CANS NEWSLETTER—April 2006

(A very busy month.)

1.  CANS Board Meeting Notes
2.  President’s Message
3.  Report from Executive Secretary
4.  CSNS and AANS actions in San Francisco  

1.  Board makes some decisions worth knowing
At the April 8th meeting of the Board of Directors, multiple noteworthy issues were addressed:
a.         Lost Members
The Newsletter editor was asked to publish the names of those members who have not paid dues for 2005 and/or 2006 in the hopes of bringing to their attention that they need to become current.  Those who didn’t pay for 2005 may become current by just paying 2006 dues and won’t have to reapply for membership; after July 1st, that group will be dropped from membership and stop receiving the newsletter and have to reapply to get back in the fold. Names are available by contacting the CANS office.

  b.         Senior Membership
Senior status was clarified by defining “retiring from the practice of neurosurgery” as no longer acting as primary surgeon.  Members who are 60 or older or who limit their practice to assisting and/or consulting may apply for Senior status with its reduced dues structure ($50/year or $500 for a lifetime membership).

  c.         Finances
CANS has approximately 60K in reserve (up from 30K a year ago) primarily due to the increased dues structure for active members.  Last year’s P&L was an L of about $4500 primarily due to limited attendance at the annual meeting and courses offered there.

  d.         Dues
The ad hoc Committee on dues structure and lobbying recommended maintaining the active dues at $500 and holding the increased income in reserve to in part fund advocacy for pertinent issues as they arise (see j. below) and to prepare for the attack on MICRA expected next year.

  e.         Neurosurgical Incentives
It was noted that hospitals in some neurosurgically underserved California cities are providing incentives of 800K to one million dollars to attract brain surgeons (hospital DRGs for neurosurgical procedures are still an institutional money maker) while small group practices cannot offer much of a guarantee considering California reimbursement rates which are about the lowest in the country.

  f.          AMA Resolutions
The Board supported two AMA resolutions introduced by California that encourage medical insurance carriers to offer a rider to enrollees covering services provided by non-participating physicians as well as requiring said carriers to use utilization reviewers licensed in the state of patient origin and that the reviewers have comparable training, competence and experience as the treating physician who is requesting authorization.

  g.         AANS Nominations
The Board nominated Jim Bean from Lexington , Kentucky for President-Elect of the AANS.  Dr. Bean came up through the ranks of the Council of State Neurosurgical Societies (CSNS) to become its Chairman, was subsequently named Chairman of the AANS/CNS Washington Committee on his way to presently holding the AANS Treasurer’s position.  Also nominated were Austin Colohan (Loma Linda) and Mike Edwards (Stanford) for Delegate-at-Large seats on the AANS Board plus Larry Shuer (Stanford) and Moose Abou-Samra ( Ventura ) for the AANS nominating Committee.  

h.         Board Travel
The Board reinstituted reimbursement for CANS Board members travel expenses to Board meetings.

  i.          CSNS Update
The Board voted to support the CSNS resolutions listed in last month’s Newsletter with the caveat that the Scope of Practice Guidelines for Advanced Practice Nurses and Physician Assistants be modified to not include ventriculostomy and ICP monitor placement by these folks under any circumstances (see Article 2 below).

  j.          Collective Bargaining
The Board voted to provide up to 5K to investigate and begin the formation of a business entity, entirely separate from CANS, to help groups of neurosurgeons and institutions communicate and bargain so as to improve the availability of neurosurgical ED care.  This activity is being spearheaded by Don Prolo ( San Jose ).

  2.  President’s message for April:  Transitions in Neurosurgery--IV
The American Association of Neurological Surgeons (Cushing Society) held the annual meeting in San Francisco April 22nd through April 27th, and I attended it for a few days.  The large national meetings don’t seem to be as pleasant or satisfy me as they did in the past.  The topics don’t seem as material and provocative or practice related as they were previously and certainly I recognize fewer attendees, and know less neurosurgeons than previously.  This has also been verbalized by others, and may just be evidence of length of time of practice and perhaps not that appreciative of the new modes of style of practice, of perhaps the complicated technologies that have developed.

The current young neurosurgeons probably view the current academics and leadership in the same way we admired Drs. Kahn, Schneider, Sugar, Schwartz, Bucy, Ray, Odom, Evans, Rand , Sweet, Ingraham and Matson, among others.  Names that most young neurosurgeons have never heard or if they have, are probably unable to identify.  The profession just doesn’t seem as cohesive and colorful, but that may be my slanted perspective.

One aspect of the transition of neurosurgery that I view as deleterious is the ongoing fractionation of the specialty. Initially we did most of the carotid endarterectomies; now we do few of them.  Orthopedic spinal surgeons and interventional radiologists have become very active in spine surgery of various types; and the treatment of aneurysms has, to a large part, become interventional radiology.  Pain surgery and treatment has migrated to a large extent to “pain surgeons and physicians” and oncologists more rarely refer pain patients and those CNS lesions caused by metastatic disease.  We have much to offer patients that many in medicine have forgotten, ignored or are not aware of.

Another aspect of neurological surgery that is being threatened is trauma care.  I would direct you to the recent issue of the Journal of the American College of Surgeons, Volume 202 No 4, April 2006.  In an article concerning trauma surgery (pp 655-667), head injuries are specifically cited and it is indicated that trauma surgeons (being renamed to Acute Care Surgeons) support inclusion of “selected neurosurgical and orthopedic trauma related procedures into their training curriculum and practice.” They indicate this is necessary due to the abandonment of trauma care by specialty surgeons.”  Specifically they want to add neurosurgical trauma procedures to their practice.  An editorial, same Journal, pp. 698 – 701, strongly supports this concept and both of these articles should be reviewed by neurological surgeons, and I view this movement as a threat to our specialty.  I view this as surrendering turf that is more properly neurosurgical, providing less quality care to patients.

I do recognize that there is a crisis in emergency room neurosurgical care and in some areas there are too few neurosurgeons available, straining their resources and availability; others avoid providing emergency care due to lifestyle, malpractice exposure and other reasons. Perhaps these latter physicians should have chosen a less demanding specialty as there is some social responsibility involved.  This does not mean that we should provide services without proper emergency coverage stipends and reimbursement possibilities, but that is a separate topic.  Also Neurotrauma and Critical Care News (AANS/CNS) Spring 2006 notes poor patient outcomes by such non-neurosurgical care in Europe .

I believe that we should not allow the Acute Care Surgeons (previously known as Trauma and General Surgeons) to infringe into our specialty.  Again I look forward to responses.

John Bonner M.D., F.A.C.S., CANS President

  3.  Report from the Executive Office
a.         Membership Update:
Welcome to new CANS member Ronnie Mimran, M.D. of Castro Valley .
Four longtime Active members have retired and become Senior members:  Drs. Robert Fink, V. Roy Smith, Murray Thale and Frederick Pitts.

Second notices were sent last week to Active members who have not yet paid 2006 membership dues.  Please submit prior to June 1 to avoid receiving another reminder.

If you are a neurosurgeon practicing in California and you are not a CANS member but would like to be, send a request for a membership packet to janinetash@sbcglobal.net.

  b.         Website
Check the CANS website next week (www.cans1.org/member services) for an EMTALA update from Dr. John Kusske, “Suggestions Regarding Efforts CANS Might Pursue to Ameliorate the Neurosurgery On-Call Question.”  Dr. Kusske represents neurosurgery on a CMS (Centers for Medicare and Medicaid Services) committee, the EMTALA Technical Advisory Group (TAG), which is comprised of 19 physicians who are charged with helping CMS develop rules to protect individual rights while minimizing unnecessary burdens on health care providers.

c.         Workers’ Comp Access to Care
The California Orthopaedic Association has asked CANS to participate in a survey to determine the extent of access problems within the Workers’ Comp system.  You will be receiving this survey very soon and we ask that you participate so that problems (but no names) can be shared with the Division of Workers’ Comp.

  d.         Pain CME
CANS has endorsed a pain management course to be presented by the American Academy of Pain Medicine (AAPM) on June 24-25, 2006 in Newport Beach .  This course will satisfy the 12-hour CME requirement (due by the end of this year) in pain management and end-of-life care mandated by AB487. To register, contact AAPM Member Services at 847 375-4731.  

4.  CSNS Activities and AANS notes from San Francisco
The Council of State Neurosurgical Societies (CSNS), at its meeting on 4/21-22 took the actions on the resolutions as noted below.  The group also noted in a report given by Nick Green, CEO of Neurosurgery Executives' Resource Value and Education Society (Nerves), which counts 65 neurosurgical practices encompassing 365 neurosurgeons as members, that the average income of the 365 was $627,000, that 42% of its members get on-call coverage pay which averages $1476/24 hours.

The group also received an extensive and thoughtful report from the Washington Committee which addressed CSNS’s previously expressed concerns about guidelines published by the AANS, CNS and others as they might pertain to malpractice litigation.  The conclusion of the report was as follows:

“Medical malpractice law and rulings involving practice guidelines are inconsistent and difficult to predict. At some point, any guidelines written by organized neurosurgery will likely become a significant factor during the litigation process and may also have other effects, like PLI coverage, as well. The bottom line is that once guidelines are deemed admissible, it is the jury's job to determine whether they articulate the standard of care in a particular case and what weight to give them. Guidelines are also likely going to play a significant role in the pre-trial process, including the decision to bring a case and settlement discussions. The exact affect on the pre-trial process is hard to determine because there is little information available because cases that are settled or dropped are not typically part of the public record.”

The resolutions considered at the CSNS meeting were dealt with as follows:
Resolution 1—to have a number of socioeconomic questions created by the CSNS appear in the ABNS/MOC re-certification exam.  Accepted.

Resolution 2—to have the AANS and CNS endorse the scope of practice of PA’s and advanced NP’s guidelines created by an ad hoc committee of the CSNS.  These guidelines, among many non-controversial recommendations, do support the placement of parenchymal ICP monitors and ventriculostomies by such personnel without the supervising neurosurgeon being physically present.  Combined with resolution 8 and modified to exclude placement of parenchymal ICP monitors and ventriculostomies by such personnel and then tabled for 6 months at the request of Phil Worth, AANS President, considering the effect it might have on the national debate regarding trauma surgeons practicing neurosurgery (see below).

Resolution 3—to have the AANS and CNS selectively schedule their “national conferences” in states that have adequately addressed the issue of medical liability.  Rejected.

Resolution 4—to endorse the concept that clinical practice guidelines, no matter who publishes them, are optional and if to be used in pay for performance or public reporting programs, must be based on Class I scientific evidence and/or consensus position statements of specialty societies.  Modified to use “AANS or CNS” instead of “specialty societies” and then accepted.

Resolution 5—to create a data bank of all medical liability lawsuits brought against neurosurgeons over the past 10 years to delineate the most common areas and causes for such suits.  Referred for further study.

Resolution 6—to require that all neurosurgeons seeking elective office in the CSNS, AANS or CNS have circulated autobiographical material to include university and hospital affiliations, licensure status, commercial affiliations, disciplinary disclosures and expert witness activity.  Modified to exclude the “disciplinary disclosures and expert witness activity” wording and then accepted.

Resolution 7—to have the AANS and CNS, when they publish evidence based clinical practice guidelines, include a prominent disclaimer indicating the individual neurosurgeon’s judgment is not superseded by such guidelines.  Accepted with slight modification and to be posted on the CSNS Web site—www.CSNSonline.org.

Resolution 8—to have the CSNS formally endorse the guidelines addressed in Resolution 2.  See resolution 2.

Finally, in his AANS Presidential address, Phil Wirth lamented the item in the recent Bulletin of the American College of Surgeons proposing that trauma surgeons, after some additional training, be allowed to place ICP monitors, evacuate clots and perform some orthopedic procedures purportedly in response to sparse neurosurgical/orthopedic coverage of trauma centers (see the CANS President’s comments above).  He suggested that this maneuver by trauma surgeons may be more in response to their failure to fill trauma surgeon residencies than in pursuit of better patient care.  He was particularly miffed because the AANS and CNS were in discussions on a collaborative basis with the ACS as how to best deal with trauma center coverage by neurosurgeons at a time when the ACS representatives knew this inflammatory Bulletin item was in press.  He vowed to keep the AANS on point on this issue and to vigorously oppose such expansion of trauma surgeon activities.  (It was because of the future anticipated debate on this issue that Dr. Wirth felt it was not the right time to be promulgating the Scope of Practice Guidelines for Advanced Practice Nurses and Physician Assistants that include increased activity by these practitioners in the ED trauma setting).  

Randy Smith, M.D., Editor

The newsletter is a mix of fact, rumor and opinion.  The facts are hopefully clearly stated.  The rest is open to interpretation.  The opinion is mine.  R.S

The assistance of Janine Tash and Jack Bonner in the preparation of this newsletter is acknowledged and appreciated.