Emergency Care: At the Breaking Point,one of three Institute of Medicine reports released June 14. The IOMspecifically called for the regionalization of certain emergency spe-cialty services; improved reimbursement for emergency services;medical liability reform; and the creation of a new acute care surgeryspecialty. The American Association of Neurological Surgeons,together with the Congress of Neurological Surgeons, offered threeof these recommendations to the IOM in February 2005. The AANSopposes the creation of an acute care surgical specialty, which, as theIOM described, would include neurosurgical and orthopedic proce-dures “that can be safely performed without the direct interventionof these specialists.”

Some of these measures are reflected in A Growing Crisis in

Patient Access to Emergency Surgical Care, a position paper by theAmerican College of Surgeons released June 23. Regarding region-alization, the ACS said it is “achieving some consensus on how toapply the trauma system model so that a blueprint can be developedfor better regionalizing specialty care services that may be requiredin an emergency situation.” The ACS also noted that support forcomprehensive medical liability reform is shared by “all medical andsurgical specialty organizations” and expressed support for broad-based improved reimbursement—reform of the Medicare paymentsystem, for example—rather than specifically for emergency servic-es. The creation of an acute care surgery specialty was not men-tioned in the report.

The AANS’ ongoing advocacy for comprehensive federal medicalliability reform is well documented in the pages of the AANSBulletin, as is the AANS’ position on improved reimbursement foremergency services, which specifies “reasonable compensation” foron-call neurosurgeons. The introduction of an acute care surgeryspecialty and the concept of regionalization as it relates to emer-gency specialty care have only recently been discussed, and theseideas are ripe for exploration.

WHAT WILL IMPROVENEUROSURGICAL EMERGENCYCOVERAGE?

MANDA J. SEAVER


Interview: ACS Medical Director of TraumaPrograms J. Wayne Meredith, MD

In June the AANS Bulletin asked ACS Medical Director of

Trauma Programs J. Wayne Meredith, MD, to comment on the

recent “acute care surgical specialty” discussion and other

issues affecting the delivery of neurosurgical emergency care.

When specifically asked whether the Esposito and Moore arti-

cles represent the position of the college, Dr. Meredith pointed

out that the JACS is a peer-reviewed journal with an editorial

board independent of the college’s leadership so that, as is true

of the AANS Journal of Neurosurgery, publication of an article

does not imply the parent organization’s endorsement unless the

article specifically states otherwise.

In describing the college’s position on acute care surgery, he

exercised caution.

“Right now there is no such thing as an acute care surgery

specialist,” he said. “We do perceive a growing multifactorial

problem with the availability of specialists to perform [neuro-

surgical emergency] care, and we need to find solutions.”

He added that the ACS is not supporting an entity—an acute

care surgeon or general or emergency surgeon—that would

replace a neurosurgeon.

“Not a trauma surgeon in the country wants to do cran-

iotomies,” said Dr. Meredith, who is himself a trauma surgeon as

Acute Care Surgery? Longing for CooperationThat a new surgical specialty was under serious consideration byseveral of surgery’s national organizations was brought to the atten-tion of Bulletin readers in 2004 by Alex Valadka, MD, then chair ofthe AANS/CNS Section on Neurotrauma and Critical Care. Theproposed new breed of specialist, who perhaps would be known asan emergency surgeon or an acute surgeon, would perform non-trauma surgical emergencies as well as some emergent neurosurgi-cal procedures including craniotomies and insertion of intracranialpressure monitors. After noting that neurosurgeons are the mostqualified physicians to help patients with injuries to or disorders ofthe nervous system, Dr. Valadka warned that “as a profession wemust determine whether neurosurgeons will continue to play adominant role in neurosurgical emergencies, or if instead someoneelse will answer when the ER calls.”

In fall 2005 the AANS Task Force on Neurosurgical Care and Physi-cian Workforce Issues was commissioned. By spring 2006 the develop-ment of an acute care surgical specialty again was addressed in theBulletin, this time by 2005–2006 AANS President Fremont Wirth,MD.

Dr.Wirth discussed the “developing crisis in delivery of neurosur-

gical emergency care” as well as the continuing efforts of the AANSto gather information and develop a plan for improving the situation.He acknowledged agreement among leadership that “neurosurgicalcare is best delivered by trained neurosurgical providers,” a positionwhich in April was sanctioned with the Board of Directors’ approvalof the AANS Policy Statement on Patient Safety:

The AANS affirms that patient safety is best achieved when surgical diseases affecting the nervous system are managed by neurological surgeons.

The development of an acute care surgical specialty, at least to theextent that it would expand into emergency neurosurgery, wouldrun contrary to the AANS position on patient safety. Dr. Wirth stat-ed that the “AANS has opposed this expansion for a number of com-pelling reasons, chief among them training and current evidence.”He also noted that “since most trauma surgeons work in level 1 trau-ma centers, additional training in neurosurgery—even if effective—is unlikely to benefit neurosurgical trauma patients because bydefinition neurosurgeons already are available at level 1 trauma cen-

well as the immediate past

chair of the ACS Committee

on Trauma. “But we do

need to know enough to

determine when to call

[a neurosurgeon].”

Overall, Dr. Meredith

expressed a desire for a col-

laborative spirit. “We need to

restore cooperation in the

house of surgery,” he said.

“Let’s figure out what these

patients need and do that.”

In support of this strategy,

he noted that on June 10 the

college approved the addition

of another neurosurgeon to the Committee on Trauma, a move

that he hopes will lead to increased involvement of neurosur-

geons in improving the

delivery of emergency care to patients. He said the committee’s

plan is to advocate for a system will lead to regionalization of

trauma care.

“There are many obstacles—EMTALA, workforce, politics, lia-

bility—and we need to get to the resources and work together,”

he said. “There’s no way to manage without each other.”

Neurosurgeons Serving onthe ACS Committee onTrauma

On June 10, the American College

of Surgeons approved the addition

of another neurosurgeon to serve

on the COT. Neurosurgeons

currently serving are:

P. David Adelson, MD, FACS

James M. Ecklund, MD, FACS

Domenic P. Esposito, MD, FACS

Karen Margaret Johnston, MD, PhD, FACS

John Hugh McVicker, MD, FACS

Shelly Diane Timmons, MD, FACS

Alex B. Valadka, MD, FACS


ters.”He was, however, optimistic following an ACS-organized meet-ing of specialty leaders that consensus could be reached. “Our col-lective goal is to develop an effective, unified message to leadershipin the U.S. Congress that will facilitate a solution to the delivery ofappropriate emergency care to our patients,” he stated.

In the meantime, some trauma surgeons embraced the develop-ment of an acute care surgical specialty, not only as a way to speedcare to patients in the ER, but also as a means for revival of their ownspecialty. Two articles published in the April 2006 Journal of theAmerican College of Surgeons discussed the creation of an acutecare surgical specialty.

Thomas Esposito, MD, and colleagues asserted in “Making theCase for a Paradigm Shift in Trauma Surgery” that the trauma sur-gery specialty is “in the throes of an identity crisis that threatens itsfuture.”Their literature review of the causes and implications of thisidentity crisis includes a table showing the Eastern Association forthe Surgery of Trauma’s proposed major areas for inclusion in corecurriculum and competencies for an acute care surgeon;“basic neu-rosurgical”appears under the heading “cognitive and technical prin-ciples of treating injuries.”

An editorial in the same JACS issue, “Acute Care Surgery: Erarit-jaritjaka,” strongly advocated for the acute care surgery concept. “Wesubmit that the only viable solution to the trauma surgery crisis is torecapture complex elective and emergent operative procedures andextend operative capabilities into other surgical traumadisciplines…and to some extent, orthopedics and neurosurgery,”stat-ed Ernest Moore, MD, and colleagues. Eraritjaritjaka, an Aboriginalexpression that translates to longing for something lost, refers in the

article to what the authors call the “golden age” of trauma surgery inthe 1970s and 1980s, a period characterized by inspiring mentors andabundant opportunity to perform challenging operative procedures.

It was “Eraritjaritjaka” that prompted a response from Dr. Val-adka, Shelly Timmons, MD, and Richard Ellenbogen, MD. Theireditorial, submitted to the JACS in June, challenged the authors’emphasis on “saving the specialty of trauma surgery” and focusedinstead on the provision of “optimal care of neurosurgical patientsin emergency departments.” They presented compelling evidencesupportive of such care being managed by neurosurgeons anddelivered via a regionalized system modeled on the military’s sys-tem of triaged care.

Valadka and colleagues recognized that neurosurgical emergencycare involves a great deal more than trauma and called for “a teamapproach to repair what is broken.” The authors argued that “it is notthe neurosurgeon who needs to be supplanted or the trauma surgeonwho needs to be reinvented [but rather the] emergency care systemwhich needs to be re-engineered!” They further acknowledged that“thoughtful and equitable regionalization and interspecialty cooper-ation are essential in any plan to optimize the individual componentsand overall delivery of emergency care,” and stated that “neurosur-geons…are eager to share in an open and honest dialogue.”

The ACS discussed the acute care surgical specialty in two arti-cles published in the July issue of the ACS Bulletin. Executive Direc-tor Thomas R. Russell, MD, called acute care surgery “one of themore controversial ideas under discussion.” He recognized the needfor thorough training as well as the input of all specialties in thetraining 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 patientsreceive appropriate care by the right person at the right time and inthe right place.”

The second article summarized practical advantages and dis-advantages of the proposed specialty. For example, an “advan-tage” of the acute care surgeon’s expanded role is the increasedattractiveness of the specialty, which is expected to assist with therecruitment and retention of trauma surgeons. How does thisbalance the “disadvantage” of the significant challenge of provid-ing this new specialist with adequate training? Author Gregory S.Cherr, MD, called “learning the subtleties of urgent neurosurgi-cal and orthopedic intervention” a “daunting” task and wondered“how this might be accomplished in a brief fellowship rotation.”Further exploration of the proposed specialty will be offered dur-ing a symposium with “open mic” to be presented at the 2006Clinical Congress in October.

While a longing for cooperation and a desire to care for neuro-surgical emergency patients appear to be the common ground withrespect to the development of an acute care surgical specialty, theconcept of regionalization enjoys comparatively widespread support.

AANS Policy Statement on Patient Safety

(Statement approved by the AANS Board

of Directors on April 22, 2006)

The AANS affirms that patient safety is best achieved when surgical diseasesaffecting the nervous system are managed by neurological surgeons.

This position statement (article ID 38148) and all

AANS position statements are available in the

online Library at www.AANS.org.

WHAT WILL IMPROVE NEUROSURGICAL EMERGENCY COVERAGE


For More Information

3 AANS Position on Improving Access to Emergency Neurosurgical

Services, www.AANS.org, Article ID 9760

3 Cherr GS: Acute care surgery: Enhancing outcomes or fragmenting

care? ACS Bulletin 91(7):40–43, 2006

3 Esposito TJ, Rotondo M, Barie PS, Reilly P, Pasquale MD: Making

the case for a paradigm shift in trauma surgery. J Am Coll Surg

202(4):655–67, 2006

3 A Growing Crisis in Patient Access to Emergency Surgical Care,

www.facs.org/ahp/emergcarecrisis.pdf

3 Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute

care surgery: Eraritjaritjaka. J Am Coll Surg 202(4):698–701, 2006

3 Ratcheson RA: Fast forwarding: The evolution of neurosurgery.

The 2005 presidential address. J Neurosurg 103:585–590, 2005

3 Russell, TR: From my perspective. ACS Bulletin 91(7):4–5, 2006

3 Valadka AB: The ER: Who is answering call? In some hospitals,

not neurosurgeons. AANS Bulletin 13(4): 6–12, 2004.

www.AANS.org, Article ID 26358

3 Wirth FP: The moral of the story: Neurosurgery’s professionals

offer best neurosurgical emergency care. President’s Message.

AANS Bulletin 15(1):3–4, 2006. www.AANS.org, Article ID 38188

Regionalization of Emergency Specialty ServicesRegionalization of emergency specialty services is proposed as asolution to a variety of emergency system ills, among them the avail-ability of on-call specialists. While there is a good deal of consensuson the concept, the details of implementing such a system remain tobe determined, although some models have been proposed.

The IOM report specifically called for “hospitals, physician organ-izations and public health agencies to collaborate to regionalize crit-ical specialty care on-call services.” Directing patients to the nearestfacility with the best resources to handle their needs will improvehealth outcomes, mitigate overcrowding, reduce costs, and ensurespecialty coverage at the regionalized facility, the report stated.

The ACS report advocated building a system of regionalized carebased on the trauma system model. The system not only would alle-viate overcrowded emergency departments, but also “would be par-ticularly appropriate for services provided by specialties withworkforce numbers in the few hundreds or thousands, such as neu-rological and hand surgery.”

Two recent AANS presidents have tackled this topic: Robert A.Ratcheson, MD, in his 2005 Presidential Address, and Fremont P.Wirth, MD, in the last issue of the AANS Bulletin.

Dr. Ratcheson offered several reasons, in addition to improvingon-call availability, for fostering regionalization:

[Regionalization] would necessarily promote the formation ofneurosurgical teams and enhanced teamwork. It should allowresources to be centralized to serve the needs of patients ratherthan the desires of hospitals. It may ameliorate the problem ofphysician fatigue and allow more efficient utilization and greaterdevelopment of subspecialty skills. It can go a long way towardmeeting society’s demands for reasonably rested, well-educated,and up-to-date neurosurgeons who are constantly available, andit can be organized to ease the burden of trauma call, which isexacerbated by the availability of too few individuals coveringmultiple hospitals. It may allow lifestyle considerations to beaddressed in more satisfactory ways and encourage more womento enter neurosurgery. I think this is a change that will be goodfor neurosurgeons, and most importantly, for our patients.

Dr. Wirth observed that “the crisis in emergency care withrespect to neurosurgery has as much to do with distribution of neu-rosurgical trauma care as with a shortage of it.” He noted the manyfactors underlying the problems with delivery of care, some of whichhave been mentioned here—medical liability, lack of reimburse-ment—and some that have not: lack of neurosurgical unit intensivecare beds, lack of appropriate imaging or neurosurgical endovascu-lar capabilities, and lack of adequately trained personnel to assist inthe complex care of neurosurgical patients.

“It is likely that the [AANS Task Force on Neurosurgical Care andPhysician Workforce Issues] will recommend some reorganizationof the system for providing neurosurgical care,” he stated. “Such anapproach has the potential for improving the quality of life for neu-

rosurgical providers as well as enhancing the availability of highquality neurosurgical care for our patients.”

Most recently, Valadka and colleagues offered support of theregionalized emergency care concept as well as two possible models,one based on the U.S. military’s medical system and the other on theemergency system in the Pacific Northwest. They described the mil-itary’s sophisticated and efficient triage system as allowing neurosur-geons to be strategically located in well-equipped facilities andpatients quickly delivered to them, or using telemedicine and telera-diology to provide neurosurgical expertise to those in remote loca-tions. They cited the Pacific Northwest for its “very well-developedemergency system…in which complex patients are rapidly stabilizedat community hospitals and then evacuated as needed to a level 1 orlevel 2 trauma center.”

Valadka and colleagues suggested that “regionalization, a planwhich eliminates redundancy, provides patient safety nets, andlessens competition for limited resources, will ultimately improvequality and safety and also save money…it simply needs to be cham-pioned at a national level by all surgeons.”

Both the proposed specialty of acute care surgery and regional-ization of emergency specialty services are likely to be among thetopics addressed in the recommendations of the AANS Task Forceon Neurosurgical Care and Physician Workforce Issues. 3

Manda J. Seaver is staff editor of the AANS Bulletin.


74th Annual Meeting InitiatesAANS’ Diamond Jubilee Year

BY MANDA J. SEAVER

When the 74th AANS AnnualMeeting officially opened onMonday, April 24, Annual Meet-ing Chair James T. Rutka, MD,announced the expectation thatthe event would be “the mostsuccessful annual meeting in the

history 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 everby this measure, and the grand total of 6,887 atten-dees puts the meeting in contention for top honorswith the year 2000 meeting. The meeting’s successsets the bar high in keeping with great expectationsfor the AANS 75th anniversary, a celebration thatbegan with the 2006 meeting, continues throughoutthe year, and culminates in the 75th Annual Meeting:Celebrating AANS’ Diamond Jubilee, to be held inWashington, 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 aparticularly memorable occasion.

The meeting owes its success in large part to Dr. Rutka and tothe entire planning team, including Mitchel S. Berger, MD, scien-tific program chair, and Timothy B. Mapstone, MD, scientificposters chair; Russell J. Andrews, MD, Nicholas M. Barbaro, MD,Sue Ellen Barbaro, Deborah L. Benzil, MD, Lawrence S. Chin, MD,E. Sander Connolly Jr., MD, Anthony L. D’Ambrosio, MD, JosephA. Hlavin, PA-C, David F. Jimenez, MD, Eric A. Potts, MD, AndreaStrayer, CNRN, Vincent C. Traynelis, MD, and Eve C. Tsai, MD.

This meeting’s 38 practical clinics, 19 general scientific ses-sions, 77 breakfast seminars, 135 oral abstract presentations, morethan 500 poster presentations, and 234 companies exhibiting thelatest neurosurgical technology and products were introduced toa broader audience through media outreach. The AANS not onlypromoted the meeting and the association itself, it also employed

Sweet Success in

a peer-review process to select scientific topics from all acceptedannual meeting oral abstracts for release to the media.

This year’s 13 annual meeting scientific press releases reflecteda wide range of neurosurgical topics, covering, for example, spinalfusion and artificial discs, the use of cortical language mappingbefore glioma surgery, skull protection offered to children by bicy-cle helmets, and deep brain stimulation. The scientific releases aswell as the public interest releases associated with NeurosurgeryAwareness Week, held concurrently with the AANS Annual Meet-ing, generated considerable media attention, with print andbroadcast media reaching an estimated worldwide audience of 636million and counting. Notable online publications covering themeeting included Yahoo!News, USA Today, Reuters, HealthScout,HealthDay, HealthCentral, Excite and Forbes. Major newspapersand magazines included The Wall Street Journal, The ClevelandPlain Dealer, Star Tribune, Indianapolis Star, and Business Week.

San Francisco


CME: A Main AttractionA major attraction of the meeting is the opportunity to earn con-tinuing medical education credit. Meeting registrants could earn20.75 category 1 CME credits, and those attending ticketed edu-cational programs such as breakfast seminars, practical clinics, thePain Section Satellite Symposium and the Japanese AmericanFriendship Symposium, additionally could earn up to 35 category1 CME credits.

While the meeting has concluded, the opportunity to learncontinues. Audio recordings on compact disc cover the plenary,scientific, subspecialty section, and socioeconomic sessions. Titlesof the individual programs recorded are listed on the order formavailable in the AANS Online Marketplace at www.AANS.org. Inaddition, DVD recordings of three programs—Cerebral TraumaState-of-the-Art Treatment, Head Trauma: Current Treatmentsand Controversies, and Minimally Invasive Microendoscopic

Discectomy—offer CME credit and alsoare available in the Online Marketplace.

Memorable MomentsFollowing two days of intensive, hands-onpractical clinics, the Sunday evening open-ing reception marked the ceremonial startof the 74th AANS Annual Meeting in an

event that offered 3,000 guests the opportunity to stroll through thestreets of San Francisco without ever leaving the friendly confines ofthe AANS headquarters hotel. Fisherman’s Wharf, Chinatown, andthe Giants’ stadium were among the attractions. The “sweet spot”anda popular destination was Ghirardelli Square, appropriately locatedon Rich Street (named, as were all these “San Francisco” streets, foran AANS president, in this case 1996–1997 President J. Charles Rich).

Cushing Medal–David G. Kline, MDDr. Kline received theCushing Medal, the high-est honor that isbestowed by the AANS.“Few have given so gen-erously of themselvesover time to the field of

neurosurgery,” said Dr. Wirth in his introduc-tion, in which he recognized Dr. Kline forlaunching a peripheral nerves clinic. Dr.Kline, recounted his experience “renderingcare without electricity, air conditioning or ele-vators” during the evacuation of intensivecare unit patients during the harrowing periodduring and after Hurricane Katrina.

Distinguished Service Award–Lyal G. Leibrock, MD“This afternoon I amhonored and sadbecause the AANS isrecognizing a neurosur-geon posthumouslyafter his protracted bat-

tle with colon cancer,” said Dr. Wirth. Henoted Dr. Leibrock’s many years of serviceand his initiation of the NeurosurgicalLeadership Development Conference. JudiLeibrock, accepting the award on behalf ofher husband, discussed his love of neuro-surgery and said, “This is wonderful, thank you.”

AWARDS AND HONORS

Humanitarian Award–Gene E. Bolles, MD Dr.Bolles was honored inrecognition of his manyprofessional accomplish-ments to the develop-ment of neurosurgeryand for his extensiveefforts in Mexico, Beliz

and Albania. “I am surprised, honored andhumbled to receive this award,” he said. Hedescribed his volunteer work as educationaland extremely rewarding and encouraged“each and every one of you to becomeinvolved in this kind of work.” He said that heand his family were leaving the following weekto volunteer in Iraq. “It’s important to expressto the rest of the world the humanness ofAmericans,” he said.

Robert Florin Award–Douglas Kondziolka, MDDr. Kondziolka receivedthe Florin Award for hispaper “Improving theInformed ConsentProcess for Surgery.” Thepaper demonstrated thata patient's recall of

informed consent information can be improvedwhen a surgeon goes through the form with thepatient followed later by a staff member askingthe same questions of the patient. “Patientscan be well informed, informed consent can bedocumented in an efficient manner, and effortsto improve the informed consent process arevalued by patients,” he said.

Cone Pevehouse Award–Ming-Yuan Tseng, MDDr. Tseng received thePevehouse Award forhis paper “SurvivalAnalysis for 540Patients With PrimarySpinal IntramedullaryGliomas in England and

Wales: A Population-Based Study.” The studyidentified old age, nonependymoma, and highgrade tumors as negative prognostic factorsfor these patients’ survival. Dr. Tseng andcolleagues concluded that results from thispopulation-based study are very helpful forcomparison with other hospital-based studiesand for public health purposes.

Continued on page 18

Judi Leibrock accepts the Distinguished Service

Award from Fremont P. Wirth, MD, in honor of her

late husband, Lyal G. Leibrock, MD.

“Chinatown”


On Monday, two luminaries from different walks of life, VolkerK.H. Sonntag, MD, and George Will, offered tales from their respec-tive experience.As the Rhoton Family Lecturer, Dr. Sonntag discussedthe “Journey of Spinal Neurosurgery in the United States,” a journeythat began in 1905 when Cushing removed an “inoperable” spinallesion. He said that neurosurgical treatment of the entire spinal col-umn began to be emphasized in the 1980s, and tension that arosebetween neurosurgery and orthopedics in 1989 with the approval ofspine fellowship training in orthopedics was not resolved until thespecialties together faced the pedicle screw challenge in the 1990s.Observing that the Journal of Neurosurgery: Spine now is publishedmonthly 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.

Cushing Orator George F.Will delivered an entertaining amalgamof economics, politics,American wit and wisdom, and baseball.“Thisis 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,”he said. He discussed entitlements, “promises we have made to our-selves,”such as Social Security.“Fixing Social Security is easy: Raise theretirement age,” he said. Noting that “medicine is another matter,” hediscussed the growth of medicine from 6 percent of the U.S. grossdomestic product in 1960 to the point at which medical centers nowoften are the largest employers in cities like Cleveland and Houston.

“Prosperity produced by a dynamic economy creates economichypochondria,” he said, a concept which he described as Americansdriving “Lincoln Navigators, barely making it from one gas station toanother, sipping designer water that costs more than a gallon of gaso-line, and talking on their cell phones discussing how arduous life inAmerica has become.”

The business meeting of the AANS and the American Associationof Neurosurgeons concluded the day with the election of 2006–2007AANS leadership: Executive Committee members are Donald O.

Quest, MD, president, Jon H. Robertson, MD, president-elect,Arthur L. Day, MD, vice-president; James T. Rutka, MD, PhD,secretary; James R. Bean, MD, treasurer; and Fremont P. Wirth, MD,past president.

Rounding out the Board of Directors are directors at largeWilliam T. Couldwell, MD, PhD, Robert E. Harbaugh, MD, Christo-pher M. Loftus, MD, Warren R. Selman, MD, Troy M. Tippett, MD;regional directors Jeffrey W. Cozzens, MD, R. Patrick Jacob, MD,Stephen T. Onesti, MD, and Edie E. Zusman, MD; historian EugeneS. Flamm, MD; ex-officio members Rick Abbott, MD, P. David Adel-son, MD, Charles L. Branch Jr., MD, Lawrence S. Chin, MD, Fernan-do G. Diaz, MD, PhD, Andres M. Lozano, MD, Richard K. Osenbach,MD, Setti S. Rengachary, MD, B. Gregory Thompson Jr., MD, andRonald E.Warnick, MD; and liaisons Richard G. Ellenbogen, MD, H.Derek Fewer, MD, and Isabelle M. Germano, MD.

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. Popprelated 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’snew 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,“Thislapel cost a thousand dollars because I’m wearing an AASNPACfounders’ pin, and I hope that as I walk though the hall today I willsee many more.”

Representing the Neurosurgery Research and Education Founda-tion, Dr. Weiss described the NREF’s impressive 25-year track recordof finding ways to fund the research projects of neurosurgeonsthrough donations and through corporate partnerships. “Researchand development, corporate or scientific, is the foundation of the

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

Alioto's on Fisherman's Wharf was among the opening reception attractions on Sundayevening. The event marked the ceremonial start of the 74th AANS Annual Meeting,offering 3,000 guests the opportunity to stroll through the streets of San Franciscowithout ever leaving the friendly confines of the headquarters hotel.

SWEET SUCCESS IN SAN FRANCISCO



future,” he said. Noting that participation in just the Young Neuro-surgeons Committee’s Silent Auction, held in the exhibit hall duringthe meeting, funds one NREF award, he encouraged broader, enthu-siastic support of the NREF.

Presidential Address Fremont P. Wirth, MD, identified five main issues with which neuro-surgery today must contend: (1) education; (2) defining the bound-aries of neurosurgical practice (3) responding to changing demandsof society (4) influencing increase in reimbursement; and (5) med-ical liability reform. He called education the fundamental issue forneurosurgery as well as a primary mission of the AANS, which is bentupon providing “modern, efficient, responsive educational programsfor neurosurgeons.”

Dr. Wirth defined the most recent challenge to the scope of

neurosurgical practice as the possible encroachment of proposedspecialists in acute care surgery. He explained that these specialistswould be expected to perform among their duties emergency neuro-surgical procedures, contrary to the idea that “patients are safestwhen neurosurgeons provide neurosurgical care.” He discussed theresults of the AANS 2006 Workforce Survey, which demonstratedthat most neurosurgeons are providing on-call services.Acknowledg-ing that there may be a better system for providing neurosurgicalemergency care, he said that ideas for improving the delivery of suchcare were being explored.

Dr. Wirth also described organized neurosurgery’s efforts formedical liability reform and other issues on the national agenda asmoving forward in cooperation with colleagues in other specialties.He warned that advocacy efforts such as these can be protracted and

Developing Science

P oster Chair Timothy Mapstone, MD, and

the Scientific Program Committee select-

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

Dandy and His Approaches to the Third

Ventricle Circa 1933”

3 Pain Aneela Darbar, MD, “Efficacy of

Gamma Knife Radiosurgery For Trigeminal

Neuralgia Associated With Multiple Sclerosis”

3 Pediatrics Richard J. Edwards, MD,

“The Development of a Telemetric

Intracranial Pressure Sensor

for Long-term Monitoring of

Intracranial Pressure”

3 Spine and Peripheral Nerves

Denis J. DiAngelo, PhD,

“Biomechanical Comparison of the

Charite and Prodisc-L Lumbar Disc

Prostheses”

3 Stereotactic and Functional Abbas F.

Sadikot, MD, “Probabilistic Maps of

Subthalamic Electrodes in an MRI-Atlas

Integrated Reference Space Correlated with

Clinical Outcome”

3 Trauma and Critical Care Lori Shutter, MD,

“Unhelmeted Motorcyclists—Higher Mortality,

Morbidity and Costs”

3 Tumor Hidenobu Ochiai, MD, “Targeted

Therapy for Glioblastoma Multiforme Neoplastic

Meningitis With Intrathecal Delivery of an

Oncolytic Recombinant Poliovirus”

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

Continued on page 20

2006 International Awardees

During the AANS Annual Meeting in San Francisco, the

following 2006 International Award recipients were

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

Cyst in the North of Iraq.”

The association also announced the first two recipients of the first

AANS International Visiting Surgeons Fellowships. They are Mirsad

Hodzic, MD, of Bosnia and Herzegovina, and Rene Fernando Paz, MD,

of Honduras.

Dr. Hodzic, whose fellowship will be at the University of New York

at Buffalo, is specifically interested in developing new knowledge in

minimally invasive neurosurgery in children.

Dr. Paz will complete his fellowship at the University of Colorado

Health Sciences Center. His research study will involve the

effects of spinal decompression and stabilization, and time of

surgical treatment on patient outcomes.

Additionally, the recipient of the FIENS/Integra Fellowship was

announced at the AANS Annual Meeting. He is Sushil Shilpakur,

MBBS, of Nepal, who is studying neuroendoscopy during his fellow-

ship at the CURE Children’s Hospital of Uganda.

With the exception of the FIENS/Integra Fellowship, these awards

are managed by the AANS International Outreach Committee. All

awards will be offered again in 2007.


that apathy toward continuinginvolvement in these matters isa worthy opponent. “We muststep up to the plate,” he said.“It’s going to take time, effortand money. Individual neuro-surgeons can have an impact.”

On Wednesday, communi-cation, science and politicswere the focus of two lectur-ers. Mark Bernstein, MD, theTheodore Kurze lecturer, hon-ored the raconteur in Dr.Kurze by discussing the im-portance of neurosurgeonsmaking their voices heardmore widely through publica-tion in nonbiomedical venues.Dr. Bernstein noted thatHarvey Cushing, a PulitzerPrize winner, could serve as

inspiration.“Narrative stories reach people,” he said.“It’s never toolate to try.” Hunt-Wilson Lecturer Arnold Kriegstein, MD,reviewed the science and politics currently affecting neural stemcell research. He said that current stem cell research in the Unit-ed States is moving forward at the state level, led by New Jersey,Illinois, Maryland, Connecticut, and California, and that the Uni-

versity of California, San Francisco has planned a stem cell train-ing program.

The Thursday socioeconomic session was highlighted by pointeddiscussion of and audience commentary on the Centers for Medicareand Medicaid Services’ pay-for-performance project. Jeffrey Flick, theCMS administrator for region IX, presented rationale for the programand said that the 262 hospitals already participating in CMS P4P havedemonstrated that “just measuring and publishing improves quality.”He said that the CMS is “looking for your help to make sure we havethis right” and encouraged physicians to participate in the CMS’ P4Pdemonstration program.“I believe that physicians are likely to be paidjust for reporting as early as next year,” he said.

Robert E. Harbaugh, MD, chair of the Quality ImprovementWorkgroup of the AANS/CNS Washington Committee, expressedneurosurgery’s concerns involving establishment of appropriate P4Pmeasurements.“All measures are focused on management of chron-ic disease, so application to surgical patients is a concern,” he said.Acknowledging that there is “widespread, bipartisan support in all ofWashington”for P4P and that the CMS is very committed to the pro-gram as a way to save money, Dr. Harbaugh suggested that neuro-surgery should participate but should develop its own qualitymeasures based on prospectively collected outcomes data.

Presentations by master neurosurgeons Kevin T. Foley, MD, spine;Patrick J. Kelley, MD, tumor; Michael T. Lawton, MD, vascular;Johannes Schramm, MD, epilepsy; and Albert L. Rhoton, MD, cere-brovascular, concluded the meeting. 3Manda J. Seaver is staff editor of the AANS Bulletin.

SWEET SUCCESS IN SAN FRANCISCO


(l–r) Donald O. Quest, MD, Julia Grubb,Peggy Ratcheson, Robert L. Grubb, MD,Ilona Quest, and Robert A. Ratcheson, MD,gather around the street sign honoring Dr. Ratcheson, the 2004–2005 AANS president, at the opening reception.

(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.


The deterioration was traced to one PPO that representedonly 3.5 percent of our business.The insurance companies with which this PPO had contracts actually paid the PPO a percentage ofthe savings from our charges.

In this era of reimbursement cutbacksand rising overhead, it is becomingincreasingly difficult to improve the netincome of a practice. Yet, there is a rela-

tively easy way to accomplish this with a lit-tle research and a willingness to drop one ormore insurance plans. This method is tofind and eliminate the “hidden PPOs.”

A hidden PPO is an insurance companythat discounts your charges without yourconsent. This can happen when insurancecompanies with which you have signedcontracts for a set fee schedule then passthese rates on to other insurance companieswith which they have contractual relation-ships, but you do not. This dubious dis-counting technique has been used at anincreasing rate in recent years.

Untangling Dubious DiscountsThere are at least two ways to discover ifyou are the victim of hidden PPOs.3 Audit EOBs The simplest method is to

audit the explanation of benefits forms thatyou receive from insurance companies—especially the EOBs of those companies thatare paying charges or a percentage ofcharges rather than those remitting basedon contractually set fees. You may find thatyou are not being paid the correct amountand that in many cases you are being paidsignificantly less. Upon contacting theinsurance company (Company B), its rep-resentative may inform you that “we pricedthe bill at the rate you contracted withCompany A, and according to your con-tract, we can apply that rate because of ourcontract with Company A.”

Your practice’s billers, particularly ifthey are rewarded on a days-in-receivablebasis, may not have delved into the under-lying problem; to move the account off thebooks, their interest may be in just postingthe payment and writing off the remainderof the charge to a contractual adjustment.

P R A C T I C E M A N A G E M E N T N I C K G R E E N

age of the savings from our charges.After a one-month failed negotiation

process, our practice decided to drop thisPPO effective Jan. 1, 2004. This was a verydifficult decision to reach within our owngroup. Some physicians were extremelyreluctant to say no to any business and alsodoubted whether we would really see anyincreased reimbursement. As shown in thechart, since that time we have seen ourpayment rates from auto insurers returnnearly to the 85 percent level, increasingour practice’s annual reimbursement bymore than $650,000.

This is not to say that your results willmatch this dramatic outcome. However,finding hidden PPOs may well be the easi-est way to significantly improve practicenet income available today. 3

Nick Green is past president of NERVES, www.nervesadmin.com, and practice administrator for MichiganHead and Spine Institute PC in Southfield, Mich.

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

The solution may be either to hire someoneto do EOB audits (a position that usuallywill pay for itself, especially in large prac-tices), have a supervisor perform theaudits, or contract a consultant.3 Analyze Financial Reports A second way

to find hidden PPOs is to perform analysisthat can help determine the possible extentof underpayment. First run reports thatprovide payments and adjustments forcharge-based payers—auto insurers, forexample. Run these reports for the last threeto five years. For each year, add the paymentsand adjustments. Divide the payments foreach year by the totals for each year calculat-ed previously. You may be able to see trendsof decreasing percentages of payment orabsolute levels of payments.

Once the Problem Is Identified, Take Action For our practice, I run payer-mix reportson cash payments instead of just charges.This method found that the actual paymentpercentages for our auto insurance charge-based payers had dropped from about85 percent of charges to about 55 percentover a five-year period. This deteriorationwas traced to one PPO that representedonly 3.5 percent of our business. The insur-ance companies with which this PPO hadcontracts actually paid the PPO a percent-

Increased Payment Rates from Auto Insurers

56.4%

72.0%

83.8%

A tough decision to drop an insurer in 2003 came afterfinancial reports revealed a decline in the insurer’s pay-ment rate. Since then, the rates have climbed back.

2003 2004 2005Sept YTD

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80

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50

40

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20

10

0

Inspirationsand Epiphanies


I n 1954 I was beginning my third year of med-ical school in Mexico, where I was born, whenI decided it was time to choose a field of spe-

cialization. At that early stage of my career I onlyknew that there were medical and surgical spe-cialties. I decided to embrace a surgical specialty,but which one?

It seemed natural to me to choose the most difficult specialty, butagain, which one? I started to ask around. The overwhelming answerfrom my fellow students, my professors and hospital personnel wasneurosurgery, which in most opinions was not only the most diffi-cult but also the most daring, glamorous and challenging of all med-ical and surgical specialties. Armed with this information, I began toponder other aspects of neurological surgery. For one, there were buta handful of trained neurosurgeons, which meant more work andless competition. For another, if a patient survived an appendecto-my, that was expected and therefore it was not a big deal. But if apatient survived and did well after a craniotomy, that was almost amiracle. Finally, and perhaps least importantly, were financial con-siderations. I learned that the fee for a craniotomy was 10 timeshigher than the fee for an appendectomy.

In 1955 I started an “apprenticeship” with Juan Cardenas, whoreceived his training from Leo M. Davidoff in New York and was thefirst neurosurgeon in Latin America certified by the American Boardof Neurological Surgeons. He was my inspiration. Finally, I started

my residency in neurosurgery at Case Western Reserve University.Finishing my training in 1965, I returned to Mexico and from thenon have had a most enjoyable and quite successful private practice.My advice to a medical student: If you are thinking about neuro-surgery, do it.Javier Verdura Riva Palacio, MD

Oaxtepec, Mexico

I decided to become a neurosurgeon as a firstyear medical student after hearing StephenMahaley at the University of North Carolina

deliver a lecture about third ventricular tumors.He was just great and I couldn’t imagine a moreinteresting career or a more inspiring role model.My decision became firm after watching him doa temporal lobectomy for tumor. During the setup of the case we allwatched 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 parkingplace for his black Porsche.

Dr. Mahaley was as inspirational a figure as I ever saw, and he stim-ulated many young UNC medical students to enter neurosurgery.Phillip S. Dickey, MD

New Haven, Conn.

B ecoming a neurological surgeon was some-thing I never anticipated either during col-lege or medical school. But when I assisted

a neurosurgeon during the third year of my gen-eral surgery residency, my love of the specialtywas immediate.

It was John (Jack) T. Bakody who introducedme to the “queen of the medical specialties,” and Iassisted him frequently in addition to my generalsurgery responsibilities. My application wasaccepted at the University of Michigan, but I wasdrafted and served in Vietnam as C.O. of the 62ndsurgical mobile unit. After service in the army, Iwas able to train with Edgar Kahn and KeasleyWelch and to complete the neurosurgical program at New York Uni-versity under Joseph Ransohoff.

Throughout my training and career, my love affair with the spe-cialty grew. Although I admit that at times the path was difficult, I

WHAT WOULD YOU TITLE YOUR STORY?

Whether standing at neurosurgery’s threshold (Great

Expectations), juggling a thousand responsibilities

at midcareer (Who Moved My Cheese?) or enjoying

the fruits of a long career (Life of [Boswell], or pos-

sibly The Expanding Universe), you have a story to

tell. 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?

During the AANS 75th anniversary year, when neurosurgery’s

origins and organizers will be recognized and remembered,

accounts of inspiration and epiphany by today’s neurosurgeons

are being published in the AANS Bulletin. Send your account

(300-word maximum) by e-mail to [email protected]. You will

receive an automatic confirmation of receipt, and you will be

contacted if your item is selected for publication in an upcoming

issue of the Bulletin.

Leo M. Davidoff, MD

Stephen Maheley, MD

Edgar Kahn, MD

Keasley Welch, MD

d Epiphanies


have no regrets. There is for me no other specialty in medicine thatcompares to neurological surgery for its challenges, rigorous intel-lectual honest analysis, consummate operative skill and compas-sionate care of patients. I cherish the moments with the programdirectors and residents, and the professional camaraderie and satis-faction of being a team leader able to successfully improve the qual-ity of life of patients.

Severe, disabling health problems abruptly precluded my con-tinuation of this beautiful and demanding specialty. Despite this,I love neurological surgery and the privileged, marvelous andunique opportunity to glimpse in wonder at the inner man, as cre-ated by the Higher Being.Michel W. Andre Kildare, MD, FACSMarysville, Calif.

I was 17 years old and in medical school.I’ll never forget the excitement I experi-enced when I saw it for the first time: the

human brain! The 1,500 grams of soft tis-sue is what imparts Homo sapiens theirunique essence and distinguishes themfrom every other animal on the planet. Abillion neurons, spreading their dendritesand axons throughout the body, create con-sciousness and contemplation and areresponsible for the birth of civilization thatgave us the Roman coliseum, Mona Lisa, TajMahal, Darwin’s theory of evolution and aplethora of religions and philosophies. Somuch function of the body is controlled byso small a mass, intricate, complex andhighly organized.

I was drawn by its aura of mystery andwonder. I knew then that I wanted to dealwith this incredible structure that requireshandling with utmost reverence, patience, unwavering hand, thor-ough knowledge, and a penchant for meticulous detail—all necessaryattributes for a brain surgeon. I decided to take up the challenge.

Thirty years later my excitement upon first seeing the brain,instead of waning, is magnified because I look at and operate onbrains that are alive, pulsating synchronously with the heartbeat.Any mishap could result in the patient’s devastating debilitation ordeath, which explains one’s healthy apprehension while perform-ing delicate brain surgery. But the rewards of emotional and pro-fessional satisfaction when an aneurysm is successfully clipped or

a life is brought back from the doorstep of death via timely evac-uation of an epidural hematoma are extremely fulfilling. So is alle-viating the pain and suffering of patients from pinched nerves andimproving their quality of life.Vivekanand Palavali, MDFlint, Mich.

W hat initially drew me to neurosurgery was the notion thatas a doctor and surgeon one would be dealing directlywith the brain, which I thought was a very privileged

position to be in. I was also attracted to the complex organizationof the nervous system, which unlike many other body systems,allows precise localization of the lesion from a history and physi-cal examination. Finally, I was attracted to the technical challenge

of brain surgery.Neurological surgery is a challenging and

demanding specialty by many criteria: hoursexpended, physical stamina required, andemotional toll exacted. Neurosurgeons haveto balance their jobs with the other impor-tant areas of their lives: family, physical fit-ness, friends, and spirituality. Furthermore,there are very few opportunities for “mid-course” career corrections once one hasbecome fully engaged in neurosurgical prac-tice. Neurosurgery’s tradition as a disciplinewhose practitioners are intellectually restlessand rarely satisfied with old maxims or cur-rent statistics holds true to the present time.

For all its difficulties, when done wellneurological surgery gives one a great senseof personal satisfaction and also is capable ofmaking great differences in the lives of ourpatients. It is undergoing fascinating changesin the way we treat patients, largely due to

new technologies. We are currently undergoing radical subspecial-ization, with pediatric, spinal and functional neurosurgery being themost obvious and well-developed examples.

All neurosurgeons have to balance decisiveness and assertivenesswith approachability and excellent patient communication skills.Aspiring neurosurgeons should be self-motivated, ambitious, obses-sive for detail and deeply analytical. They should be willing to learnand able to perform well under pressure and handle stress.Sanjay Mongia, MDMumbai, India


R E S I D E N T S ’ F O R U M L A W R E N C E S . C H I N , M D

Cost per RVU (that’s relative valueunit) can be determined by dividingtotal practice expenses by totalRVUs, yielding a number that can

be compared annually as an indicator of apractice’s performance. If you didn’t knowthat, you are not alone. Neurosurgicalresidency programs do a great job ofteaching how to diagnose and operate, butthey typically do a poor job of preparingresidents for the practical aspects ofmanaging a neurosurgical practice, whichin reality is a small business. This articleoffers some basics of practice managementfor the new-to-practice neurosurgeon,with focus on four primary areas: com-pliance, billing, office management, andpatient relations.

With the passage of the Health Insur-ance Portability and Accountability Act,ensuring compliance is one of the mostimportant functions of an office manager.In addition to HIPAA, there are federal,state, and local regulations regarding theflow of information between patients anddoctors, doctors and doctors, and doctorsand the insurance carriers (including gov-ernment payers). Medicare regulationsgenerally are followed by most insuranceplans, but specifics for a particular regioncan be found by accessing the Web site ofthe regional Medicare intermediary. Forexample, Trailblazers is the intermediaryresponsible for handling all Medicareclaims in Baltimore.

The most visible aspect of HIPAA in anoffice setting relates to patient privacy. Ingeneral, relating more than one uniquepiece of identifying information should beavoided. For example, patients may beidentified by name, but not also with theirdoctor’s name or diagnosis. Release ofpatient information is allowed to referringphysicians only; all others must havepatient consent. Use of patient informa-

one person, but a dissatisfied patient tells13 people.” Find out what the patientsthink; send out surveys, and make sure thatthe practice’s phones are answered by a liveperson. Listen to patients’ concerns andrespond to them quickly.

Probably the best advice is to avoidmicromanaging the practice. Let the prac-tice manager handle the details, but knowwhat he or she is doing because ultimatelythe neurosurgeon is responsible.

Resources for the Real WorldIn acknowledgement of the complex prac-tice environment faced by today’s neuro-surgical residents, resources that betterprepare residents for the transition areunder development. At least one trainingprogram, the Medical College of Georgiain Augusta, requires a Web-based coursethat acquaints its residents with basics ofpractice management. The AANS recent-ly offered the course Neurosurgery in theReal World, which covered coding andreimbursement, government regulations,contract negotiations, practice develop-ment and professional liability. In addi-tion, print resources such as Starting aMedical Practice and Managing the Med-ical Practice are available from the AANSOnline Marketplace, www.AANS.org.

Perhaps the greatest resource for neuro-surgeons entering practice is the AANSYoung Neurosurgeons Committee. TheYNC provides information at www.AANS.org > Young Neurosurgeons and developsprograms like the Real World course thatrespond to the needs of early career neuro-surgeons while opening the door toinvolvement in the AANS. 3

Lawrence S. Chin, MD, is chair of the Department ofNeurosurgery at Boston University School ofMedicine and chair of the AANS YoungNeurosurgeons Committee. Gloria Jones, office man-ager at University of Maryland NeurosurgicalAssociates, contributed to this article.

tion for research must also be approved;one strategy is to have patients sign a con-sent form at initial consultation thatallows their information to be used forresearch purposes.

Knowing how to code a surgical proce-dure properly is important for every neuro-surgeon because even when someone elsehandles coding, the neurosurgeon isresponsible for the accuracy of submittedbills. All residents should attend a billingcourse such as those offered by the AANSbefore starting practice. The most commonCurrent Procedural Terminology codes,which describe the operation, and ICD-9codes, which provide the diagnosis or thesymptoms, should be learned. Medicarepublishes quarterly updates that detailwhich codes may be added on (for morereimbursement) and when “unbundling”—breaking down a procedure into smallerparts for greater reimbursement—is disal-lowed.An average practice of five neurosur-geons performing 1,400 cases and seeingpatients in 6,000 office visits per year willneed two coders and two collectors. At leastone of the coders should be certified, aprocess that requires at least two years’experience and annual recertification.

A medium-to-large practice will need apractice manager. A bachelor’s degree is aminimum requirement, and often this per-son will have an MBA or other master’sdegree, or other appropriate credentialssuch as a CPA. A practice manager’sresponsibilities include hiring and evaluat-ing staff, promotions, preparing the budg-et and payroll, cash management, andmaintaining supplies. The practice manag-er as well as coders and collectors should beincluded in a practice’s incentive programto reward them for going the extra mile.

Patient satisfaction is the ultimate goalof a neurosurgical practice. An office man-agement axiom is “A happy patient tells

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

The Fight to Pass Reform—By the Numbers

65 million The number of people who have heard DMLR’s message on the radio.

150,000 The number of people who have joined DMLR’s grassroots network.

40,000 The number of individuals who have signed DMLR’s petition for reform.

15,000 The number of letters that have been sent to Congress.

800 The number of physicians who have requested DMLR’s patient outreach materials.


Aminority of U.S. senators used pro-cedural devices to prevent two med-ical liability reform bills fromreaching the Senate floor for an up

or down vote on May 8.First, the Medical Care Access Protection

Act of 2006, S. 22, was effectively blockedwhen its supporters were unable to gain thenecessary 60 votes to break a Democrat-ledfilibuster. The MCAP is modeled afterrecent Texas reform legislation and includes,among other things, a $250,000 cap onnoneconomic damages against physicians,limits on attorneys’ fees, and expert witnessreforms. The motion to proceed (requiredbefore action on the underlying bill could beconsidered) on S. 22 was defeated by a voteof 48 to 42.All Democrats who voted, joinedby three Republicans, opposed the measure.Regrettably, 10 senators were not present,among them four senators who had previ-ously supported reform legislation.

Immediately following the first vote, theSenate considered a motion to proceed todebate the Healthy Mothers and HealthyBabies Access to Care Act, S. 23, which

W A S H I N G T O N U P D A T E

Tort Reform Falls Short in SenateDMLR Campaign Presses Forward

K A T I E O . O R R I C O , J D

applies the same reform provisions as S. 22,but for obstetrics and gynecological servicesonly. This motion also failed, but by a voteof 49 to 44 with seven not present. Of thethree additional senators voting, one was aRepublican and two were Democrats.

Despite the Senate filibuster, some inCongress have vowed to continue the fightin support of comprehensive medical liabil-ity reform legislation. The talk on CapitolHill is that the House of Representativesmay take up this issue again sometime thissummer and the Senate may revisit medicalliability reform before the November cam-paign season gets into full swing. Organizedneurosurgery, through its participation inDoctors for Medical Liability Reform, willcontinue to press Congress for action.

DMLR Campaign Builds Momentum for Tort ReformDMLR’s Protect Patients Now national cam-paign for medical liability reform continuesto build impressive momentum. Using cre-ative animations, Web advertisements, andradio and print media, DMLR is building its

activist database and grassroots network. Asof early June, DMLR has reached approxi-mately 65 million listeners through several“radio tours” held since the campaign rede-ployed last October. Neurosurgeons TroyTippett, MD, from Pensacola, Fla., and JohnCaruso, MD, from Hagerstown, Md., partic-ipated in these radio interview programs.DMLR has collected more than 40,000 sig-natures for its petition drive, and more than15,000 letters have been sent to Congress(over 5,000 in the week immediately beforethe Senate vote). The grassroots network isnearly 150,000 strong, and it continues toexpand every day.

In light of the recent unsuccessful votesin the U.S. Senate, DMLR is redoubling itsgrassroots outreach efforts and is workinghard to recruit more patients to join thecampaign to stop medical lawsuit abuse.The success of the program depends onneurosurgeons helping to spread the wordabout the medical liability crisis andDMLR’s Protect Patients Now campaign. Itis vital that neurosurgeons stay the courseand stay involved in the DMLR campaign.

Members of the U.S. Senate need to hearfrom patients as well as doctors on thisvitally important health care issue. One easyway to help is by introducing patients tomedical liability reform issues and solutionsthrough the DMLR’s Patient Outreach Kit.The kit includes:

3 a packet of informational brochuresthat have a tear-off portion allowingpatients to sign and mail a petition in support of reform;

3 a poster, which dramatically illustratesthe crisis;

3 a pad of tear-off postcards that areattached to the poster and can be filledin and mailed back to DMLR; and

3 wearable “Stop Medical Lawsuit Abuse” buttons.


abuse. DMLR also will continue to keepneurosurgeons informed and involvedthrough regular e-mail messages. In addi-tion, neurosurgeons are encouraged towatch for new information and campaignupdates on the Protect Patients Now Website, www.protectpatientsnow.org. Remem-ber, this is a marathon, not a sprint, and allneurosurgeons must get involved and

continue to stay involved until we succeedat passing reform legislation. 3

Katie O. Orrico, JD, is director of the AANS/CNSWashington Office, (202) 628-2072, [email protected].


3 How They Voted: S. 22, Medical

Care Access Protection Act of 2006,

and S. 23 Healthy Mothers and Healthy

Babies Access to Care Act,

www.senate.gov > Votes >

Roll Call Tables 2006 (109th, 2nd) >

Votes 00115 and 00116

3 DMLR’s Patient Outreach Kit, www.pro

tectpatientsnow.org > Physicians >

Patient Outreach Kit

3 Texas Teaches That Tort Reform

Works, page 34

The talk on Capitol Hill is that the House ofRepresentatives may take up this issue again sometime this summer and the Senate may revisit medical liability reform before the November campaignseason gets into full swing.

These materials are free of charge andwill be shipped directly to your office oncethe order is placed. Neurosurgeons are en-couraged to get an outreach kit and helpspread the word about the crisis and ourcampaign for reform.

With your help, DMLR will continue tobuild its grassroots network, educatepatients, and put a stop to medical lawsuit


C O D I N G C O R N E R G R E G O R Y J . P R Z Y B Y L S K I , M D

The increase in spinal fusion proce-dures during the past decade hasdrawn scrutiny from the Centers forMedicare and Medicaid Services and

third party payers, resulting in coveragelimitations for some of these procedures.Recent CMS coverage decisions for estab-lished, concurrent spinal procedures will beexamined in this Coding Corner.

Coding for Decompression andArthrodesis for SpondylolisthesisA common procedure for lumbar spondy-lolisthesis involves decompression of thenerve roots and a lumbar arthrodesis. Avariety of procedures exist for decompres-sion including laminectomy for lateralrecess stenosis (63047) or for Gill fragmentremoval (63012), and discectomy for pos-terolateral herniation (63030), for far later-al disc herniation (63056), or forre-exploration of a disc herniation (63042).

Several years ago, the Current Procedur-al Terminology Editorial Panel approved aneditorial change to posterior lumbar inter-body arthrodesis (22630) that includeslaminectomy and discectomy work otherthan that needed for decompression. How-ever, the National Correct Coding Initiativeof the CMS excluded coding of 22630 con-currently with the decompression codesunder ordinary circumstances.

The vignette describing posterior lumbarinterbody arthrodesis identifies a patientwith mechanical back pain after prior dis-cectomy and failed posterolateral fusionwho undergoes a laminectomy, discectomyand interbody arthrodesis. Since thedescribed patient does not have radiculopa-thy, a decompression above and beyondwhat is required to perform the posteriorinterbody fusion is not included in thevignette. However, the vignette doesdescribe mobilization of nerve roots anddural sac as well as dissection of scar tissue

necessary to perform the fusion. It may bedifficult when coding to differentiate theincidental decompression that occurs dur-ing the laminectomy and discectomyapproach for the interbody fusion from theadditional decompression that may be war-ranted because of neurological symptomsfrom compressive lesions. Correct codingfor interbody fusion is further complicatedwhen a unilateral approach using a trans-foraminal technique is performed becausecode 22630 describes a bilateral procedure.In either instance, if a decompression proce-dure is performed beyond what is requiredfor the interbody exposure, then the decom-pression should be appended with the –59modifier (unusual procedural services) toacknowledge this as separately identifiableadditional work, and it is critical for the neu-rosurgeon to document the separate loca-tion of compression that is being treated.

Another recent limitation imposed bythe CMS is for concurrent performance ofa posterior arthrodesis and a posterior lum-bar interbody fusion. The authors of thelumbar fusion guidelines, published in June2005, concluded that complications andcosts were higher and without an observedbenefit when a posterior fusion is per-formed in addition to an interbody fusion.This year, CMS payment policy precludespayment for a posterior fusion when aninterbody fusion is performed. The varioussurgical societies representing spinal sur-gery are reviewing the guidelines and theirimplications before preparing a response tothe CMS decision.

Coding for Revision Spinal SurgeryAdditional difficulties in proper coding areencountered when revision spinal surgeryis performed. For example, a revision of aprior fusion may include procedures suchas exploration of a fusion (22830), removal(22852), reinsertion (22849), or placement

of spinal instrumentation (22840-22844),and performance of a fusion at the same oradjacent levels (22612, 22614, 22630,22632). The CMS has used National Cor-rect Coding Initiative edits for years to pre-clude payment for an exploration of fusionwith arthrodesis, despite introductory lan-guage in CPT that specifically identifiesarthrodesis and instrumentation as sepa-rate physician work. Although an explo-ration of fusion and arthrodesis at thesame level should be considered inclusive,arthrodesis at adjacent levels is separatelyidentifiable and the arthrodesis codeshould be appended with the –59 modifi-er. If spinal instrumentation is removedand replaced at the same levels, only code22849 should be used, rather than aremoval code and an insertion code.

When spinal instrumentation is re-moved and then replaced with instrumen-tation extended to additional levels, onemust balance the lesser work of replacingfixation in sites that have been preparedpreviously with the new work of exposingand placing fixation at new levels. Aninsertion code that describes the entirespan of instrumentation (both revised andnew) would reflect the physician workunder most circumstances because thework of removal and replacement at anindividual level is similar to work of prepa-ration and insertion at a new level. Theneurosurgeon should be aware that theremoval and reinsertion of instrumenta-tion codes are 90-day global codes towhich the multiple procedure modifier–51 applies, whereas the insertion codesare ZZZ global codes and are not subject toa 50 percent payment reduction whenused with other stand-alone codes.

The area of spinal coding and reim-bursement is frequently changing. There-fore, it behooves neurosurgeons to keepabreast of these changes annually. 3

Gregory J. Przybylski, MD, is professor and director ofneurosurgery at JFK Medical Center in Edison, N.J. Heis chair of the AANS/CNS Coding and ReimbursementCommittee and a member of the CMS PracticingPhysicians Advisory Council, and he chairs andinstructs coding courses for the AANS and the NorthAmerican Spine Society.

Concurrent Spinal ProceduresCoding Frequently Changes for Established Procedures, Too


After neurosurgeon Steve Catheyinvested in the Arkansas SurgicalHospital—a private, for-profit 16-bed specialty hospital designed for

orthopedic and neurosurgical spine care—his wife, gynecologist Janet Cathey, wasthreatened with revocation of privileges atBaptist Health Hospital in Little Rock.According to American Medical News, thisaction was possible because Baptist HealthSystem’s board had “adopted a policy thatmandates denial of initial or renewed staffprivileges to any practitioner who, directlyor indirectly, acquires or holds an owner-ship or investment interest in a competinghospital” and had extended the restrictionto the immediate family members of any-one who invested in a competing hospital.

Such economic-based criteria, however,are not among the goals for medical staffcredentialing and privileging as defined bythe Joint Commission on Accreditation ofHealthcare Organizations. Instead, theJCAHO goals center on quality patient careand safety and specifically state that thepurpose of medical staff credentialing andprivileging is to determine competency ofphysicians, assess physical and mental abil-ity of physicians to discharge patient careresponsibilities and perform ongoingassessment of the safety and quality of careprovided by physicians.

JCAHO further asserts that the credi-bility of the credentialing process requirescooperation between the hospital govern-ing body and medical staff through itsappointed designees. The medical staffleadership designees make recommenda-tions to the hospital governing bodyregarding a physician’s appropriateness forcredentials and privileges. The hospitalgoverning body must act on these recom-mendations and report back to the med-ical staff regarding its decisions and theunderlying rationale.

P A T I E N T S A F E T Y P A T R I C K W . M C C O R M I C K , M D

Thus, hospital credentialing and privileg-ing are a medical staff function. As such,physicians who participate in this processare guided by the American Medical Associ-ation Code of Medical Ethics, Opinion 4.07:

The mutual objective of both the gov-erning board and the medical staff isto improve the quality and efficiencyof patient care in the hospital. Deci-sions regarding hospital privilegesshould be based upon the training,experience, and demonstrated com-petence of candidates, taking intoconsideration the availability of facili-ties and the overall medical needs ofthe community, the hospital, andespecially patients.... Physicians whoare involved in the granting, denying,or termination of hospital privilegeshave an ethical responsibility to beguided primarily by concern for thewelfare and best interests of patientsin discharging this responsibility.

The inclusion of this opinion in the Codeof Medical Ethics underscores the integralrole credentialing fulfills in the professionalsocial contract to ensure patient access toappropriate, safe and quality care. The AMA,as it notes in a recently adopted Council onMedical Service report, additionally has sev-eral existing policies that oppose loss orrestriction of privileges based solely on eco-nomic factors.

Despite the alignment of the JCAHOgoals with the professional medical code ofconduct as well as AMA policies opposingeconomic credentialing, the legal system hasallowed healthcare delivery organizations touse credentialing to address market con-cerns over patient interests.

Some hospitals have adopted policies tolimit or effectively prohibit perceived com-petitive behavior by credentialed physi-cians. Targeted physician behaviors includefailing to sign loyalty oaths, perform adefined percentage of procedures at a hos-pital, or admit a specific percentage of theirpatients to a hospital; referring patients outof an integrated system; accepting staffprivileges or leadership positions at a com-peting hospital; and having financial in-terest in a competing healthcare deliveryentity. These “competitive behaviors” haveresulted in denial or revocation of physi-cian hospital privileges.

Legal Challenges to EconomicCredentialingHospital policies involving economic cre-dentialing have been met by legal chal-lenges on several grounds.

In Mahan v. Avera St. Luke’s, the SouthDakota Supreme Court stressed that the“continued economic viability of the hos-pital” is sufficient reason to deny privi-leges to physician applicants, and thatsuch denials may be based on “any rea-sonable basis,” including “the commongood of the public and the hospital.” Thisdecision allows the credentialing processfor physician hospital privileges to beused to erect barriers to competition,impeding function of competitive marketforces and raising anticompetitive behav-ior concerns. Challenges to such behaviorunder Section 1 of the Sherman Act onbalance have failed to prevail because it isdifficult to demonstrate a conspiracy. This

Whom Does Credentialing Protect?Medical Professionalism Meets Hospital Board Protectionism

Patrick W.McCormick, MD,

FACS, MBA,is a partner in

Neurosurgical NetworkInc., Toledo, Ohio.


is due in part to the prevailing judicialphilosophy that the stakeholders in thehospital credentialing process (that is, themedical staff and hospital governance)are a single entity.

Claims of willful acquisition or mainte-nance of monopoly power under Section 2of the Sherman Act also have been unsuc-cessful in providing relief to physicianplaintiffs. Such claims have been complicat-ed by the fact that exclusion of physiciansfrom a medical staff via the credentialingprocess could diminish rather than enhancehospital revenues. The impact of corollaryclaims of intimidation and adhesion con-tracting to control market competition isyet to be vetted in the judicial process.

The courts have been less permissivewhen hospital privileges are denied basedon claims of conflict of interest, such asstaff privileges at competing organizations,ownership in competing entities, or failureto attain admission or procedure volumes.In Potters Medical Center v. City HospitalAssociation, the court found that restrict-ing a physician’s ability to practice at com-peting facilities for reasons of conflict ofinterest may constitute monopolization. InMiller v. Indiana Hospital, the court foundthat hospital privileges were unreasonablyterminated when a surgeon opened a com-peting healthcare delivery facility.

A common defense theme for hospitalswhen accused by physicians of anticom-petitive behavior based on conflict-of-interest rationale for denial or revocationof privileges is that of “cherry picking”patients for the physician-owned facilityto the detriment of the hospital. In BlueCross v. Kitsap Physician Service, thecourt substantially weakened this claimwhen it found that financial interests are afundamental motivation in a free marketand necessary for rational healthcaredelivery in such a market.

In addition to insulating hospitals fromcompetitive market forces, the courts havesupported credentialing for physician hos-pital privileges as a mechanism to protectand enhance hospital revenues. In these

instances, the economic impact of physi-cian admissions, treatment plans, and pro-cedure performance is seen as a sufficientbasis to deny or revoke hospital privileges,and the courts have upheld such decisions.In general, economic criteria used to adju-dicate credentialing must be explicitlycharacterized in the organization’s bylaws.The bulk of legal arguments have centeredon contract law, and in general, the courtshave deferred to “reasonable” managementdiscretion for hospital governance.

Public policy law also has helped shapethe legal debate regarding the appropriatedenial of hospital privileges to physicians.A hospital’s nonprofit status is statutorilydefined in the Internal Revenue ServiceRuling 69.545. This rule outlines the nec-essary preconditions for a hospital to claimnonprofit status and explicitly requiressuch a hospital to maintain a medical staffthat is open to all qualified physicians. Inthe event of an investigation, the burden ofproof falls to the hospital to demonstratethat the underlying purpose of the restric-tive credentialing policies and decisions isbeneficial to the community and consis-tent with a nonprofit mission. Because it isdifficult for a hospital to develop substan-tive, demonstrable arguments for commu-nity benefit that override a statutoryobligation to credential all qualified physi-cians, physician challenges to the nonprof-it status of hospital organizations are themost effective approach to challengingcredentialing policies.

However, the courts have been sym-pathetic to hospital boards that cite a fidu-ciary rationale to place organizational,

economic considerations above patientinterests. This is due in part to a commonbut questionable judicial philosophy thatfor-profit governance principles are appro-priate in the nonprofit sector. Broad man-agement discretion under the businessjudgment rule may well be inappropriate inthe nonprofit sector because of lack of pub-lic reporting, transparency of decisionmaking, and public accountability.

Overall, the courts have supported theuse of credentialing to shield hospitalsfrom market competition and protectestablished revenue. The impact of thelegal system has been to place patientquality and safety as a necessary but insuf-ficient basis for physician hospital privi-leges in opposition to the professionalethical code which guides physicians whoare willing to represent the medical staff inthe credentialing process.

Credentialing Should Protect PatientsThe divergence of professional ethicalopinion and the legal adjudication of hos-pital credentialing for physician privilegescalls for physicians involved in the medicalstaff credentialing process to effect change.

Physicians should advocate for a hospi-tal credentialing process that establishesprivileges based on patient interests and inaccordance with the Code of MedicalEthics, which clearly places patient interestsabove market and financial considerations.Perhaps this is best accomplished by physi-cian advocacy for public access to the hos-pital institutional bylaws and medical staffbylaws. Physicians further can supportrevisions to these documents as necessaryto maintain credentialing on the basis ofphysician competency and quality. Modelmedical staff bylaws to accomplish thesegoals are available through the AMA.

These physician actions would restorecredentialing to its proper position as asafeguard to society for accessible andexcellent healthcare rather than a mecha-nism that shields hospitals from competi-tive market forces. 3

Physicians should advocate for a hospitalcredentialing process thatestablishes privilegesbased on patient interests.


T I M E L I N E :Is It Really Brain Surgery?

MICHAEL SCHULDER, MD

Is it only neurosurgeons who can per-form neurosurgical procedures? If thereare places where patients suffer delayedtreatment because of the need to trans-

fer them to a medical facility with neuro-surgical coverage, might not the answer beto train a new cadre of “generalist” traumaor “acute care” surgeons?

It may be useful to consider these ques-tions in light of the environment that gaverise to neurosurgery as a specialty. GilbertHorrax described this period in his bookNeurosurgery: An Historical Sketch. In theearly years of the 20th century, general sur-geons “unfamiliar as yet with any specialknowledge of how to handle brain tissue,were attempting at infrequent intervals todo something to which they were entirelyunaccustomed.”It became apparent that “toattain the desired end someone would haveto devote his entire time to working out anew technic [sic] for operations upon thecentral nervous system.”

Horrax proceeded to document HarveyCushing’s thoughts on the subject in 1905:

…many of [his colleagues in surgery]have expressed themselves emphati-cally against any form of operativespecialization…I do not see how suchparticularization can be avoided if wewish more surely and progressively toadvance our manipulative therapy.Are practice of hand and concentra-tion of thought to go for nothing?

Wartime brought a new urgency to thequestion of who should perform neurolog-ical surgery. In his memoir Fifty Years ofNeurosurgery, Ernest Sachs Sr. describedthe situation as the United States enteredWorld War I. Cushing was already inEurope in 1917 when nearly every otherAmerican neurosurgeon was summonedto Washington. The U.S. Army planned tocreate 100 hospitals and wanted a neuro-surgeon in each one. When informed thatthere were not 100 neurosurgeons in the

N e u r o s u r g e r y T h r o u g h H i s t o r y

world (remember, this was a specialty thatwas 12 years old at the time), Surgeon Gen-eral William Gorgas replied, “That doesn’tinterest me! It’s up to you to furnish themen!” In response, three centers wereestablished, in New York, Chicago, and St.Louis, where experienced general surgeonslearned the essentials of neurosurgery insix- to 12-week courses. The Army got its“neurosurgeons,” and as far as Sachs knew,“none of them went into neurological sur-gery as a specialty after the war.”

History more or less repeated itself ageneration later. In 1941 the United Statesentered World War II, shortly after theAmerican Board of Neurological Surgerycame into being. There were only 30 or soAmericans who were qualified in neuro-surgery and ready for active military duty.Again, plans were made to turn “medicalofficers trained in general surgery” intocombat-ready neurosurgeons. The trainingthis time was slightly more elaborate, witha six-week introductory course taught bycivilian neurosurgeons followed by two to

three months at an Army neurosurgical cen-ter, as described by Eben Alexander Jr. in theAANS Journal of Neurosurgery. Some promi-nent neurosurgical careers arose out of thistraining, including those of Dr. Alexanderhimself, Donald Matson, Joseph Ransohoff,and Bertram Selverstone.

We would be foolish to pretend thatappropriately intense training cannot teachother surgeons the necessary rudiments ofneurosurgery. But we are not at war, at leastnot the kind mandating complete mobiliza-tion and massive deployments as in theworld wars. Would we really be satisfied inturning the clock back so far that the rudi-ments of head trauma management wouldsuffice as appropriate, quality care for ourpatients today? Shouldn’t we insist that neu-rosurgeons are those best equipped to man-age diseases affecting the nervous system?Indeed, are practice of hand and concentra-tion of thought to go for nothing? 3

Michael Schulder, MD, is professor and vice-chair inthe Department of Neurological Surgery at NewJersey Medical School in Newark.

Ernest Sachs Sr. Donald MatsonEben Alexander Jr. Joseph Ransohoff Bertram Selverstone

During World War I SurgeonGeneral William Gorgas calledfor 8,000 nurses, as theposter at right testifies. Healso needed 100 neurosur-geons, at a time when thereweren’t that many in theUnited States. Ernest SachsSr. (pictured below) wasamong the neurosurgeonswho created three programswhere general surgeons weretrained for the Army’s neuro-surgical positions. (Poster:

Library of Congress, Prints &

Photographs Division, WWI

Posters, LC-USZC4-7781.)

Training general surgeons in neurosurgery during World War II involved a six-week introductory course by civilian neuro-surgeons followed by two to three months at an Army neurosurgical center. Prominent neurosurgeons who arose out ofthis training included Eben Alexander Jr., Donald Matson, Joseph Ransohoff, and Bertram Selverstone.


E D U C A T I O N

Collaboration Benefits EducationEndovascular Course for Residents Generates Enthusiastic Response

On April 1, the AANS hosted a uniqueeducational opportunity for seniorneurosurgical residents. The course,Endovascular Techniques for Resi-

dents, was held at the Medical Educationand Resource Institute in Memphis, Tenn.While as a state-of-the-art facility MERIcontributed to the course’s success, it wasthe dedication of expert faculty and thefinancial support and equipment dona-tions of corporate sponsors that made thecourse possible and available at no cost tothe 14 residents selected for participation.

The endovascular course was the brain-child of Jon H. Robertson, MD,AANS pres-ident-elect and Development Committeechair. He selected Robert H. Rosenwasser,MD, to serve as course director based on hisreputation and extensive expertise in theever-growing endovascular neurosurgeryfield. Dr. Rosenwasser designed the coursewith topical instruction and instrumenta-tion that would appeal to senior residentsinterested in advanced training in endo-vascular procedures, including arterial andvenous femoral access; therapies foraneurysms and arteriovenous malforma-tions; use of mechanical devices to treatstrokes; carotid angioplasty; and stenting.

Dr. Rosenwasser chose course facultywho provided additional endovascularexpertise, including B. Gregory Thompson,MD, Elad I. Levy, MD, Erol Veznedaroglu,MD, and Charles J. Prestigiacomo, MD.

Residents attended a morning of didac-tic instruction that included presentationson hemorrhagic and ischemic disease andthen performed endovascular techniquesusing balloons and catheters on live hogs. Asimulator provided by Cordis gave residentsan opportunity to develop endovascularskills using the same equipment they will useon actual patients, but in an environmentthat provides instructive feedback as theyprogress on the learning curve.

J O N I L . S H U L M A N

Comments provided by participantsindicated that the program was outstand-ing.“Learning how to manipulate cathetersand wires and experiencing how it feels in areal brain was so helpful along with learn-ing how to use the stent and deploy it,”noted Sheila Smitherman, senior resident atBaylor. “Overall, the lab was superb.”

Warren Roberts, senior resident at Port-land University, summarized the course as“[an] excellent presentation of topics [thatare] extremely important in the training ofneurosurgeons.”Residents also overwhelm-ingly expressed appreciation for the oppor-tunity to meet with the endovascularthought leaders and learn concepts fromrenowned experts in the field.

“This course was designed to be anintroduction for neurosurgical residentsto endovascular techniques,” said Dr.Robertson. “It represents a wonderfuleducational experience which will influ-ence those in training to consider a careerin endovascular neurosurgery.”

What made this course so unique wasthat it forged a perfect marriage betweencorporations and education. Support forthis course was secured from corporatepartners Boston Scientific, Micrus Endo-vascular and Cordis Neurovascular Inc. For

these corporate sponsors, the courseprovided an opportunity to interact withresidents on a variety of levels. Industryrepresentatives participated side by sidewith residents and displayed their newesttechnologies as well as provided instructionon how to use the equipment.

“The number of work stations [in theanimal lab] was ideal, giving everyone theopportunity for hands-on experience witheach product and procedure,” commentedRoberto Refeca of the Regulatory AffairsDepartment of Cordis Neurovascular, Inc.“Where necessary, the residents were ableto repeat procedures as they desiredbecause resources were not restricted.”

The generous corporate financial sup-port made it feasible for the AANS to pro-vide neurosurgical residents consideringfellowship opportunities in endovasculartechniques with a specialized learningopportunity that the AANS would beunable to provide on its own. In order toparticipate in the endovascular course, thecorporate sponsors agreed to becomemembers of the AANS Pinnacle PartnersProgram. Each company invested an addi-tional $25,000 beyond the cost of thecourse for future funding of neurosurgicaleducation and research opportunities.

“Generous corporate support providesadvanced educational instruction that aug-ments resident learning,” said John A. Wil-son, MD, chair of the AANS Education andPractice Management Committee. “I lookforward to working closely with the Devel-opment Committee on similar initiatives.”

The AANS continues to invest in educa-tional offerings for residents. Two addition-al courses have been scheduled for 2006,including a minimally invasive spine coursein August at MERI and a socioeconomiccourse for senior residents in September.3

Joni L. Shulman is AANS associate executive director,education and meetings.

Charles J. Prestigiacomo, MD, demonstrates a proce-dure during Endovascular Techniques for Residents, anew AANS course held April 1 at MERI in Memphis.


tacted by more than two dozen companiesfor information on entering the malprac-tice insurance market, and an insurer whohad announced plans to pull out of theTexas market began expanding and writingnew business.

The reforms have wrought additionalbeneficial changes in Texas healthcare,among them:

3 From May 2003 through July 2005 therewas an increase of approximately 3,000new doctors establishing practices in Texas,many of whom serve in high-risk specialtymedicine. (Texas Medical Association,March 23, 2006).

3 Some Texas communities (CorpusChristi, Beaumont, the Rio Grande Valley,Webb County) are experiencing surges inphysician recruitment (American MedicalAssociation, May 9, 2005).

3 Texas physicians are now able to shopfor medical malpractice insurance since thenumber of new and start-up medicalmalpractice insurers increased from fourpre-reform to roughly 20 new entities.(Beaumont Enterprise, Feb. 22, 2005).

Texas teaches that appropriate medicaltort reform does indeed work. It lowersmedical malpractice premiums andincreases the number of available doctors,thus increasing patients’ access to care. Animportant caveat, however, is that Texasvoters passed a constitutional amendmentthat makes it highly unlikely for the state’shigh court to overturn the cap. The ques-tion now is whether other states will learnTexas’ very valuable lesson. 3

David F. Jimenez, MD, FACS, is professor and chair of the Department of Neurosurgery at the University of Texas Health Science Center, San Antonio.

Neurosurgeons are well aware of thesignificant financial impact thatskyrocketing medical liability insur-ance premiums can have on their

practices, and organized neurosurgery hasbeen at the forefront of efforts to institutemedical tort reform at both the federal andstate levels.Yet a long-standing debate con-tinues on the real impact of tort reform onmalpractice insurance premiums. Someargue that there is no correlation betweenthe capping of noneconomic damageawards and the annual insurance premi-ums and argue further that the premiumsset by the insurance industry have nothingto do with jury verdicts and awards.

However, medical tort reform enactedin Texas on Sept. 12, 2003, refutes that ideaand supports the position that appropriatereforms will reduce medical malpracticepremiums and increase patients’ access tocare. In fact, Texas House Bill 4 and its con-stitutional amendment, Proposition 12,have served to reduce high rates of medicalmalpractice insurance by granting theTexas Legislature the authority to limitnoneconomic medical civil liability dam-ages to no more than $250,000 in medicalmalpractice lawsuits. The cap was estab-lished at $250,000 for all doctors (no mat-ter how many are named in a lawsuit) and$250,000 per healthcare institution (up totwo institutions). All actual medicalexpenses, lost past and future income andother expenses that can be translated intoan actual dollar amount (such as maid serv-ice, transportation) are still recoverable.

The reforms, which were intended tohelp reduce frivolous medical malpracticelawsuits and to decrease escalating medicalliability insurance rates, began to pay divi-dends soon after enactment. As early asJan. 1, 2004, Texas Medical Liability Trust,the largest medical malpractice insurer inTexas, reduced its rates by 12 percent across

the board. This was followed nine monthslater by another 5 percent rate reduction.Between February 2005 and March 2006,additional rate decreases were announcedby numerous other Texas professional lia-bility insurance underwriters, includingAmerican Physicians Insurance Company(9 percent–14 percent), The Joint Under-writing Association (10 percent), MedicalProtective (2 percent), Texas Medical Lia-bility (an additional 5 percent) and TheDoctors Company (18 percent).

In 2005, Bernard Black and colleaguesreported that the total number of medicalmalpractice claims for 2002 was 6,929compared with a high of 8,943 claims filedthe preceding year. In 2003, the year inwhich tort reform passed, there was atransition drop in claims to 5,967 asreported to the Texas Department ofInsurance by the four largest medical mal-practice insuring companies in Texas; fig-ures from these companies representclaims for approximately 60 percent ofTexas physicians, according to KennethMcDaniel of the Texas Department ofInsurance Professional Liability Commer-cial Property/Casualty Division. Addition-al decreases in claim rates also are beingobserved using the same TDI data set,indicating a reduction in medical mal-practice claims in 2004 to 2,359 and in2005 to 2,259. The overall number ofclaims in 2005 was roughly just one thirdof the number reported in 2002, the yearimmediately prior to reform enactment.

This dramatic difference is echoed byTexas Department of Insurance data whichshows that medical malpractice lawsuit fil-ings decreased by half by 2006. Addition-ally, the agency reported its action to denyrate increases that did not take into accountthe reduced exposure to frivolous claims.The agency further reported that withinmonths of reform passage, it had been con-

M E D I C O L E G A L U P D A T E

Texas Teaches That Tort Reform WorksWill Other States Learn the Lesson?

D A V I D F . J I M E N E Z , M D


L E T T E R S

Editor:I read this particular article [“To Prevail, First Prepare,” AANS Bulletin, 15(1):22, 2006; www.AANS.org, article ID 38174] with interest. However, I believe that item 10 in the article,Trust your lawyer, is a generalized statement that should be carefully considered.

In my experience in the past 30-plus years, I have found thatmost defense attorneys do not expedite matters in court. Eventhough many medical liability cases are dropped or dismissed by ajudge as frivolous, these lawsuits drain the money from insurancecompanies, and most of the money, unfortunately, goes to ourown defense lawyers. For example, instead of taking 90 or 120 daysto get an expert’s report, the process is deliberately delayed becausethe attorneys make no money if the case is disposed of quickly.This is not to say that all defense attorneys are the same, but onecan say that there is little financial incentive to expedite cases.

Also, your defense attorney should provide you with insightinto the plaintiff attorney you are dealing with because they arenot all the same. A very good attorney will tell you what to expectand how to respond to questioning.

I must add that we must make every effort nationwide toresolve this medical liability crisis.

David A. Yazdan, MD, FACSBrick, N.J.

The Author Responds:My best advice is, Don’t sweat the small stuff. Concentrate andremain focused on the medical aspects of your case. Leave the“lawyering” to the lawyer and “the lawyer’s bill” with your insur-ance company. That’s why you pay insurance. He must justify hisfees to the insurance company. You have more than enough toworry about.

Remember the operant word is “trust.” If you don’t trust yourlawyer, get another lawyer! Keep the lines of communicationopen. If you have questions and concerns about your case, callyour lawyer and don’t worry about “running up the tab.” Yourprofessional integrity and personal assets are on the line. Don’t bepenny-wise. Ask him about opposing counsel if he has notprepped you in that regard.

With regard to solving the medical liability crisis: Not in ourlifetime.

Stanley W. Fronczak MD, JD, FACSOak Brook, Ill.

A Defense Attorney’s Perspective:This letter to the editor illustrates the need for effective communi-cation between the three parties involved in defending a malprac-tice claim: the physician, the insurer and defense counsel. A

successful defense of a malpractice suit is often affected by howwell the physician, defense counsel and the insurer’s claim counselwork together. Ideally, these three parties should act in partner-ship to pursue resolution of a claim. However, due to the varyingconcerns and interests that each party has, and the failure to com-municate, the relationship often fails to approach that ideal.

It is no secret that being sued for malpractice is a traumaticexperience that often elicits emotional responses ranging fromoutrage to resignation. These emotions often influence how aphysician prefers that a case be defended. In some cases, a physi-cian might desire a fast settlement of the claim, period. In oth-ers, the physician’s goal might be to seek vindication throughcomplete litigation of the claim.

The insurer’s goal is to resolve the claim in a cost-efficientmanner. Unfortunately, this goal has the potential to create a conflict of interest between the insurer and the insured physi-cian. For example, while the physician might want a claim set-tled as quickly as possible, the insurer, based on its assessment of the exposure, might not be willing to accede to the plaintiff ’searly settlement demands.

Conflicts between the insurer and the insured place defensecounsel in an uncomfortable position. It is without question thatdefense counsel’s paramount duty is owed to the insured. How-ever, defense counsel is obligated to report to the insurer, whichis paying defense counsel’s bills, to provide objective advice con-cerning what is necessary and appropriate for a defense and toassess exposure and the reasonableness of a potential settlement,regardless of whether such advice might displease either theinsurer or the insured.

The single most important factor in developing and maintain-ing a productive relationship between the physician, the insurerand defense counsel is communication. Defense counsel mustmake the physician and the insurer feel that they are informedand involved in the management of the defense. Similarly, thephysician and the insurer need to continuously advise defensecounsel about their respective views concerning the case. A break-down in communication between the physician, the insurer anddefense counsel only serves to benefit one party: the plaintiff.

Michael A. Chabraja, JDChicago, Ill.

COMMUNICATE YOUR THOUGHTS Share your point of view regarding malpractice litigation, reim-

bursement, ER coverage or other issues in neurosurgery with

the editor at [email protected]. Letters are assumed to be for

publication unless otherwise specified. Correspondence select-

ed for publication may be edited for length, style and clarity.


G O V E R N A N C E

Two Disciplinary Actions AnnouncedAANS Board Approves Four PCC Recommendations

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

At its meeting April 21 in San Francis-co, the AANS Board of Directorsapproved the recommendation ofthe Professional Conduct Commit-

tee that four members be disciplined forunprofessional conduct while testifying asexpert witnesses in medical malpracticelawsuits. Two of those disciplinary actions,an expulsion and a six-month suspension ofmembership, are being appealed to the gen-eral membership of the AANS. The two dis-ciplinary actions that are not beingappealed are summarized below.

Edwin R. Buster, MD In the underlying malpractice litigation, a53-year-old man who experienced suddennontraumatic onset of back pain, sense ofleg heaviness, and leg pain was admitted toa hospital through the emergency room inJanuary of 2000. The admitting neurolo-gist ordered that vital signs and neurolog-ical evaluations be obtained every fourhours by the nursing staff during the night.When the neurologist examined his

patient the next morning on rounds, hefound him to be densely paraparetic/para-plegic. The ordered neurological checkshad not been documented and apparentlyhad not been performed during the night.An emergency MRI of the thoracic andlumbar spine demonstrated a large left-sided disc herniation with cord compres-sion at T8–9. A neurosurgeon was thenconsulted and performed an emergencydecompression with left posterolateralexcision of the herniated disc at T8–9. Thepatient gradually improved from his essen-tially paraplegic state to a paraparesis withneurogenic bladder.

The patient sued the hospital, the nursewho had been on duty the night of thepatient’s deterioration, and the neurosur-geon. The neurosurgical expert witness forthe plaintiff testified to the hospital’s neg-ligence but was not at all critical of the sur-gery for removal of the thoracic discherniation. Dr. Buster, the defense medicalexpert for the hospital, testified in his dis-covery deposition that the failure of the

nursing staff to check vital signs and neu-rological function as ordered by the admit-ting neurologist did not fall below theacceptable standard of nursing care. Dr.Buster further testified that the surgicalprocedure was inappropriate and that thedefendant neurosurgeon could have been“up to 50 percent responsible” for thepatient’s resulting neurological deficit.

During the Professional Conduct Com-mittee hearing, Dr. Buster stated that hehad not thoroughly reviewed the nursingrecords prior to testifying in his depositionand that “looking back on it now” the stan-dard of proper nursing care was not met.The Professional Conduct Committeeconcluded that Dr. Buster’s testimony as adefense expert witness for the hospitalconsisted of improper advocacy in denyingnegligence by the hospital and in misrep-resenting the range of surgical standardsfor excising thoracic disc herniations in anattempt to shift responsibility for the neu-rological deficits from the hospital to thetreating neurological surgeon. The AANSBoard of Directors agreed with the PCC’sfindings and voted to suspend Dr. Buster’smembership in the AANS for one year.

William H. Bloom, MD The underlying lawsuit in this case involveda 44-year-old man who complained of ahistory of right arm pain with numbness inhis right index and middle fingers. Theproblem reportedly began when he awak-ened one morning with scapular pain thatwas soon followed by right arm pain. A CTscan showed foraminal narrowing withspondylosis and some spinal stenosis.Approximately one month later the patientreported having experienced some “electricshock” sensations in his left arm. Surgerywas carried out in the lateral position withbilateral laminectomies at C4, C5, C6 andC7. The operative note describes decom-

ABOUT THE AANS PROFESSIONAL CONDUCT PROGRAM

The AANS Professional Conduct Committee evaluates complaints by one or more AANS

members about another member or members and makes recommendations to the Board

of Directors. Established in 1982, the PCC has served as a model for other professional

associations to structure and adopt similar professional conduct programs. In June of

2001, the AANS Professional Conduct Committee’s work was examined by the 7th Circuit

Court of Appeals in a landmark case for professional associations, Austin v. AANS. This

opinion strongly supported the AANS Professional Conduct Program and the importance

to a professional association of having an internal mechanism for self-regulation. The

program also received an honor roll designation from the American Society of Association

Executives in 2002.

The AANS rules for expert witness testimony are reprinted on page 37. These rules,

the AANS Code of Ethics and more information related to association governance are

available online at www.aans.org/about in the Governance and Leadership area.


pression of the right C5, C6 and C7 nerveroots and the left C6 and C7 nerve roots.Postoperatively the patient experiencedpain in his left hand, and his right deltoidwas very weak. The deltoid strength recov-ered spontaneously, but the left-hand painpersisted. A cervical MRI done postopera-tively showed an abnormal signal in the leftparacentral region of the cord at aboutC5–6. The patient was treated with somesympathetic blocks that did not relieve thepain, and he underwent implantation of acervical epidural stimulator. The patientfiled his lawsuit shortly after learning aboutthe abnormal signal shown in the MRI.

Dr. Bloom, the plaintiff ’s medicalexpert, testified in his deposition that thepostoperative abnormal cervical cord MRI

signal indicated a surgical cord contusiondespite having disclaimed personal expert-ise in the interpretation of abnormal MRIsignals. In his deposition, Dr. Bloom wasexcessively vague, unclear, and forgetfulabout what he reviewed or did not review.He did not recall whether he saw all of theMRI films or any of the CT films.

The Professional Conduct Committeeconcluded that, despite some problems withdocumentation, surgical indications andconfusion about some aspects of the surgi-cal procedure on the part of the treatingneurosurgeon, Dr. Bloom failed to suffi-ciently review and familiarize himself withthe relevant medical records. Because Dr.Bloom disclaimed any expertise in theinterpretation of abnormal MRI signals, he

therefore improperly gave unequivocal tes-timony that nothing other than operativecontusion could have caused the postoper-ative MRI findings. The Professional Con-duct Committee concluded that Dr. Bloomdemonstrated inadequate subject matterknowledge and/or improper advocacy inparts of his testimony. The AANS Board ofDirectors concurred and since Dr. Bloom’smembership in the AANS had previouslybeen suspended in another matter, theboard voted to extend that suspension byone year from whatever point Dr. Bloommight otherwise be entitled to reapply foractive AANS membership. 3

W. Ben Blackett, MD, JD, is chair of the AANS Professional Conduct Committee, and Russell M. Pelton, JD, is AANS general counsel.

PreambleThe American legal system often calls for expert medical testimony.Proper functioning of this system requires that when such testimonyis needed, it be truly expert, impartial and available to all litigants.To that end, the following rules have been adopted by the AmericanAssociation of Neurological Surgeons. These rules apply to all AANSmembers providing expert opinion services to attorneys, litigants, orthe judiciary in the context of civil or criminal matters and includewritten expert opinions as well as sworn testimony.

A. Impartial Testimony1. The neurosurgical expert witness shall be an impartial educatorfor attorneys, jurors and the court on the subject of neurosurgicalpractice.2. The neurosurgical expert witness shall represent and testify as tothe practice behavior of a prudent neurological surgeon giving dif-ferent viewpoints if such there are.3. The neurosurgical expert witness shall identify as such any per-sonal opinions that vary significantly from generally accepted neu-rosurgical practice.4. The neurosurgical expert witness shall recognize and correctlyrepresent the full standard of neurosurgical care and shall with rea-sonable accuracy state whether a particular action was clearly with-in, clearly outside of, or close to the margins of the standard ofneurosurgical care.

5. The neurosurgical expert witness shall not be evasive for thepurpose of favoring one litigant over another. The neurosurgicalexpert shall answer all properly framed questions pertaining to hisor her opinions on the subject matter thereof.

B. Subject Matter Knowledge1. The neurosurgical expert witness shall have sufficient knowledgeof and experience in the specific subject(s) of his or her writtenexpert opinion or sworn oral testimony to warrant designation asan expert.2. The neurosurgical expert witness shall review all pertinent avail-able medical information about a particular patient prior to ren-dering an opinion about the appropriateness of medical or surgicalmanagement of that patient.3. The neurosurgical expert witness shall be very familiar withprior and current concepts of standard neurosurgical practicesbefore giving testimony or providing written opinion about suchpractice standards.

C. Compensation1. The neurosurgical expert witness shall not accept a contingencyfee for providing expert medical opinion services.2. Charges for medical expert opinion services shall be reasonableand commensurate with the time and effort given to preparing and providing those services.

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


The 2006 Research Fellows include: Ming(David) Cheng, MD (University of NorthCarolina), Lewis Chun Hou, MD (StanfordUniversity), Eric M. Jackson, MD (Univer-sity of Pennsylvania),Adrian W. Laxton,MD(University of Toronto), Daniel A. Lim, MD,PhD (UCSF), Neil R. Malhotra, MD (Uni-versity of Pennsylvania), Wael Musleh, MD,PhD (University of Chicago), and LymanWhitlach, MD, PhD (Duke University).

The 2006 Young Clinician Investigators

include: John A. Boockvar, MD (CornellMedical College), Alfredo Quinones-Hino-josa, MD (Johns Hopkins University),Michael D. Taylor, MD, PhD (Hospital forSick Children, Toronto), and G. EdwardVates, MD (University of Rochester).

Cutting-Edge ResearchTwo examples of the cutting-edge researchthe NREF is funding this year are the proj-ects of Dr. Lim and Dr. Boockvar. Dr. Lim’sresearch has established an in vitro SVZstem cell culture system which will allowhim to determine the role that the Mll geneplays in stem cell self-renewal, differentia-tion, cellular migration, and cell survival.Dr. Boockvar’s research seeks to identifythe mechanism by which EGFR signalingenhances human progenitor cell invasive-ness for the purpose of improving thetreatment of glioblastoma multiforme.

It is hoped that the exciting potential ofprojects like these will stimulate continuedgrowth in financial support from neurosur-geons, as well as partnerships with industryand other funding sources. The extent towhich the entire neurosurgical communityrecognizes the importance of research anddevelopment to the future of the specialtyand the patients it serves will determine theoutlook for the NREF research grant pro-gram over the next 25 years.

For information about the NREF or tomake a donation, visit www.aans.org/research or contact the AANS Develop-ment department at (847) 378-0500. 3Michele S. Gregory is AANS director of development.

The Neurosurgery Research and Edu-cation Foundation is celebrating twomilestones in 2006. The first is theNREF’s silver anniversary. In 1981

Robert Ojemann, MD, Robert King, MD,Sidney Goldring, MD, and William Buch-heit, MD, with the help of a number ofother AANS members, formed the NREFto: provide private, nongovernmental fund-ing for neurosciences research; to ensurecontinued viability and expansion of thefield based on fundamental research in thebasic sciences and clinical enterprises; toaugment support for research by the neuro-surgical community; and to stimulate life-long learning by neurosurgeons. During thepast 25 years, the NREF has awarded near-ly $4.5 million dollars in one- and two-yeargrants to 113 residents and junior neuro-surgical faculty members.

Alone, the NREF’s 25th anniversary is acause for celebration; however, an equallyimportant milestone also was achieved thisyear. For the first time the NREF awarded adouble-digit number of grants, 12 total.Eight applicants received research fellow-ships and four received young clinicianinvestigator awards.

Robert Grossman, MD, chair of theNREF’s Scientific Advisory Committee,thinks that some of the most innovative andinteresting investigations occurring in neu-rosurgical labs today are funded by theNREF. “The scientific quality of the grantapplications has increased each year andmeets our highest expectations,” he stated.

Thanks to generous support of theCorporate Associates program by AANSmembers, hospitals, neurosurgery depart-ments, the general public, and our corpo-rate partners, the NREF has committed$500,000 in research support for 2006, anincrease of $100,000 from last year.

“The NREF continues to secure supportfrom neurosurgeons, neurosurgical prac-

tices and programs, hospitals and the gen-eral public,” noted Martin H. Weiss, MD,FACS, chair of the NREF Executive Council.“However, we are consistently exploringother partnerships in an effort to fund asmuch great science as we can.”

Partnerships with industry, founda-tions and voluntary health associationshave enabled the NREF to maximize itsfunding without compromising itsintegrity. In 2004, the AANS Develop-ment Committee, under the leadershipof Jon H. Robertson, MD, developed theGuidelines for Corporate Relations doc-ument. The guidelines define appropri-ate relationships between the AANS andNREF and their corporate partners suchas DePuy Spine, Kyphon Inc., Medtron-ic Neurological, and W. Lorenz Surgical.According to Dr. Weiss, such partner-ships enable the NREF to allocate morefunding for research grants each yearwhile building ethical relationships withindustry.

In 2006 the AANS and NREF willcosponsor an annual research grant fromfunds raised through the AANS PinnaclePartners in Neurosurgery corporate giv-ing program.“The Pinnacle Partners pro-gram provides an opportunity forindustry to financially support neurosur-gical research and education through theNREF in a responsible and ethical man-ner,” said Dr. Robertson. “A company’sparticipation in the Pinnacle Partnersprogram generates recognition thatreflects its commitment to the future ofneurosurgery and the public good.”

The 2006 NREF awardees come from 11different neurosurgery programs. Theresearch grants encompass neurosurgicalareas of pediatric brain tumors, spine trau-ma, deep brain stimulation, aneurysms,epilepsy, pain biomaterials and stemcell research.

A D V A N C I N G N E U R O R E S E A R C H

Two NREF Milestones25 Years, Record Number of Awards Are Reasons to Cheer

M I C H E L E S . G R E G O R Y


DENVER, COLORADOSeeking Neurosurgeon

Wonderful opportunity to practice state of the artNeurosurgery in “base camp for the Rockies,” Denver,Colorado. Enjoy an academic practice with three otherneurosurgeons and two orthopedic spine surgeons,while living in a cultural center at the foot of the world’sgreatest mountains for skiing, hiking, fishing, golf and a true outdoor lifestyle. Over 300 days of sunshineyearly! Support staff includes two hospital physicianassistants and two office physician assistants, and a dedicated Neurosurgical scrub technician. TheNeurosurgery service provides exclusive coverage forover 430,000 insured patients. This yields an excellentmix of elective cranial and spine cases, with relativelylittle trauma care. Surgical residency program includesintern on the neurosurgical service with 24-hour in-house coverage. Competitive pay scale and none of the business hassles of running a private practice. If interested please contact Eileen Jones-Charlett, Colorado Permanente Medical Group,(303)344-7838. Or fax your CV with a cover letter to Physician Recruitment at 303-344-7818 or e-mail to [email protected]. EOE

Luther MidelfortMayo Health SystemLuther Midelfort – Mayo Health System in EauClaire, Wisconsin, has an opening for a BC/BE(upon arrival) neurosurgeon with a broad range ofskills. Call of 1:3 is shared equally. Draw area of 300,000. Our neurosurgeons practice “state ofthe art” medicine, have equal earning potentialfrom the beginning, have their office in the onlyhospital they cover, and share a close workingrelationship with their neurosurgery colleagues atMayo Clinic. Eau Claire is a university city of63,000 with a metro area of 90,000, 90 minuteseast of Minneapolis. You may expect a safe family environment, a city that serves as theregional hub for the arts and shopping, andschools that are in the top 10% of preferredschools nationally. For more information contact:

Christie Blink, DirectorPhysician RecruitmentPhone: 1-800-573-2580Fax: 715-838-6192

E-mail: [email protected]

Neurosurgery - Roanoke, Virginia-Affiliated with Carilion Medical Center, largest hospital inSouthwest Virginia, Level I Trauma Center, 880-beds.Dedicated neuro ICU, seven residency programs, and medicalschool affiliations with University of Virginia and Via Collegeof Osteopathic Medicine

-State of the art neurosurgical equipment, including biplanarflouroscopic image guidance, Stealth and CyberKnife.

-Comprehensive, established neurosurgical practice.

-Hospital-employed group practice, with collaborativeapproach and cross coverage.

-Competitive salary and benefits, paid malpractice insurance.

-A five time "All America City", one of the top rated smallcities in the US, nestled in the gorgeous Blue Ridge Mountainsof Southwest Virginia.

-Metropolitan population of 250,000, referral market population of 1.5 million.

-Region offers affordable housing, recreational, cultural, andprofessional opportunities. Mild weather and four seasons.

For detailed information about the opportunity, or to submit acover letter and CV please contact Andrea Henson, PhysicianRecruiter, Carilion Health System [email protected] 540-224-5241 office, 540-985-5329 fax. www.carilion.com

Southern Oregon Neurosurgery Opportunity

Join a well-established group of four neuro-surgeons and five neurologists in southern Oregon.Income guarantee with a partnership track.Medford is a community of approximately 75,000with a medical service area of 750,000. There are two hospitals that share a joint medical staffand the neurosurgeons provide coverage at bothhospitals, but this is not a hospital-based practice.The medical community is sophisticated and reputable, and the clinic, medical facilities andequipment are state-of-the-art. The draw to thisarea and this opportunity is the ability to recognizean unprecedented balance of personal and professional quality of life in a very desirable location.

Contact:

Anne Folger, Executive Director, Health Future – A unique healthcare consortiumowned byOregon hospitals and healthcare systems Email: [email protected] Phone: 541/618-7240


“Today, were it not for an army base thatbears his name, we would never hear ofLeonard Wood.” For neurosurgeons, thatmay not be true. Those of us who have readCushing biographies by John Fulton andmore recently by Michael Bliss knowLeonard Wood as a famous patient. McCal-lum sets the record straight as to Wood’smedical history, but does much more inallowing us to know the doctor whobecame a soldier.

Leonard Wood was born Oct. 9, 1860, inPocasset, Mass., and died in the operatingroom at Boston’s Peter Bent Brigham Hos-pital at 1:50 a.m., Aug. 6, 1927. The 1880swere the decade in which American medi-cine transformed itself from a cult to a sci-ence, and Harvard Medical School, whereWood framed as a physician, was the nexusof that revolution. But Wood enlisted as amilitary surgeon and became a soldiermore than a doctor. His medical back-ground, however, had profound influenceon his legacy as an administrator.

Wood’s first military experience waschasing Geronimo, and he won the Medalof Honor just as Frederick Jackson Turnerdeclared the American frontier closed. Hespent a year as Georgia Tech’s first footballcoach before moving to Washington wherehe developed a lifelong friendship with theassistant secretary of the U.S. Navy,Theodore Roosevelt.

Leonard Wood’s conversion from physi-cian to professional soldier was completedwhen Roosevelt convinced PresidentMcKinley that a cowboy regiment shouldjoin the Spanish War. The Rough Riderswere a combination of Wood’s western con-tacts plus Roosevelt’s assortment of IvyLeague ex-athletes. When the war ended,Wood accomplished great things as a natu-ral administrator and a zealous autocrat.Within one year, he was military governor ofCuba. The crowning achievement of all his

Too Much Like Ourselves?Neurosurgeons Author Two New Books

B O O K S H E L F G A R Y V A N D E R A R K , M D

Another Day in the FrontalLobe: A Brain Surgeon ExposesLife on the Inside, by KatrinaFirlik, 2006, Random House,271 pp., $24.95.

Leonard Wood: Rough Rider,Surgeon, Architect of AmericanImperialism, by Jack McCallum,2006, New York UniversityPress, 355 pp., $34.95.

Neurosurgeons are writing books!Hot off the presses are two newtitles by Jack McCallum, MD, andKatrina Firlik, MD. McCallum,

who is on the neurosurgery faculty at Bay-lor and also teaches history at the TexasChristian University, has written a schol-arly biography of Leonard Wood; Firlik, arecent neurosurgical graduate from theUniversity of Pittsburg, has published thestory of her neurosurgical residency withthe attention-getting moniker of AnotherDay in the Frontal Lobe.

Firlik’s book is in the tradition of RudyGiuliani and Erin Brockovich. Books thatglorify the American dream come true havealways found an audience, and RandomHouse is betting that people will want toread the story of a woman from HarveyCushing’s hometown who has made it inthe male-dominated world of brain surgery.

Firlik has a gift for making neuro-surgery sound intriguing. The book beginswith this attention grabber: “The brain issoft. Some of my colleagues compare itsconsistency to toothpaste, but that’s notquite right. Tofu—the soft variety, for thoseknowledgeable about tofu—may be a moreaccurate comparison.” Neurosurgeons willprobably not find this book as fascinatingas some of our patients might.

McCallum says of Leonard Wood,

training was funding and taking responsibil-ity for Walter Reed’s yellow fever experi-ments and authorizing William Gorgas touse the finding to virtually eradicate yellowfever and malaria from Cuba.

The later chapters of Wood’s life as mil-itary commander and governor general ofthe Philippines were not as successful.Wood had a dark side and at times his dis-dain descended to cruelty and even mur-der. Wood at his best was altruistic,intelligent, creative, self-confident andindefatigable. On the other had, he wasintolerably self-righteous and his insatiableappetite for power culminated in hisunsuccessful run for the U.S. presidency.

McCallum offers an interesting conclu-sion in the epilogue of his book:“In the end… Wood never quite discovered how tofulfill himself or to satisfy others in theexertion of his own remarkable powers.Perhaps we have forgotten him because hewas too much like ourselves.”

Ah, there’s the rub.Here you have two new books by fellow

neurosurgeons. Both of these books willserve as mirrors, and both will help us tounderstand ourselves better. 3

Gary Vander Ark, MD, is director of the NeurosurgeryResidency Program at the University of Colorado. He isthe 2001 recipient of the AANS Humanitarian Award.

Firlik’s book is in the tradition of Rudy Giulianiand Erin Brockovich.Books that glorify theAmerican dream cometrue have always foundan audience….


Chief Operating OfficerDepartment of Neurosurgery

University of Minnesota Medical School

The Department of Neurosurgery at the University of Minnesotaseeks a Chief Operating Officer to provide oversight of all aspects ofbilling, coding and collection for services provided by faculty andextenders of the Neurosurgery Clinical Staff Unit.

This position is accountable for the efficiency of the Neurosurgeryoutpatient clinic functions in concert with the clinic leadership, 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 managing hiring, promotion, discipline, payroll, work hours, vacationand sick leave, in order to adequately staff the daily operations of theNeurosurgery department and CSU.

Qualifications include a Bachelor’s degree with a minimum of 4-6years of progressively responsible experience, and with specific experience in a senior management position in the clinic administrationof a physician’s practice. Supervision of personnel in the areas ofbilling and collection of provider fees, third party agreements, andphysician support. Knowledge of coding and billing, financial reporting,and staff management in a physician-oriented clinical setting is essential.

Interested candidates may send a resume and letter of interest to:

Rob Super, Search Committee ChairUniversity of Minnesota

MMC 391, 420 Delaware Street SEMinneapolis, MN 55455e-mail: [email protected]

The University of Minnesota is an equal opportunity employer and educator

Neurosurgery Locum TenensWhether you’re interested in working a few days a week,a week or two a month, or considering locum tenens full-time, The Surgeons Link can direct you to the besthospital-sponsored and group practice locum tenensopportunities from those available in the marketplace,nationwide. As a locum tenens provider through TheSurgeons Link you will enjoy:

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Spinal Surgery FellowshipJuly 2007 & 2008

Twelve month combined research and clinical fellowship in spinal disorders for individuals completing neurosurgicalresidency and contemplating academic careers. Exposure to a large volume of tumors and fractures at all levels of the vertebral column, including decompression and fusion techniques and spinal instrumentation. Extensive experiencein management of degenerative diseases of the spine.

Research opportunities include biomechanics, neurophysiologyof the spinal cord, and spinal cord regeneration. Extensiveclinical research opportunities also exist.

Individuals interested in pursuing this fellowship shouldsend inquiries to:

Dennis J. Maiman, MD, PhD, ProfessorDepartment of Neurosurgery

MEDICAL COLLEGE OFWISCONSIN9200 W. Wisconsin Avenue Milwaukee, WI 53226

414-805-5410Email: [email protected]

Equal Employment Affirmative Action Employer M/F/D/V

AANS Bulletin:A Top Member Benefit and a Leading Predictor of Satisfaction With AANS MembershipThe AANS Bulletin is the primary source of news that affects thepractice of neurosurgery: practice management, legislation, codingand reimbursement, professional development and education, andmore. Readers are invited to participate in the Bulletin:

Neurosurgical Professionals• Write a letter to the editor.• Submit an article or article idea.• Submit socioeconomic research papers for peer review.• Provide news briefs to News.org.• Submit a neurosurgical meeting to the online calendar.

Corporations• Advertise in the Bulletin.• Sponsor the Bulletin

(an exclusive opportunity).

Learn more at www.aans.org/bulletin.


CNS, formalized this concern in a resolution sub-mitted in May to the American Medical AssociationHouse of Delegates. The resolution “to developstandards for MRI equipment and interpretationfor the purpose of improving patient safety” asked:“That our American Medical Association convene ameeting(s) with representatives from MRI manu-facturers, radiology and other interested medicalspecialties, and imaging facilities, with the goals of:(1) agreeing to standards in electronic imaging for-mats (e.g., left to right, axial, coronal, sagittal); (2)developing standards of data manipulation andlocalization consistent throughout all units for bestinterpretation of the data; and (3) ensuring thateach electronic format is equipped with the capabil-ity of loading and launching its contained imageson the physician’s computer.”

2007 Humanitarian Award Nominations Due Oct. 15Voting members of the AANS are invited to submitnominations for the 2007 Humanitarian Award byOct. 15. The award will be presented at the 2007AANS Annual Meeting in Washington, D.C., April14–19, 2007. The Humanitarian Award honors amember of the AANS whose activities outside ofmedicine bring great benefit to society. Nomineescan be living members from any category of AANSmembership who give selflessly of time or talents toa charitable or public activity; who are deserving ofrecognition by the AANS; and whose actionsenhance neurosurgery’s image. Activities may beinternational, national, regional or local in natureand benefit humanity collectively or individuallywithout providing remuneration to the recipient.Additional details and the nomination form areavailable at www.aans.org/shared_pdfs/nomination_%20form.pdf, or contact Susan E. Funk [email protected] or (847) 378-0507.

AANS Streamlines Disclosure Process for SpeakersSpeakers at AANS educational meetings are requiredannually to disclose their financial relationships withcommercial interests. Individuals can now meet therequirement by completing the online DisclosureStatement once. After it is submitted, the informa-tion will remain available online, where it must be

AANS Releases New Mission and Vision During75th Anniversary Year On April 21, the AANSBoard of Directors approved a new mission andvision for the organization:

AANS Mission The American Association of Neurological Sur-geons (AANS) is the organization that speaksfor all of neurosurgery. The AANS is dedicatedto advancing the specialty of neurological sur-gery in order to promote the highest quality ofpatient care.

AANS VisionThe American Association of Neurological Sur-geons will ensure that neurosurgeons are recog-nized as the preeminent providers of quality careto patients with surgical disorders that affect thenervous system.

The American Association of Neurological Sur-geons will work to expand the scope of neurosur-gical care as new technologies and treatments ofneurological disorders become available.

The American Association of Neurological Sur-geons will be the organization speaking for neu-rosurgery through its communications andinteractions with the public, media, government,medical communities, and third party payers.

The American Association of Neurological Sur-geons will be its members’ principal resource forprofessional interaction, practice information andeducation.

The American Association of Neurological Sur-geons will promote and support appropriate clin-ical and basic science to expand the scope ofneurosurgical practice.

AANS Seeks Standardization of Radiological ImagesPresented on CD At the suggestion of an AANSmember during the AANS Annual Meeting inApril, the AANS asked the American College ofRadiology to consider development of standardsfor production of radiological images on CD.AANS President Donald O. Quest, MD, communi-cated neurosurgeons’ concern about this issue in aMay 10 letter to ACR Board of Chancellors ChairJames P. Borgstede, MD. The AANS, joined by the

AANS HumanitarianAwardees

Nominations for the 2007award are due Oct. 15.

2006Gene Bolles, MD

2005Tetsuo Tatsumi, MD, FACS

2004Charles L. Branch Sr., MD

2003No award

2002Edgar M. Housepian, MD

2001Gary D. Vander Ark, MD

2000Merwyn Bagan, MD, MPH

1999Thomas B. Flynn, MD

1998Lee Finney, MD

1997Robert J. White, MD

1996 No award

1995Melvin L. Cheatham, MD

1994E. Fletcher Eyster, MD

1993Manuel Velasco-Suarez, MD

1992William H. Mosberg Jr., MD

1991George B. Udvarhelyi, MD

1990A. Roy Tyrer Jr., MD

1989Hugo V. Rizzoli, MD

1988Gaston Acosta-Rua, MD

1987Courtland H. Davis Jr., MD

N E W S . O R GN E W S . O R GA A N S /C N S S e c t i o n s C o m m i t t e e s A s s o c i a t i o n s S o c i e t i e s


the AANS, Controversies confronts many of the top-ics fueling neurosurgical discussions, with detailedcoverage of treatments for ischemic diseases such asextracranial and intracranial atherosclerosis. Manyof the organizational issues of integrating subspe-cialties and training subspecialists are discussed. The336-page book contains 240 illustrations, figures,and radiological images and offers 15 continuingmedical education credits. Information is availablein the AANS Online Marketplace, www.AANS.org.

AANS Members Serving on Committees Get NewInformation Management Tool Members now canaccess information about their committees at www.MyAANS.org, including a committee roster withcontact information, an archive of past minutes andother materials, and upcoming meeting informationfor each committee on which an individual serves.The information is accessible after logging in towww.MyAANS.org and selecting “Committees” fromthe navigation bar. Those who want to volunteer fora particular committee can do so in this area as wellby selecting “Edit” next to Volunteer for Committee.

updated yearly or as necessary to report statuschanges. The Disclosure Statement and additionalinformation are accessible at www.MyAANS.org byselecting “Disclosure” from the navigation bar.Questions about this new process can be directed tothe AANS at (888) 566-2267.

Abstract Deadline for the 2007 AANS AnnualMeeting Is Sept. 15 Abstract submissions for the2007 AANS Annual Meeting: Celebrating theAANS’ Diamond Jubilee are being accepted untilSept. 15. The Call for Abstracts brochure containinginstructions on the submission process and accessto the online Abstract Center are available atwww.aans.org/annual/2007/abstract.asp.

New Book Tackles Tough Topics Controversies inNeurological Surgery, a new book by Michael T.Lawton, Daryl R. Gress, and Randall T. Higashida,provides insight into trends and controversialissues regarding state-of-the-art techniques inneurosurgery, interventional neuroradiology andendovascular surgery. Copublished by Thieme and

Submitted by Hiroshi Nakano, chair of the

NERVES Survey Committee

T he Second Annual NERVES

(Neurosurgery Executives’ Resource

Value and Education Society) Socio-

Economic Survey was released to participat-

ing neurosurgical practices in April 2006.

The overall response rate from NERVES

member practices was 28 percent. The par-

ticipation of practices in this 2005 survey

increased by 27 percent over participation in

the inaugural 2004 survey, and the number

of neurosurgeons represented in the survey

results increased by 23 percent.

The consulting group of Heaton and Eadie

provided survey design, data collection and

reporting services for the second straight

year. The survey was based on 2004 data.

Survey methodology and overall results from

the first NERVES Socio-Economic Survey

were published in the Fall 2005 issue of

the AANS Bulletin in an article that provided

results of the 2004 survey and highlighted

several areas important to the practice

of neurosurgery.

The data collected through the survey is

demonstrating its value to any neurosurgical

practice that aims to improve operational

and financial results by benchmarking itself

against peer practices.

A comparison of 2005 survey results with

those of the 2004 survey highlighted several

emerging trends that should be watched in

the future, including the following.

3 Practices are looking for additional

sources of revenue. As neurosurgery contin-

ues to face the challenges of falling reim-

bursement, increasing practice costs, and

competition from other specialties, the survey

results showed that an increasing number of

practices are expanding their lines of service

(36 percent reported in 2005 compared with

15 percent in 2004), including the addition of

ancillary services and surgery centers.

3 Neurosurgery incomes are rising.

Despite the concerns of falling reimburse-

ment, the median income for a neurosur-

geon increased by approximately 16 percent

in 2005. Perhaps this is a result of the

increasing interest and success of ancillary

revenue streams or practices are becoming

better managed. Future surveys should help

show this trend. However, this may also sim-

ply be an aberration in the data collection

process, due to increased numbers of prac-

tices reporting for this survey.

3 Malpractice costs continue to rise.

While in certain parts of the country, malprac-

tice premiums are reportedly stabilizing after

several years of large increases, the NERVES

survey reported a 21 percent increase in

average malpractice premiums nationally.

Two data points do not make a trend. But

the availability of practice data through the

NERVES survey is beginning to provide

answers that have long been sought by neuro-

surgeons and their professional practice

administrators. The NERVES organization is

providing a valuable resource for addressing

the socioeconomic issues facing neurosurgery

today. The quality of the data and the value to

neurosurgery will improve as participation

improves. We would ask neurosurgeons to

encourage their administrators to participate in

the survey by joining NERVES. 3

Additional information about NERVES is

available at www.nervesadmin.com.

NERVES Releases Results of Second Annual Neurosurgical Practice Survey

Softball Tournament Has Raised $100,000 for Pediatric Brain Tumor ResearchOn June 10 in New York’s

Central Park, teams

representing eight of

the nation’s medical

centers competed in the

Third Annual Neurosurgery

Charity Softball Tournament

benefiting Columbia Univ-

ersity’s Pediatric Brain

Tumor Research Fund.

Top finishers were the

University of Pennsylvania,

Columbia University and

Mt. Sinai School of

Medicine. The next event

is planned for June 9,

2007 (www.KidsBrain

Research.org).

OFFICERSDonald O. Quest, MD, president

Jon H. Robertson, MD, president-elect

Arthur L. Day, MD, vice-president

James T. Rutka, MD, PhD, secretary

James R. Bean, MD, treasurer

Fremont P. Wirth, MD, past president

DIRECTORS AT LARGEWilliam T. Couldwell, MD, PhD

Robert E. Harbaugh, MD

Christopher M. Loftus, MD

Warren R. Selman, MD

Troy M. Tippett, MD

REGIONAL DIRECTORS

Jeffrey W. Cozzens, MD

R. Patrick Jacob, MD

Stephen T. Onesti, MD

Edie E. Zusman, MD

HISTORIANEugene S. Flamm, MD

EX-OFFICIORick Abbott, MD

P. David Adelson, MD

Charles L. Branch Jr., MD


Fernando G. Diaz, MD, PhD

Andres M. Lozano, MD

Richard K. Osenbach, MD

Setti S. Rengachary, MD

B. Gregory Thompson Jr., MD

Ronald E. Warnick, MD

LIAISONSRichard G. Ellenbogen, MD

H. Derek Fewer, MDIsabelle M. Germano, MD

AANS EXECUTIVE OFFICE5550 Meadowbrook Drive

Rolling Meadows, IL 60008

Phone: (847) 378-0500

(888) 566-AANS

Fax: (847) 378-0600

E-mail: [email protected]

Web site: www.AANS.org

Thomas A. Marshall, executive director

Ronald W. Engelbreit, CPA,deputy executive director

Susan M. Eget, associate executive director-governance

Joni L. Shulman, associate executive director-education & meetings

DEPARTMENTSCommunications, Betsy van Die

Development, Michele S. Gregory

Information Services, Anthony P. Macalindong

Marketing, Kathleen T. Craig

Meeting Services, Patty L. Anderson

Member Services, Chris A. Philips

AANS/CNS WASHINGTON OFFICE725 15th Street, NW, Suite 800

Washington, DC 20005

Phone: (202) 628-2072

Fax: (202) 628-5264

Web site: www.aans.org/legislative/

aans/washington_c.asp


For information or to register call (888) 566-AANS or visit www.aans.org/education.

3 Managing Coding & Reimbursement Challenges in NeurosurgeryPower Coding Sept. 8–9, 2006 Chicago, Ill.

“Coding for the Pros” Nov. 3–4, 2006 Los Angeles, Calif.Prerequisite: AANS coding course taken within two years.

3 Neurosurgery Review by Case Management: Oral Board Preparation

Nov. 5–6, 2006 . . . . . . . . . . . . . . . . . . . . . .Houston, Texas

May 20–22, 2007 . . . . . . . . . . . . . . . . . . . .Houston, Texas

Nov. 4–6, 2007 . . . . . . . . . . . . . . . . . . . . . .Houston, Texas

3 Neurosurgical Practice Management: Improving the Financial Health of Your PracticeSept. 10, 2006 . . . . . . . . . . . . . . . . . . . . . . . . .Chicago, Ill.

E V E N T SC a l e n d a r o f N e u r o s u r g i c a l E v e n t s

AANS Courses

Aspen Symposium on Brain TumorImmunotherapyAug. 7–9, 2006Aspen, [email protected]

2nd International Conference onIntracranial AtherosclerosisAug. 11–12, 2006San Francisco, Calif.www.cme.ucsf.edu

Tennessee Neurosurgical Society+

Aug. 19–20, 2006Chattanooga, Tenn.(423) 265-2233

Hydrocephalus 2006Sept. 6–9, 2006Goteborg, Swedenwww.hydrocephalus2006.com

Spinal Surgery in Elderly PatientsSept. 7–9, 2006Frankfurt, Germanywww.bgu-frankfurt.de

8th Annual InterventionalNeuroradiology SymposiumSept. 8–9, 2006Toronto, Canadawww.cme.utoronto.ca

Egyptian Society of NeurologicalSurgeons: Minimally InvasiveNeurosurgerySept. 13–15, 2006Alexandria, Egyptwww.esns.org.eg

Western Neurosurgical Society+

Sept. 16–19, 2006Blaine, Wash.www.westnsurg.org

56th Annual Meeting of the Congressof Neurological SurgeonsOct. 7–12, 2006Chicago, Ill.www.neurosurgeon.org

American Neurological AssociationAnnual MeetingOct. 8–11, 2006Chicago, Ill.www.aneuroa.org

American Academy of NeurologicalSurgery+

Oct. 18–22, 2006Greensboro, Ga.(602) 406-3159

XXXII Meeting of the Latin American Federation ofNeurosurgical SocietiesOct. 21–26, 2006Buenos Aires, Argentinawww.clan2006.com.ar

Research Updates in Neurobiologyfor NeurosurgeonsOct. 21–28, 2006Woods Hole, Mass.www.societyns.org

Neurocritical Care 2006:SynchronicityNov. 2–5, 2006Baltimore, Md.www.neurocriticalcare.org

3rd International Symposium on Microneurosurgical AnatomyNov. 5–8, 2006Antalya, Turkeywww.isma2006.org

67th Annual American Academy of Physical Medicine and Rehabilitation Annual AssemblyNov. 9–12, 2006Honolulu, Hawaiiwww.aapmr.org

AANS/CNS Section on PediatricNeurological Surgery+

Nov. 28–Dec. 1, 2006Denver, Colo.www.neurosurgery.org/pediatric

19th Annual Contemporary Updateon Disorders of the Spine+

Jan. 13–19, 2007Whistler, Canadawww.cme.hsc.usf.edu/dots

Southern Neurosurgical SocietyAnnual Meeting+

March 15–18, 2007Sea Island, Ga.www.southernneurosurgery.org

75th AANS Annual MeetingApril 14–19, 2007Washington, D.C.www.aans.org

+ These meetings are jointly spon-sored or cosponsored by the AmericanAssociation of Neurological Surgeons.

The frequently updated MeetingsCalendar and continuing medical edu-cation information are available atwww.aans.org/education.

completing the picture - aansneurosurgeon.org

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