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The Socioeconomic and Professional Quar terly for AANS Members • Volume 14 No. 4 • Winter 2005 

TIME 

TELLS 

Residents Get Less 

Operative Experience After 

Workweek Restrictions 

I N S I D E T H I S I S S U E 

AANS 

5550 MEADOWBROOK DRIVE 

ROLLING MEADOWS, IL 60008 

NON-PROFIT ORG 

U.S. POSTAGE PAID 

AMERICAN ASSOCIATION OF 

NEUROLOGICAL SURGEONS 

● AANS survey shows the 

PE potential, 26 

● CPT 2006: coding changes, 50 

● The microeconomics of 

cranial surgery, 30 

● Medical error leads to 

paradigm shift, 28

C 

ONTENT 

ONTENTS 

VOLUME 14 NO. 4 

PRESIDENT’S MESSAGE 

5 | Neurosurgery: The Expedition 

The AANS is strategically planning for next year—and for 

neurosurgery’s next 75 years. 

Fremont P. Wirth, MD 

FEATURES 

26 | The PE Potential 

New AANS study supplies a snapshot of physician 

extenders in neurosurgical practices. 

Kathleen T. Craig 

30 | When Neurosurgeons Drop Cranial Surgery Privileges 

Microeconomics may play a role in these decisions. 

Richard N.W. Wohns, MD 

ON THE COVER 

12 | Time Tells: Residents Get Less Operative 

Experience After Workweek Restrictions 

Will the newly minted neurosurgeon you hire be as 

well-trained as you were For academicians and private 

practitioners alike, this is the million-dollar question. 

Now, with more than two years of data available, 

neurosurgery is beginning to apply evidence-based 

methodology to determine the actual impact of the 

restrictions on the medical education of its residents. 

14 | ACGME-Mandated Work Hours: Implementation 

at the University of Oklahoma 

A peer-reviewed study finds that limited work hours 

are feasible, but residents operate less. 

Michael D. Martin, MD, and 

Christopher E. Wolfla, MD 

17 | Work Hour Restrictions: Impact on Neurosurgical 

Resident Training at the University of Utah 

A peer-reviewed study demonstrates significant decreases 

in the operative experience of junior residents. 

Todd McCall, MD, Ganesh Rao, MD, 

and John Kestle, MD 

23 | Restrictions Get Reality Check 

A neurosurgeon assesses the past, present and future 

of resident work hour restrictions. 

Deborah L. Benzil, MD 

46 | MOC Takes Shape 

The ABNS begins its Maintenance of Certification 

program rollout in 2006. 

Ralph G. Dacey Jr., MD, M. Sean Grady, MD, Hunt Batjer, 

MD, and William Chandler, MD 

NEWS AND EVENTS 

7 | Newsline: From the Hill 

Don’t claim unpaid services for indigents as 

charitable deductions. 

8 | Newsline: Neuro News 

FDA approves titanium implant for treatment of 

lumbar spinal stenosis. 

48 | News.org 

The AANS endorses NextGen electronic 

medical record system. 

51 | Calendar of Neurosurgical Events 

AANS Annual Meeting set for April 22–27 in San Francisco. 

OPINION 

52 | AANS Answers 

The AANS serves up success and prepares for 

increased innovation. 

Thomas A. Marshall 

11 | Personal Perspective 

AANS Bulletin delivers data. 

William T. Couldwell, MD 

Volume 14, Number 4 • AANS Bulletin 3

C 

C ONTENTS 

S 

DEPARTMENTS 

41 | Bookshelf 28 | Patient Safety 

New Cushing biography fleshes out neurosurgery’s A medical error results in a neurosurgeon’s 

founder. 

paradigm shift. 

Gary Vander Ark, MD 

Arnold A. Zeal, MD 

50 | Coding Corner 36 | Residents’ Forum 

Payers may lag behind Jan. 1 implementation of CPT To evaluate a new job, rank your priorities and do 

2006 coding changes. your homework. 

Gregory J. Przybylski, MD 

K. Michael Webb, MD, and Lawrence S. Chin, MD 

35 | Computer Ease 39 | Risk Management 

Online learning and performance-assessment tools A physician may be liable when a patient delays 

are evolving. 

surgery with adverse results. 

Joel D. MacDonald, MD 

Michael A. Chabraja, JD, and Monica Wehby, MD 

49 | In Memoriam 

Remembering Lyal G. Leibrock, MD 

James R. Bean, MD 

32 | Medicolegal Update 

Can contracts preclude frivolous lawsuits 

Jeffrey Segal, MD, and Michael J. Sacopulos, JD 

40 | NREF 

NREF corporate partner matches donations 

100 percent. 

Michele S. Gregory 

38 | Timeline 

When their residence isn’t the hospital, what do you 

call physician trainees 

Michael Schulder, MD 

42 | Washington Update 

Contributors to NPHCA support neurosurgery’s 

medical liability campaign. 

AANS MISSION WRITING GUIDELINES Correspondence is assumed to be for publication unless 

The AANS is dedicated to advancing the specialty of neuro- www.aans.org/bulletin otherwise specified. 

logical surgery in order to provide the highest quality of 

neurosurgical care to the public. 

BULLETIN ONLINE 

ARTICLE SUBMISSIONS AND IDEAS 

The current issue and searchable archives to 1995 are 

Articles or article ideas concerning socioeconomic topics 

AANS BULLETIN 

available at www.aans.org/bulletin. 

related to neurosurgery can be submitted to the Bulletin, 

The official publication of the American Association of bulletin@AANS.org. Objective, nonpromotional articles that 

Neurological Surgeons, the Bulletin features news about the are in accordance with the writing guidelines, are original, PUBLICATION INFORMATION 

AANS and the field of neurosurgery, with a special emphasis and have not been published previously may be considered The AANS Bulletin, ISSN 1072-0456, is published four times 

on socioeconomic topics. for publication. a year by the AANS, 5550 Meadowbrook Drive, Rolling 

William T. Couldwell, MD, editor 

The AANS reserves the right to edit articles for compliance 

Meadows, Ill., 60008, and distributed without charge to the 

Robert E. Harbaugh, MD, associate editor 

with publication standards and available space and to 

neurosurgical community. Unless specifically stated otherpublish 

them in the vehicle it deems most appropriate. 

wise, the opinions expressed and statements made in this 

Manda J. Seaver, staff editor 

Articles accepted for publication become the property of the 

publication are the authors’ and do not imply endorsement 

AANS unless another written arrangement has been agreed 

by the AANS. 

BULLETIN ADVISORY BOARD 

upon between the author(s) and the AANS. 

© 2005–2006 by the American Association of Neurological 

Deborah L. Benzil, MD Mick J. Perez-Cruet, MD Surgeons, a 501(c)(6) organization, all rights reserved. 

Frederick A. Boop, MD A. John Popp, MD PEER-REVIEWED RESEARCH Contents may not be reproduced, stored in a retrieval system, 

Alan S. Boulos, MD Gregory J. Przybylski, MD The Bulletin seeks submissions of rigorously researched, or transmitted in any form by any means without prior written 

Lawrence S. Chin, MD Michael Schulder, MD hypothesis-driven articles concerning socioeconomic topics permission of the publisher. 

Fernando G. Diaz, MD Gary D. Vander Ark, MD related to neurosurgery. Selected articles will be reviewed by the 

David F. Jimenez, MD Monica C. Wehby, MD Peer-Review Panel. Submit articles to the Bulletin, 

ADVERTISING SALES 

Patrick W. McCormick, MD Richard N. Wohns, MD bulletin@AANS.org. 

Bill Scully, Cunningham Associates, (201) 767-4170, or 

Katie O. Orrico, JD Peer-Review Panel led by Mick J. Perez-Cruet, MD; bscully@cunnasso.com. Rate card, www.aans.org/bulletin. 

Deborah L. Benzil, MD; William E. Bingaman Jr., MD; 

Frederick A. Boop, MD; Fernando G. Diaz, MD; David F. 

DEPARTMENT EDITORS AND CORRESPONDENTS 

Jimenez, MD; Mark E. Linskey, MD; Richard N. Wohns, MD 

Deborah L. Benzil, MD (Education); Larry Chin, MD 

(Residents' Forum); Fernando Diaz, MD (CSNS Report); 

Alan S. Boulos, MD (Computer Ease); William T. Couldwell, LETTERS 

MD (NS Innovations); Monica Wehby, MD (Risk 

Send your comments on articles you’ve read in these 

Management); Katie O. Orrico, JD (Washington Update); pages or on a topic related to the practice of neurosurgery 

Gregory J. Przybylski, MD (Coding Corner); Michael 

to bulletin@AANS.org. Correspondence may be published 

Schulder, MD (Timeline); Gary Vander Ark (Bookshelf) in a future issue edited for length, clarity and style. 

4 AANS Bulletin • www.AANS.org

P RESIDENT’ S M ESSAGE 

F REMONT P . 

W IRTH, MD 

Neurosurgery: The Expedition 

Strategic Planning Guides the Way 

“I walked down and joined the 

party at their encampment…much 

pleased at having arrived at this 

long-wished-for spot.” 

Meriwether Lewis thus recorded the 

arrival of the Corps of Discovery 

expedition at the junction of the 

Missouri and Yellowstone rivers in 

what today is Montana thinking his company 

was closing in on its goal of finding a 

water route to the Pacific Ocean. Though 

they would not attain their goal for many 

months, Lewis’ journal entry of April 26, 

1805, describes a point at which to reflect 

on the wonders of the journey so far and 

prepare for the yet unknown challenges 

that lay ahead. 

As the nation commemorates the bicentennial 

of Lewis and Clark’s influential 

journey, the AANS prepares for celebration 

of its 75th anniversary, acknowledging an 

expedition of a different kind. It seems an 

appropriate time at which to pause and take 

stock of what our association has accomplished 

and what it seeks to accomplish in 

the future. 

Numerous wonders in neurosurgery 

have come to pass since the association’s 

inception in 1931 as the Harvey Cushing 

Society in homage to that first “neurosurgeon.” 

The venerable icon himself is 

explored in a new biography that reveals 

fresh insights into Cushing’s progress in 

neurological surgery. In many ways, his 

professional journey is early neurosurgery’s 

own. 

Initially the association’s primary goal 

was to serve as an infrastructure for meetings 

that involved “investigation and 

advancement in the fields of neurosurgery, 

with the fundamental needs of establishing 

methods of early diagnosis and postoperative 

treatment, directed toward the protection 

of the patients, and a decrease in 

mortality,” according to Temple Fay, a 

AANS founder. 

Like the Corps of Discovery members 

who equipped themselves for an arduous 

journey and expected the unknown and 

unforeseen—wooly mammoths and pure 

salt mountains were considered among the 

possibilities—the AANS founders prepared 

themselves for an expedition into the estab- 

Fremont P. Wirth, 

MD, is the 2005–2006 

AANS president. He is 

in private practice at 

the Neurological 

Institute of Savannah 

in Georgia. 

lishment and development of a new and 

demanding surgical specialty. Though 

surely they could not have anticipated the 

astonishing technological advances available 

to us today—functional magnetic resonance 

imaging, artificial lumbar discs, 

robotic surgery—the mission they articulated 

pointed the organization in the right 

direction. 

Revitalized Mission, Focused but 

Flexible Goals 

Over the years the AANS has formalized 

and expanded upon its founders’ ideas. 

The current mission and vision statement 

is accessible at www.aans.org/about, and 

we anticipate release of a revitalized mission 

and vision statement during the 75th 

anniversary year. However, that the 

founders’ concerns remain at the core of 

the AANS today is apparent in the association’s 

annual meetings, as the 2006 AANS 

Annual Meeting will exemplify. 

In April, the AANS will convene in San 

Francisco to present its 74th annual neurosurgical 

event under the direction of 

James T. Rutka, MD, annual meeting 

chair, and Mitchel S. Berger, MD, scientific 

program chair. A total of 646 abstracts 

have been selected for presentation at the 

meeting. Over the years the meeting has 

grown to encompass plenary and scientific 

sessions, AANS/CNS subspecialty section 

sessions, breakfast sessions and 

special lectures. Hands-on practical clinics 

hearken to the AANS founders’ concern 

for improved patient outcomes 

through refinement of surgical technique, 

and enjoyable social activities continue to 

foster a collegial spirit. 

While the meeting itself will focus on 

scientific advances that promote quality 

patient care and safety, its theme, Challenges 

of Neurosurgery: Expanding 

Resources for a Growing Population, was 

chosen to ensure that the meeting also 

incorporates valuable information regarding 

the impact of current societal influences 

on the practice of neurosurgery. I 

selected this theme because issues underlying 

workforce and other concerns that are 

significantly challenging our profession 

now and in the next 10 years must be 

uncovered and addressed today. 

To that end, the AANS Task Force on 

Neurosurgical Care and Physician Workforce 

Issues met for the first time in November. 

I asked several neurosurgeons, chosen 

for their seniority and representation of 

various practice situations across the nation, 

to join me in this endeavor: Paul J. Camarata, 

Mark H. Camel, Martin B. Camins, Stewart 

B. Dunsker, Robert Grubb, Hal L. 

Hankinson, Julian T. Hoff, David L. Kelly Jr., 

Lawrence H. Pitts, Donald O. Quest, Robert 

A. Ratcheson, Jon H. Robertson, Richard A. 

Roski,Alex B.Valadka, and Martin H.Weiss. 

Continued on page 6 


P RESIDENT’ S 

M ESSAGE 

Continued from page 5 

After reviewing available information, 

the task force identified distribution of neurosurgical 

services and organization of neurosurgical 

care as areas in need of further 

inquiry. Therefore, the AANS is conducting 

an online workforce survey in early 2006; if 

you are contacted, I encourage you to help 

us in this important effort. The task force 

plans to report on its findings in April. 

Another group, the AANS Physician 

Extenders Task Force, spearheaded a survey 

conducted last fall to discover how neurosurgeons 

are using or would like to use 

nurse practitioners and physician assistants 

in their practices and to discern how they 

are, and should be, trained. Charles Hodge, 

MD, led the effort, the results of which are 

featured in this Bulletin issue. 

Workforce was one of three issues identified 

in my fall column as top AANS concerns; 

the other two topics, medical liability 

reform and physician reimbursement, 

surely are among the forces that are stressing 

the neurosurgical workforce. All three 

areas remain top priorities, and they will be 

addressed in detail in future issues of the 

Bulletin as well as at the annual meeting. 

Progress According to Plan 

Provisioned with a clear mission, today’s 

AANS leadership employs a detailed document, 

the AANS Strategic Plan, which 

maps the way to ensuring that our profession 

maintains excellence in providing our 

patients with high quality neurosurgical 

care while simultaneously addressing professional 

issues such as workforce. The 

strategic planning process was formalized 

in 2003 by A. John Popp, MD, leading the 

Long Range Planning Committee. Since 

then the successive plans have articulated 

goals aligned with the AANS mission, with 

specific tasks then assigned to specific committees 

and tied to the budget. 

For example, in the tradition of professional 

education at the core of the 

AANS mission, a plan goal of developing 

member services and benefits specified a 

task that called for the AANS to reassess 

benefits for young neurosurgeons—our 

profession’s future workforce. Today residents 

in North America not only attend 

the annual meeting at no cost to them, 

they also receive free AANS membership 

and the AANS Journal of Neurosurgery. 

Another task called for the AANS to establish 

a central repository for continuing 

medical education and maintenance of 

certification. The AANS has since worked 

closely with the American Board of Neurological 

Surgery to meet this goal and 

others in advance of the board’s MOC 

program launch in January, and today 

CME credits for MOC are tracked at 

www.MyAANS.org. ABNS directors discuss 

MOC implementation in this issue of 

the Bulletin. 

Challenges...need not 

deter us in pursuing what 

we know to be a worthwhile, 

stimulating profession 

that provides essential 

services to our patients. 

The plan also called for the development 

of member services and benefits via a 

biennial member needs assessment that 

would “assure that members’ feedback is 

continually factored into leadership decision-making.” 

AANS leadership, including 

all the committee volunteers who make this 

organization work, can attest to the value of 

this data in tailoring an association that 

works for you. 

The updated AANS Strategic Plan, currently 

in development by AANS President-Elect 

Don Quest and the Long Range 

Planning Committee, will address financial, 

organizational, customer service and 

advocacy areas of the association. The new 

plan will be detailed in an upcoming issue 

of the Bulletin. 

By providing a consistent yet flexible 

base, the AANS Strategic Plan is an essen- 

tial element for meeting the needs of our 

members and our profession today and 

anticipating the needs of our successors 

another 75 years hence. It also serves to 

remind us that challenges such as workforce, 

medical liability reform and physician 

reimbursement—as I write this, we 

may or may not have staved off the 4.4 percent 

reduction in Medicare physician reimbursement 

scheduled to take place in 

January—need not deter us in pursuing 

what we know to be a worthwhile, stimulating 

profession that provides essential services 

to our patients. 

Taking stock of the AANS’ first 75 years 

inspires great confidence that the organization, 

volunteer leaders and members are 

equipped with the tools, sense of purpose 

and fortitude to meet the challenges yet to 

be imagined and faced. I believe that our 

planning will prove to be as prudent, 

responsible and visionary as that of our 

forebears. 

With appreciation for the journey we 

have taken together and in anticipation of 

what is to come, I thank you for your 

involvement in the AANS and invite your 

future participation in our organization. 

April 26, 2006, exactly 201 years after 

Lewis paused to reflect on his journey at the 

confluence of two great rivers, coincidentally 

will mark the conclusion of my 

sojourn as AANS president. The entire 

AANS leadership team and I are working to 

launch the 75th anniversary year memorably 

at the 2006 Annual Meeting. I hope 

you will join me in San Francisco April 

22–27 not only for superlative science and 

celebration, but also in feeling much 

pleased at having arrived at a long-wishedfor 

spot. 3 

Related Articles 

3 2005 AANS Physician Extender Survey 

results reported, page 26 

3 ABNS directors discuss Maintenance of 

Certification program launch, page 46 

3 New Cushing biography reviewed in 

Bookshelf, page 41 


N 

N EWSLINEE 

WSLINE 

NewsMembersTrendsLegislation 

F R O M T H E H I L L 

HHS Opens IT Office 

Notice of the establishment 

of the Office of 

Health Information 

Technology, a new branch 

of the U.S. Department 

of Health and Human 

Services, was officially 

given in the Federal 

Register on Dec. 27. 

The office’s administrator 

sits on the Health 

Resources and Services 

Administration’s Health 

Care Quality Council. 

Creation of the new 

office is the latest 

evidence of the Bush 

administration’s strong 

support for nationwide 

adoption of health information 

technology, an 

integral component of 

so-called pay-forperformance 

programs. 

3 Don’t Claim Unpaid Services for Indigents as Charitable Deductions As a new year begins, taxes are on 

the minds of many. The AANS Board of Directors recently asked AANS legal counsel for an opinion on 

whether doctors can claim a charitable deduction for the value of uncompensated services performed 

for Medicaid patients or otherwise indigent individuals. “The answer is no, primarily because Congress 

specifically excluded individuals from the list of charitable organizations set forth in the Internal 

Revenue Code,” said Russell M. Pelton, JD. “To receive a charitable deduction for services provided to 

individuals would require an amendment to the Internal Revenue Code by Congress, an event that is 

unlikely to occur in the foreseeable future.” The two main reasons why the value of services performed 

for Medicaid patients are not deductible are that Medicaid patients do not constitute a charitable organization 

within the meaning of section 170(c) of the tax code and that deductions are not allowed for 

the performance of services on behalf of a charitable organization. According to Pelton, a substantial 

number of court decisions hold that services do not constitute property for charitable deduction purposes. 

The full text of the opinion, “Charitable Deduction Issues,” is available at www.AANS.org. 

3 CMS Pledges Rapid Implementation of New Reimbursement Rates Although Congress adjourned in 

December without finalizing budget legislation that would have prevented a 4.4 percent cut to physician 

reimbursement from taking effect Jan. 1, the Centers for Medicare and Medicaid Services advised 

Congress of its readiness to quickly implement the legislation once it is passed. In a letter to Rep. Bill 

Thomas, Herb Kuhn, director of the Center for Medicare Management, said the CMS would instruct 

Medicare contractors to begin paying claims at the revised update of 0.0 percent within two business 

days of the legislation’s passage. Contractors also would be instructed to automatically reprocess claims 

received between Jan. 1 and passage of legislation, relieving physicians of the resubmission process. The 

reprocessed claims would be paid in a lump sum to providers by July 1. The CMS also plans to offer 

physicians a second enrollment period of 45 days following enactment of the budget legislation. 

Complete text of the letter is available at www.aans.org/ltr_to_leadership01_06.pdf. 

3 AANS/CNS Prevent a 3 Percent Reimbursement Cut, Proclaim Victory for Neurosurgeons On Nov. 2 the 

Centers for Medicare and Medicaid Services announced that it would withdraw its proposal of last 

August to change the practice expense calculation under the Medicare fee schedule, thus preventing a 

nearly 3 percent cut in neurosurgeons’ Medicare reimbursement. The AANS and CNS, along with 

numerous other specialty societies, had objected to the proposed changes. The CMS also adopted two 

additional policy changes that will result in increased Medicare reimbursement for neurosurgeons. First, 

the agency made minor modifications to its formula for calculating malpractice expenses. Second, the 

CMS is applying a multiple procedure payment reduction for diagnostic imaging (similar to the multiple 

surgery payment reduction policy). Together, these changes result in a modest 0.5 percent increase in 

reimbursement for neurosurgeons. Regulation CMS-1502-FC can be found at www.cms.gov. 

Frequent updates to 

legislative news are 

available in the 

Legislative Activities 

area of www.AANS.org. 

3 Medical Liability Reform Initiative Progresses In November Doctors for Medical Liability Reform 

released a new animated e-mail message calling for reform. The e-mail message from A. John Popp, MD, 

president of the AANS/CNS advocacy organization Neurosurgeons to Preserve Health Care Access, 

encourages recipients to extend the medical liability reform message by forwarding the e-mail to as 

many people as possible. The e-mail initiative is one facet of the nationwide grassroots education and 

advocacy campaign, Protect Patients Now. More information about the DMLR campaign is available at 

www.protectpatientsnow.org. A listing of donors in 2005 to the NPHCA, an organization that funds the 

DMLR Protect Patients Now campaign, is available in this issue’s Washington Update, page 42. 


N 

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NewsMembersTrendsLegislation 

N E U R O N E W S 

.MD DOMAIN 

OFFICIALLY LAUNCHES 

A domain unique to 

members of the medical 

community, .md, officially 

launched in December. 

The .md domain differs 

from .com and .net 

domains in that it is 

dedicated to physicians, 

healthcare providers and 

medical organizations, 

allowing them to be 

located quickly by 

patients using the 

Internet. Additional 

information is available 

at www.maxmd.md. 

3 FDA Approves Device to Treat Lumbar Spinal Stenosis In November the U.S. Food and Drug 

Administration announced approval of a new titanium implant designed to limit extension of the spine 

in the area affected by lumbar spinal stenosis, which may relieve the painful symptoms if the disorder. The 

X-stop Interspinous Process Decompression System, invented by James Zucherman, MD, fits between the 

spinous processes. “By wedging those bones apart, the tube is indirectly opened up,” explained Dr. 

Zucherman in an Associated Press story. “The bones don’t collapse on the nerves like they did before [and] 

the patient doesn’t have to bend over to protect the nerves.” The X-stop is indicated for treatment of 

patients age 50 or older who have been diagnosed with lumbar spinal stenosis, suffer from pain or cramping 

in the legs, and have undergone a regimen of at least six months of nonoperative treatment. Additional 

information is available at www.fda.gov/cdrh/mda/docs/p040001.html. 

3 Bone Marrow Stem Cell Approach Tested for Children With TBI A phase I trial underway in early 2006 is 

studying the safety and potential of treating children who have sustained traumatic brain injury with stem 

cells from their own bone marrow. The study at the University of Texas Medical School at Houston and 

Memorial Hermann Children’s Hospital involves extracting mesenchymal and hematopoietic stem cells 

from the bone marrow of each of 10 patients between the ages of 5 and 14, processing a stem cell preparation 

and giving it intravenously to the injured child, all within 48 hours of injury. “This would be an 

absolutely novel treatment, the first ever with potential to repair a traumatically damaged brain,” said neurosurgeon 

James Baumgartner, co-principal investigator on the project. 

3 Two Studies Explore Benefits and Risks of Vertebroplasty In two separate studies published in the 

American Journal of Neuroradiology, Mayo Clinic researchers report that patients with compression fractures 

are more functional for up to a year after vertebroplasty, but that the procedure may increase the risk 

of fracture in adjacent vertebrae. In the November–December issue of AJNR, Trout and colleagues report 

results of their retrospective review of patients treated with vertebroplasty who had completed the Roland- 

Morris Disability Questionnaire at baseline and at four points during the year following the procedure. 

Patients’ pain during rest and activity improved an average of seven points one week after treatment and 

remained improved one year following treatment. In the January issue of AJNR, the researchers found 

that following vertebroplasty the risk of new fractures in adjacent vertebrae was 4.62 times the risk for 

nonadjacent vertebrae and that vertebrae adjacent to those treated with vertebroplasty fracture significantly 

sooner than more distant vertebrae. “This is not definitive evidence, but [it] should be considered 

when discussing risks with patients before embarking on vertebroplasty,” said David 

Kallmes, MD, senior study investigator. 

Send Neuro News briefs 

to the Bulletin, 

bulletin@AANS.org. 

3 Door Opens for Drugs That Turn Off Stroke-Induced Brain Damage A new study indicates that the EP1 

receptor on the surface of nerve cells is the switch that triggers brain damage caused by lack of oxygen during 

a stroke or seizure and that ONO-8713 is the compound that can turn the switch off. The study, published 

in the January issue of Toxicological Sciences, found significant differences among mice whose ventricles 

were injected with EP1 stimulator ONO-DI-004, EP1 blocker ONO-8713, or the solvent used to 

carry the drugs. The volume of damage in mice treated first with ONO-8713 was only about 71 percent 

that of the control group injected with only the solvent. The researchers at Johns Hopkins University also 

showed that ONO-8713 can exert its influence only by binding to the EP1 receptor and that the stimulation 

of the EP1 receptors triggers the damage caused when blood flow is restored after a stroke. Researchers 

concluded that future efforts should focus on development of drugs that block the EP1 receptor. 


P ERSONAL P ERSPECTIVE 

W ILLIAM T . 

C OULDWELL, MD 

Considering the Evidence 

AANS Bulletin Delivers Data 

On July 1, 2003, resident work-hour 

restrictions were imposed by the 

Accreditation Council for Graduate 

Medical Education. In this issue of 

the Bulletin, we highlight two studies that 

examine the effects of the 80-hour workweek 

on neurosurgical resident education. 

At the University of Oklahoma, both junior 

and chief residents were exposed to less volume 

of surgery following introduction of 

the restrictions. In the University of Utah 

study, the number of cases in which the 

junior residents were involved decreased 45 

percent after the implementation of the 

work hour restrictions. 

The reduced work hour rules were 

imposed without neurosurgical program 

directors’ input, and many do not agree 

with the changes implemented. Many residents, 

on the other hand, have welcomed 

the work hour limitations. What will be the 

impact of these changes on the practicing 

neurosurgical graduate As noted by Martin 

and Wolfla, while it is apparent that many in 

our field do not agree with these rules, it is 

imperative that further study be carried out 

to ensure that trainees graduating from 

neurosurgical residency are competent. 

Further, while the issue of competency 

has been a concern for many program 

directors, no studies to date have objectively 

assessed the effect of such work 

restrictions on trainee technical competency. 

Will this limitation of experience 

affect competency, or will extra nonwork-hour 

time be compensated by 

increased reading and hence knowledge of 

the resident These questions should be 

the focus for careful analysis over the next 

few years. If the residency training will 

limit technical involvement and competency, 

then we must consider other alternative 

means for education, such as 

surgical simulation training. Alternatively, 

fellowship training will continue to propagate 

as a mechanism to develop competency 

in focused areas of practice. 

As many neurosurgeons are contemplating 

practice restrictions, Richard N.W. 

Wohns, MD, has compiled a thoughtful 

analysis of the microeconomics of per- 

William T. Couldwell, 

MD, is editor of the 

AANS Bulletin. 

forming cranial surgeries. Individual 

neurosurgeons will be able to mirror this 

template analysis and consider the implications 

of ceasing performance of these procedures 

in the context of their own 

particular practice demographics, reimbursement 

patterns, malpractice premiums, 

AANS Bulletin: 

A Top Member Benefit and a 

Leading Predictor of Satisfaction 

With AANS Membership 

The AANS Bulletin is the primary source 

of news that affects the practice of neurosurgery: 

practice management, legislation, 

coding and reimbursement, professional 

development and education, and 

more. Readers are invited to participate 

in the Bulletin: 

Neurosurgical Professionals 

• Write a letter to the editor. 

• Submit an article or article idea. 

and on-call responsibilities. These factors 

impact the profitability of cranial procedures, 

another of the many factors that 

must be considered when weighing the 

decision to restrict one’s practice. 

Also in this issue is an overview of the 

Maintenance of Certification program put 

forth by the American Board of Neurological 

Surgery for rollout in January 2006. 

The key elements are published in the 

MOC handbook and are summarized in 

this issue of the Bulletin. MOC will be a 

foremost consideration for many neurosurgeons 

in the coming years. Neurosurgery 

has been one of the last medical 

specialties to adopt an MOC initiative, and 

we thank the ABNS and the many individuals 

involved with the question-writing 

committee for their efforts in the development 

of the MOC program. 3 

William T. Couldwell, MD, is professor and Joseph J. 

Yager Chair of the Department of Neurosurgery at the 

University of Utah School of Medicine. 

• 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. 


TIME 

TELLS 

Residents Get Less 

Operative Experience 

After Workweek 

Restrictions 

Will the newly minted neurosurgeon you hire be as 

well-trained as you were For academicians and 

private practitioners alike, this is the million-dollar 

question. When the 80-hour workweek for all 

medical residents became effective July 1, 2003, the 

Summer 2003 issue of the AANS Bulletin offered 

an overview of the restrictions that were mandated 

by the Accreditation Council for Graduate 

Medical Education and explored their anticipated 

consequences. An opinion survey by Chang and 

Bell reported that the majority of respondents, 80 

percent of neurosurgical residency program directors 

and 56 percent of residents, said they expected 

the restrictions to have a negative impact on 

neurosurgical training, among other findings. 

Some articles attempted to foresee the future of 

neurosurgical education, exploring workweek 

implementation methodologies and associated 

costs, while others reviewed the cost of New York’s 

405 Regulations, which preceded the ACGME 

restrictions by a decade, and reported the progress 

of federal legislation that threatened to supersede 

the ACGME restrictions. 

Now, with more than two years of data available, 

neurosurgery is beginning to apply evidence-based 

methodology to determine the actual impact of the 

restrictions on the medical education of its residents. 

Authors of the two peer-reviewed studies in this 

issue analyzed data at their own neurosurgery training 

programs to determine the level of compliance 

with the work hour restrictions as well as the impact 

of the restrictions on the operative experience of residents. 

Both studies found compliance with ACGME 

restrictions. Both also found that the number of 

operative cases generally and significantly decreased 

for all residents. Interestingly, the distribution of the 


operative cases between junior and chief residents was 

inverted at the two institutions studied: At the University 

Okalahoma, chief residents performed significantly 

fewer cases compared with data predating 

July 2003, and junior residents, more cases. At the 

University of Utah, junior residents performed 

roughly half the cases they had prior to implementation 

of the restrictions while chief residents’ 

caseload remained largely unchanged. 

Even if the results of these two studies were 

extrapolated to all of neurosurgical education, 

would less operative experience necessarily mean 

that the neo-neurosurgeon you hire won’t be as well 

trained as you were Common sense may suggest an 

affirmative response but, as authors suggest in this 

issue, the answer is far more complex. 

To date, little additional data has been published 

regarding the impact of work hour restrictions on 

neurosurgical education. One study by Cohen- 

Gadol and colleagues surveyed neurosurgical program 

directors and residents in the three months 

immediately following implementation of the work 

hour restrictions. They found that 79 percent of the 

program directors and 61 percent of the residents 

said the ACGME guidelines have had a negative 

effect on their training programs, findings similar 

to those reported by Chang and Bell. The Cohen- 

Gadol study also reported that 93 percent of all 

respondents said the work hour restrictions have 

had a deleterious impact on patient care. 

Of course, improving patient care as well as 

patient and physician safety was the primary aim of 

the ACGME in instituting the restrictions, and this 

also is the focus of related nationwide legislation. 

Whether the ACGME work hour restrictions are 

robust enough to stave off federal legislation 

remains to be seen. Federal legislation that restricts 

resident work hours and increases resident supervision 

has been introduced every year since 2001, 

most recently in the 109th Congress as the Patient 

and Physician Safety and Protection Act of 2005. In 

March H.R. 1228 was referred to the House Ways and 

Means Subcommittee on Health, and in June S. 1297 

was sent to the Senate Committee on Finance. Text of 

each bill is available at http://thomas.loc.gov. 

Data on the cost to neurosurgery programs of 

implementing the restrictions also is scarce in the 

published literature. The annual cost of hiring physician 

extenders to replace residents has been reported 

in the AANS Bulletin to be $350,000 and $400,000 at 

two different training programs. In this issue’s 

“Restrictions Get Reality Check,” the total annual 

cost of implementing work hour restrictions at one 

teaching hospital is estimated at nearly $1 million. 

At least one study outside of neurosurgery 

attempted to analyze cost of the work hour reforms 

in relation to the benefit of preventing adverse 

events. In the October 2005 issue of the Journal of 

Internal Medicine, Nuckols and Escarce concluded 

that a decline in adverse events of 5.1 percent to 8.5 

percent would make the reforms cost-neutral to 

society, but that a much larger drop of 18.5 percent 

to 30.9 percent would be needed to make them costneutral 

for teaching hospitals. 

The impact of the resident work hour restrictions 

on neurosurgery is one of many areas ripe for 

further research. Those interested in pursuing such 

research are encouraged to review the writing 

guidelines for the AANS Bulletin, available at 

www.aans.org/bulletin. 3 

SUMMARY OF ACGME RESTRICTIONS 

Complete information is available at www.acgme.org > Resident Duty Hours. 

3 80 hours per week, averaged over four weeks, inclusive of all in-house call 

activities, with up to a 10 percent exception possible. 

3 One day in seven “off” (one continuous 24-hour period free from all 

clinical, educational, and administrative activities) averaged over four weeks, 

inclusive of call. 

3 10 hours off between all daily duty periods and after in-house call. 

3 In-house call every third night, averaged over four weeks. 

3 24 consecutive hours on-site, including call, with up to six additional hours for 

participating in educational activities and maintaining continuity of medical 

and surgical care. 

“Specialty Specific” Language for Neurological Surgery 

3 Continuous on-site duty, including in-house call, must not exceed 24 consecutive 

hours. Residents may remain on duty for up to six additional hours to participate 

in didactic activities, transfer care of patients, conduct outpatient clinics, and 

maintain continuity of medical and surgical care. This may include resident participation 

in the first surgical case of the day. 

3 No new patients may be accepted after 24 hours of continuous duty. A new 

patient is defined as any patient for whom the neurological surgery service or 

department has not previously provided care. The resident should evaluate the 

patient before participating in surgery. 


On The Cover: Time Tells 

ACGME-Mandated Work Hours: 

Implementation at the University 

of Oklahoma 

PEER-REVIEWED 

RESEARCH 

Michael D. Martin, MD 

University of Oklahoma 

College of Medicine, 

Department of 

Neurological Surgery, 

Oklahoma City, Okla. 

Christopher E. Wolfla, MD 

Medical College of 

Wisconsin, Department of 

Neurological Surgery, 

Milwaukee, Wis. 

Correspondence to: 

M. Martin 

Michael-Martin@ouhsc.edu 

Introduction 

Since July 1, 2003, all residents in U.S. training programs 

have been required to comply with restrictions 

on work hours mandated by the Accreditation 

Council for Graduate Medical Education. Residents 

may work no more than 80 hours per week averaged 

over a four-week period. In addition, specific 

restrictions apply to the number of continuous 

hours that “in-house” and “home call” residents 

may spend in the hospital. These restrictions were 

widely debated before their implementation, and 

the discussion continues today (5,9). 

The purpose of this study was to quantify the 

number of times these limits were exceeded at the 

University of Oklahoma neurosurgery residency program 

since the inception of the 80-hour workweek. 

The study was also designed to characterize the most 

common reasons and situations for violations of the 

work hour rules. Additionally, the impact of the new 

work restrictions on residents’ ability to participate in 

surgical cases was examined. 

Materials and Methods 

The University of Oklahoma accepts one resident per 

year, and the program is seven years in length. The 

Abstract 

All residents in U.S. training programs are required to comply with work hour restrictions 

mandated by the Accreditation Council for Graduate Medical Education. The purpose of 

this retrospective study was to quantify the number of times this limit was exceeded since 

its implementation on July 1, 2003, as well as to gauge the impact of restricted work hours 

on operative case experience of residents. Data from the University of Oklahoma resident 

work hour database was analyzed and incidents of violation were characterized. Operative 

attendance was collected from departmental records. During the study period seven violations 

were recorded. Further investigation revealed that all supposed violations were 

attributable to errors in calculation or data entry and were not truly violations of 

ACGME-mandated rules. Residents were available to assist in more cases the year before 

the work hour restrictions took effect compared to the first year after they were in place. 

The differences were evaluated by the chi-square test and found to be significant (p < 

0.0001). These results suggest that limited duty hours are feasible, albeit with a decrease in 

operative cases in which residents take part. The impact on patient care, continuity and 

training experience, however, must be studied further to determine if work hour restrictions 

are truly in the best interest of trainees and patients. 

department has six residents in the second through 

seventh years of the program. Four residents cover 

the neurosurgery service, with one on elective and 

one in the laboratory at any given time. During the 

study period the department had six attending physicians. 

The facility, which encompasses a children’s 

hospital, veterans hospital, adult hospital and a level 

1 trauma center, has the capacity of approximately 

700 beds. The junior residents take call one night in 

four; senior residents alternate taking backup call 

from home one week at a time. The resident workday 

is 12 hours. Following call, junior residents must 

leave by 10 a.m., while senior residents function on a 

flextime system and must subtract the number of 

extra hours they worked from the following day’s 

time. In other words, a senior resident who comes in 

at night and operates for three hours must leave three 

hours early the next day. 

For this study, a retrospective analysis of data 

taken from the University of Oklahoma resident 

work hour database was performed. The university’s 

data system tracks the in-hospital hours of every 

resident on the campus. Hours are entered daily and 

averages are calculated every four weeks. When a 

resident is found to have exceeded 80 hours, the 

incident is forwarded to the program director and a 

written explanation must be made for the violation. 

The data system also tracks residents by their current 

rotation. Our study used this data to analyze 

and characterize the incidents in which a violation 

occurred. 

For the second part of the study, departmental 

records were reviewed to assess the availability of neurosurgical 

residents to participate in operative cases. 

The department keeps these records, and their accuracy 

is checked in weekly meetings with all members 

of the resident and attending staff and then crosschecked 

with the online ACGME Resident Case Log 

System. For the purpose of this study, bedside procedures 

and stereotactic radiosurgery procedures were 

excluded. Residents are given credit for being present 

for part of the case, and in our internal reporting sys- 


tem only one resident may be credited for each case. 

There is no system in place for measuring the number 

of cases residents had to leave before completion 

due to work hour restrictions or other commitments. 

Results 

During the period from July 1, 2003, to June 28, 2004, 

seven violations were reported by the University of 

Oklahoma resident duty hour database. In two 

instances, residents had entered the wrong information. 

Four instances were termed “frame of reference” 

violations. Examination revealed that these 

incidents did not violate ACGME or university rules, 

but were in fact related to which four-week period 

(or “frame”) the program chose to recognize. The 

other violation involved switching from at-home call 

to in-house call and confusion about the hour calculation 

in these different situations. 

We calculated that junior residents averaged 71.2 

hours per week while on the neurosurgery service, 

52.1 hours per week during the research year, and 

58.2 hours per week while on electives. Senior residents 

averaged 66.8 hours per week, excluding call 

taken from home. 

From July 2002 through June 2003, 1,601 major 

operative procedures were performed in the neurosurgery 

department (Table 1). Residents were unable 

to assist with 146 of these cases, or 9.1 percent. Each 

resident performed an average of 242.5 cases. From 

July 2003 through June 2004, 1,517 major operative 

procedures were performed in the neurosurgery 

department. The department performed fewer operations 

during the second year of the study 

(2003–2004) in part due to the departure of one 

attending neurosurgeon near the end of the study 

period. Residents were unable to be present for 240 

cases, or 15.8 percent. Each resident covered an average 

of 212.8 cases. The difference was evaluated by chisquare 

test and found to be significant (p < 0.0001). 

We then analyzed the operative experience of 

chief residents (Figure 1). During the year before the 

study, chief residents performed 90.2 percent of all 

operations at which a resident was present, or 81.9 

percent of the caseload of the entire service. In the 

year after work hour restrictions were implemented, 

however, the chiefs performed only 81.5 percent of the 

cases that had a resident present, or 68.6 percent of the 

service’s overall caseload. This data was evaluated via 

chi-square testing, and a significant decline was shown 

in chief resident operative experience for both percent 

TABLE 1 

Resident Operative Cases Before and After ACGME 

Resident Work Hour Restrictions 

2002-2003 2003-2004 

Total Cases 1,601 1,517 

Cases Covered by Residents 1,455 1,277 

Cases Not Covered by Residents 146 240 

Junior Resident Cases 143 236 

Chief Resident Cases 1,312 1,041 

of resident-covered cases and percent of all cases they 

performed (p < 0.0001 in both analyses). 

Discussion 

Resident work hour restrictions have forced training 

programs to monitor the hours of their trainees. 

Prior investigations have yielded mixed reviews of 

the restrictions and their impact on surgical training. 

Studies have shown that program directors, practicing 

surgeons and senior residents do not generally 

believe that training has improved as a result of the 

limited work hours (4,10,12–14). Evidence suggests 

that, on the whole, current surgical trainees believe 

that work hour reductions have improved their quality 

of life (3). In one study of otolaryngology program 

directors, 45 percent of respondents felt that 

the restrictions had resulted in increased faculty 

workload (8). Still another study showed that signs of 

“burnout” were unaffected by the decreased work 

hours (6). Some programs have reported difficulty in 

maintaining the new work hour limits due to factors 

such as level 1 trauma status (4) and activities 

deemed to be “noneducational” (2). 

In general, neurosurgery residents and program 

directors have reported that ACMGE guidelines have 

had a negative impact on training and continuity of 

care (4). On the other hand, in some studies more 

residents have reported an improved quality of life 

without a negative impact on training (7). Two 

reports that evaluated general surgery programs 

showed that for their specialty the number of cases 

preformed by chief residents was unaffected by the 

work hour restrictions (11,1). 

Our study is limited in that the data obtained is 

from only one institution and only covers a two-year 

period. The aforementioned lack of surveillance of 

residents who must leave cases early is another 


Received: Sept. 16, 2005 

Accepted: Oct. 10, 2005 

AANS Bulletin 

14:14–16, 2005 

Key Words: 

resident duty hours, 

neurosurgical residency, 

neurosurgical training 

Abbreviations: 

ACGME, Accreditation 

Council for Graduate 

Medical Education 



FIGURE 1 

Chief Resident Operative Cases Before and After ACGME Resident 

Work Hour Restrictions 

Percent of 

“Resident 

Present” Cases 

Covered by 

Chief Resident 

90.2% 

2002-2003 

Total No. Chief Resident Cases: 1,312 

81.5% 

2003-2004 


before the critical portion of the operation was 

accomplished. At this time the long-term effects of 

decreased operative exposure are not known. 

Clearly more research must be done, especially 

regarding the impact that the work hour restrictions 

will have on those currently in neurosurgical training. 

The restricted hours simply have not been in 

place long enough for their impact on lengthy training 

programs such as neurosurgery’s to be fully realized. 

While it is apparent that many in our field do 

not agree with these rules, it is imperative that further 

study be carried out to ensure that trainees graduating 

from neurosurgical residency are equipped to 

operate in this most challenging specialty. 3 

Percent of 

Total Cases 

Covered by 81.9% 

68.6% 

Chief 

Resident 

2002-2003 


2003-2004 



potential piece of information that would make the 

data more robust. We also have made no attempt to 

determine whether the personal preferences of the 

chief residents for certain cases over others may have 

falsely elevated or decreased their numbers. Also, 

although every measure was taken to ensure accurate 

recording, no guarantee can be made that the systems 

used for recording data are without flaws. 

Conclusions 

This study examined the feasibility of working within 

the ACGME-mandated guidelines and the effect 

that the presumably reduced time at work had on 

resident surgical exposure. The results clearly show 

that even in a one-resident-per-year program covering 

four hospitals, compliance can be achieved. This 

compliance, however, was not achieved without significant 

changes to the resident operative experience. 

The percentage of cases not covered by residents 

increased, and further examination revealed that the 

operative experience of the chief residents dropped 

significantly. These numbers are conservative estimates. 

No account can be made for residents who 

may have had to leave the case before completion or 

REFERENCES 

1. Bland KI, Stoll DA, Richardson JD, Britt LD: Brief communication 

of the Residency Review Committee-Surgery (RRC-S) on 

residents’ surgical volume in general surgery. Am J Surg 

190(3):345–350, 2005 

2. Brasel KJ, Pierre AL, Weigelt JA: Resident work hours: what they 

are really doing. Arch Surg 139(5):490–493; discussion 493–494, 

2004 

3. Breen E, Irani JL, Mello MM, Whang EE, Zinner MJ, Ashley SW: 

The future of surgery: today’s residents speak. Curr Surg 

62(5):543–546, 2005 

4. Cohen-Gadol AA, Piepgras DG, Krishnamurthy S, Fessler RD: 

Resident duty hours reform: results of a national survey of the 

program directors and residents in neurosurgery training programs. 

Neurosurgery 56(2):398–403; discussion 398–403, 2005 

5. Friedman WA: Resident duty hours in American neurosurgery. 


6. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson 

SE, Williams RA: Effect of the 80-hour workweek on resident 

burnout. Arch Surg 139(9):933–938; discussion 938–944, 2004 

7. Irani JL, Mello MM, Ashley SW, Whang EE, Zinner MJ, Breen E: 

Surgical residents’ perceptions of the effects of the ACGME duty 

hour requirements 1 year after implementation. Surgery 

138(2):246–253, 2005 

8. Kupferman TA, Lian TS: Implementation of duty hour standards 

in otolaryngology-head and neck surgery residency training. 

Otolaryngol Head Neck Surg 132(6):819–822, 2005 

9. Lowenstein J: Where have all the giants gone Reconciling medical 

education and the traditions of patient care with limitations 

on resident work hours. Perspect Biol Med 46(2):273–282, 2003 

10. Reiter ER, Wong DR: Impact of duty hour limits on resident 

training in otolaryngology. Laryngoscope 115(5):773–779, 2005 

11. Spencer AU, Teitelbaum DH: Impact of work-hour restrictions 

on residents’ operative volume on a subspecialty surgical service. 

J Am Coll Surg 200(5):670–676, 2005 

12. Underwood W, Boyd AJ, Fletcher KE, Lypson ML: Viewpoints 

from generation X: a survey of candidate and associate viewpoints 

on resident duty-hour regulations. J Am Coll Surg 

198(6):989–993, 2004 

13. Whang EE, Mello MM, Ashley SW, Zinner MJ: Implementing 

resident work hour limitations: lessons from the New York State 

experience. Ann Surg 237(4):449–455, 2003 

14. Whang EE, Perez A, Ito H, Mello MM, Ashley SW, Zinner MJ: 

Work hours reform: perceptions and desires of contemporary 

surgical residents. J Am Coll Surg 197(4):624–630, 2003 


Work Hour Restrictions: Impact on 

Neurosurgical Resident Training at 

the University of Utah 

PEER-REVIEWED 

RESEARCH 

Introduction 

In April 2001, the Committee of Interns and Residents, 

the American Medical Student Association, 

and Public Citizen sent a petition to the Occupational 

Safety and Health Administration requesting 

restrictions on resident work hours for all medical 

specialties (4,9). As a result, Rep. John Conyers Jr., D- 

Mich., and Sen. Jon Corzine, D-N.J., introduced the 

Patient and Physician Safety and Protection Act in the 

107th Congress (H.R. 3236 and S. 2614) (5,6). 

Around the same time, the Accreditation Council for 

Graduate Medical Education developed its own 

nationwide guidelines that as of July 1, 2003, restricted 

resident duty hours to 80 averaged over four weeks. 

Arguably, of all surgical residencies, these work 

hour limitations have hit neurosurgical residencies 

the hardest. Unlike many other busy medical and 

surgical residencies, neurosurgical residencies usually 

have only one, and occasionally two or three, residents 

per class. The neurosurgical service at a major 

hospital often has a patient census and operative 

schedule that is as busy as any surgical service. The 

impact of the ACGME work hour restrictions on 

neurosurgical residencies is sure to be significant. 

More than two years after the work hour restrictions 

were mandated, little objective information is 

available regarding their impact on the surgical 

experience and education of neurosurgical residents. 

Many recent reports in the literature that discuss 

perceived effects of the 80-hour workweek 

reflect the experience of general surgery. Most of 

these reports are based on surveys and discuss quality 

of life, continuity-of-care issues, and whether or 

not the rules are beneficial to surgical training 

(1,2,8,9). Cohen-Gadol et al. recently performed a 

survey of residents and program directors in neurosurgery 

training programs that evaluated the perceived 

impact of the ACGME regulations (4), but 

objective data that assess the effect of these regulations 

is scarce in the neurosurgical literature. 

The University of Utah neurosurgery service has 

been compliant with the ACGME workweek rules 

beginning with the 2003–2004 academic year. We 

reviewed the impact of the work hour restrictions on 

the surgical experience at the junior and senior neurosurgical 

resident levels. 


Todd D. McCall, MD, 

Ganesh Rao, MD, and 

John R.W. Kestle, MD 

Department of 

Neurosurgery, 

University of Utah and 

Primary Children’s 

Medical Center, 

Salt Lake City, Utah 

Correspondence to: 

J. Kestle 

john.kestle@hsc.utah.edu 

Received: Nov. 2, 2005 

Accepted: Nov. 14, 2005 

AANS Bulletin 

14:17–22, 2005 

Abstract 

Resident work hour restrictions imposed by the 

Accreditation Council for Graduate Medical Education 

became effective on July 1, 2003. To evaluate the effect of 

these regulations on resident operative experience, we 

reviewed and compared the surgical experience of 

junior and senior neurosurgical residents four years 

before and one year after the ACGME restrictions were 

implemented. Resident work hours since May 2003 and 

operative caseload during the study period were recorded 

in commercially available data systems. The mean 

number of hours worked per week by junior and chief 

residents decreased from 104 and 110 hours before the 

ACGME work hour restrictions to 81 and 84 hours 

afterward, respectively. During the four academic years 

before the work hour limitations took effect, the mean 

number of major cases performed each year was 802.5 

for the chief residents and 849.3 for the junior residents. 

Following the restrictions, little changed for the chief 

residents. However, the junior residents averaged only 

467 cases, a 45 percent decrease from the previous years 

studied. The mean number of cases covered by each 

junior resident per month decreased by 30.5 percent 

after the work hour restrictions were instituted, and the 

mean number of cases covered per post-call junior resident 

in one month declined 47.8 percent, from 23 to 12. 

At our institution, the ACGME work hour restrictions 

have resulted in decreased resident work hours for all 

residents at the expense of the operative experience for 

junior residents. The operative caseload for chief residents 

has not been affected. 

Key Words: 

ACGME; resident work 

hours 

Abbreviations: 

ACGME, Accreditation 

Council for Graduate 

Medical Education 



FIGURE 1 

Work Hours (May 2003-April 2004) 

Mean 130 No. of Resident Work Hours (May 2003–April 2004) 

120 

MEAN HOURS PER WEEK 

110 

100 

90 

80 

CHIEF 

JUNIOR 

ACGME 

70 

60 

50 

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 

The work hours of residents were recorded beginning in May 

2003. The mean number of resident work hours per week is 

graphed on a monthly basis for both junior and chief residents 

over one year. The shaded background represents the maximum 

of 88 hours averaged over four weeks that residents can work 

under the new ACGME guidelines. The 88-hour maximum includes 

an eight-hour extension that the ACGME granted to the University 

of Utah neurosurgical residency program. 


Methods 

Work Hours 

Resident work hours were recorded beginning in 

May 2003, before implementation of the work hour 

restrictions. Residents were required to report their 

work hours weekly using the software TimeClock 

Plus (Data Management, Inc., San Angelo, Texas). 

On July 1, 2003, the ACGME work hour restrictions 

took effect. Briefly, these rules limit the workweek 

to 80 hours averaged over a four-week period 

and place restrictions on the number of hours a resident 

may work after on-call service. The University 

of Utah neurosurgery service was granted the 

optional 10 percent exception, which allowed our 

residents to work an 88-hour average workweek. 

We implemented three changes to the University 

of Utah neurosurgery service to comply with the 

new work hour regulations. First, a senior resident 

was moved from service at the veterans hospital to 

the University of Utah Hospital for coverage of 

junior call responsibilities one day per week and 

chief call one weekend each month. Second, the residents 

on the research elective were each required to 

cover junior call one Friday and one Sunday per 

month. Third, the intern no longer took call with a 

junior resident and became available every weekday 

to help with work on the ward. No physician extenders 

were hired. 

Operative Case Load 

For the duration of the reported years (1999–2004), 

all neurosurgical operative cases at the University of 

Utah Hospital were recorded in a FileMaker database 

(FileMaker Inc., Santa Clara, Calif.). The data for 

each case included the attending physician, assisting 

residents, date, and description of the case. We 

reviewed the caseload for chief residents and for 

junior residents (those in the first or second year of 

neurosurgery residency) in each academic year 


eginning in 1999 and ending in 2004, for a total of 

five academic years. The number of major operative 

cases performed by junior and chief residents as first 

assistant and second assistant was totaled for each 

academic year. The number of major cases performed 

by junior residents per month was totaled. 

Minor procedures, as defined on the ACGME institutional 

data forms (biopsy, intracranial pressure 

monitors, halo tongs, and other), and cases done 

with fellows or residents on research or on neurocritical 

care rotations were not included. Pediatric 

cases, placement of lines, and neurosurgical cases 

managed nonoperatively were not included. 

Before the implementation of the work hour 

restrictions, the post-call day typically was considered 

protected operating time for the junior residents. 

However, the new regulations require residents 

to leave the hospital within six hours of the end of 

their shift. To assess the impact of the work hour 

rules on the post-call day’s operative experience, we 

totaled the number of cases in one month (May) that 

were performed on the post-call days by the junior 

residents before and after the work rules were instituted. 

Additionally, to determine differences in 

operative experience when taking at-home and 

in-hospital call, the total number of junior resident 

cases in May at the University of Utah Hospital was 

compared with similar data at the Primary Children’s 

Medical Center, where the junior resident takes 

home call and therefore is not required to leave the 

facility following on-call service. 

Results 

Work Hours 

The mean number of hours junior residents and 

chief residents worked per week (averaged over four 

weeks) from May 2003 to April 2004 is summarized 

in Figure 1. Before July 1, 2003, junior residents 

averaged 104 hours per week and the chief residents 

averaged 110 hours per week. With the implementation 

of changes to conform to the work hour regulations 

after July 1, 2003, the number of hours 

worked per week decreased to below 88 hours for 

both junior residents (80.7 hours) and chief residents 

(84.2 hours). 

Operative Case Load 

The total number of major operative cases performed 

at the University Hospital has increased steadily over 

the last five years (Figure 2). There was a 26.9 percent 

increase in cases, from 1,123 during the 1999–2000 

academic year to 1,425 during the 2003–2004 academic 

year. During the four academic years preceding 

implementation of the work hour limitations, the 

mean number of major cases performed by the two 

chief residents was 802.5 per year. The mean number 

of major cases performed by junior residents during 

these same four years was 849.3, including 269.5 as 

the first assistant and 579.8 as the second assistant. For 

the academic year 2003–2004, after the work hour 

regulations became effective, the mean number of 

cases performed by the chief residents was 809, but 

the mean number of junior resident cases during that 

same period was 467, including 151 as the first assistant 

and 316 as the second assistant. This represents a 

45 percent decrease in the number of cases performed 

by junior residents. 


FIGURE 2 

Total No. of Major Operative Cases (July 1999–June 2004) 

TOTAL NO. 

Major Operative Cases (July 1999-June 2004) 

1600 

1400 

1200 

1000 

800 

600 

400 

200 

0 

TOTAL UNIV. CASES 

CHIEF 

JUNIOR 

99-00 00-01 01-02 02-03 03-04 

ACADEMIC YEAR 

PEER-REVIEWED 

RESEARCH 

For five consecutive academic years beginning in July 1999, the total number of major neurosurgery 

cases performed at the University of Utah Hospital is reported along with the 

number of cases with junior resident and chief resident involvement. ACGME guidelines for 

resident duty hours took effect at the beginning of the 2003–2004 academic year. Junior 

resident cases combine both first and second assistant experiences. The sum of junior resident 

and chief resident cases can be more than the total number of cases for a given year 

because two residents may be involved with a single case. 




FIGURE 3 

Cases Covered by Junior & Chief Residents 

Percentage of Cases Covered by Junior and Chief Residents 

PERCENT OF CASES COVERED 

80 

70 

60 

50 

40 

30 

20 

10 

0 

99-00 00-01 01-02 02-03 03-04 

ACADEMIC YEAR 

CHIEF 

JUNIOR 

The percentage of total neurosurgery cases covered by junior and chief residents was calculated 

for each academic year to correct for the variable number of total operative cases in each year. 

FIGURE 4 

Mean No. of Operative Cases for Junior Residents in One Month 

Number Operative Cases for Junior Residents in One Month 

MEAN NO. 

30 

25 

20 

15 

10 

5 

0 

3 

4 5 

99-00 00-01 01-02 02-03 03-04 

ACADEMIC YEAR 

The mean number of operative cases for a single junior resident per month was calculated to correct 

for the variable number of junior residents each year. For each time point, the number of junior 

residents that year is indicated. In the 2003–2004 academic year the number of junior residents 

decreased by 50 percent from the previous year. Therefore, even though there were more total 

operative cases on the university service per junior resident, the number of cases per month that 

junior residents operated still declined. 

6 

3 

Both the number of operative cases and the number 

of junior residents varied in each academic year 

studied. To correct for the variable number of operative 

cases in each year, the percentage of total neurosurgery 

cases covered by junior residents and chief 

residents was calculated for each academic year (Figure 

3). There was a 52.5 percent decline in the percentage 

of total neurosurgery cases at the University 

of Utah Hospital with junior resident involvement. 

To correct for the variable number of junior residents 

each year, the mean number of cases per junior resident 

per month was calculated (Figure 4). During the 

2003–2004 academic year, each junior resident was 

involved in an average of 18 cases per month, which 

represents a 30.5 percent decline from the previous 

four academic years, when each junior resident averaged 

involvement in 25.9 cases per month. 

To evaluate the impact of the work hour restrictions 

on the post-call operative experience of junior 

residents, operative data for May 2003 was compared 

with data for May 2004. The number of cases covered 

per post-call junior resident declined from 23 before 

the restrictions to 12 after they were instituted (Figure 

5). At University Hospital the total number of 

cases performed by all post-call junior residents 

declined from 50 before the restrictions to 25 after the 

restrictions, compared with a decline from 42 to 36 

cases at Primary Children’s Medical Center (Figure 6). 

Discussion 

Several studies have evaluated the attitudes of both 

resident and attending general surgeons toward the 

work hour limitation (1,2,8-10). Not surprisingly, the 

attitudes toward the new rules have been mixed. 

Many studies have shown that senior residents and 

faculty view these new rules as having a negative 

impact on surgical training, whereas junior residents 

tend to view them favorably. However, these studies 

do not objectively address the impact that the 

restricted work hours have on the technical aspects of 

training a surgeon. The authors of one survey-based 

study reported that among surgical residents, 44 percent 

believed that the work hour restrictions would 

negatively impact the surgical experience (1). This 

same study showed that the number of cases performed 

by graduating chief residents actually 

increased after the work hour restrictions were in 

place. More recently, Cohen-Gadol et al. reported 

that the majority of residents (61 percent) and program 

directors (79 percent) believed that the 


FIGURE 5 

No. of 

Operative 

Operative 

Cases 

Cases Covered 

Covered 

per 

by Post-call 

Post-Call Junior Junior Residents Resident in In One One Month Month 

TOTAL NO. 

25 

20 

15 

10 

5 

0 

02-03 03-04 

ACADEMIC YEAR 

The total number of operative cases performed by post-call 

junior residents during one month was tallied for the 

academic years before (2002–2003) and after (2003–2004) 

the ACGME guidelines became effective. There was a 

47.8 percent decline in junior residents’ operative experience 

after implementation of the work hour restrictions. 

experience. Residents at the junior levels are those 

who take in-hospital call, work 24-hour shifts, are 

primarily responsible for patient care, and are the 

target of the work hour restrictions. These are the 

residents who likely will lose out on operative experience. 

Our study shows that, indeed, residents at the 

junior levels suffer a decrease in operative experience. 

Since the implementation of the restrictions on 

work hours, at our institution the number of cases 

with junior resident involvement has declined by 45 

percent, and the percentage of cases covered by 

junior residents declined by 52.5 percent. The 

absolute number of cases performed by junior residents 

can be influenced by several factors, such as 

the total number of available operative cases and 

the number of junior residents. At our institution, 

the total number of operative cases has increased 

26.9 percent in the past five years, suggesting that 

without the new ACGME regulations, the operative 

volume of the junior residents would have 

increased. We corrected for the varying number of 

junior residents each year by calculating the mean 

number of operative cases for a single junior resident 

per month. In the four years before the 

ACGME regulations were implemented, each junior 

resident averaged 25.9 cases per month and the year 

after, 18 cases per month, a 30.5 percent decline. 

Therefore, we believe that the decline in the number 

of cases performed by junior residents in the 

2003–2004 academic year most likely is explained 

by the ACGME work restrictions. 

To be compliant, programs have had to make 

drastic changes in the way their resident staff is used. 

These changes have included the addition of physician 

extenders, such as nurse practitioners or 

physician assistants, as well as drawing residents from 

the previously protected research rotations into the 

clinical service (3). 

We did not employ physician extenders at our 

institution during the period of this study. Instead, 

residents on their research year took additional 

junior call, and a senior resident from the veterans 

hospital was added to the University of Utah service. 

As a result, the added senior resident was able 

to provide operative coverage that was lost when 

junior residents began going home following their 

on-call service. The post-call operative experience 

that had been significant at our program for junior 

residents decreased 47.8 percent after we became 

ACGME guidelines have had a detrimental effect on 

their training programs (4). 

No study to date has examined the impact of the 

ACGME regulations on the junior resident operative compliant with the new ACGME guidelines. At Pri 

. . . . . . 

mary Children’s Medical Center, where the junior 

resident takes home call and therefore does not 

leave the facility after on-call service, total junior 

resident operative cases for one month only 

declined 14.3 percent after the new work hour 

restrictions were implemented compared with a 50 

percent decline at the University of Utah Hospital 

service. Chief residents generally are not affected by 

the post-call restrictions, and therefore their operative 

caseload has not diminished. 

We considered a number of strategies for 

improving the operative experience of our junior 

residents. In one study, 22 percent of resident work 

hours were unrelated to educational activities (2). 

We therefore hired a physician assistant to perform 

noneducational duties, freeing the junior residents 

for the operating room. Since this change, the 

monthly operative caseload for the junior residents 


PEER-REVIEWED 

RESEARCH 



FIGURE 6 

Operative Cases for Junior 

Total No. of Operative Cases in One Month 

Residents in One Month 

for Junior Residents 

TOTAL NO. 

60 

50 

40 

30 

20 

10 

0 

Primary Children’s 

Medical Center 

Univ. of Utah Hospital 

02-03 03-04 

ACADEMIC YEAR 

The total number of operative cases performed by all post-call 

junior residents during one month at Primary Children’s Medical 

Center was compared with the number at the University of Utah 

Hospital for the academic years before (2002–2003) and after 

(2003–2004) the ACGME guidelines became effective. 


cover junior duties and allowing the junior residents 

to operate on less complicated cases. 

CHIEF 

Conclusions 

JUNIOR 

The ACGME restrictions on resident work hours 

represent a paradigm shift in the education of surgical 

residents in the United States. These new restrictions 

are likely to affect several issues, including 

patient care, resident training, resident health, and 

resident quality of life. This study addresses one 

aspect of resident training: the operative experience. 

At our institution, we have managed to comply with 

the 80-hour workweek at the expense of the operative 

experience of the junior residents. Any analysis of 

the ACGME work hour restrictions will need to consider 

the impact of these regulations on several different 

aspects of resident training, such as number of 

publications, board scores, and serial faculty evaluations, 

as well as on patient care. As additional objective 

data become available for assessing the impact of 

the ACGME regulations, residency programs will 

need to be able to develop strategies to optimize the 

residents’ learning experience while maintaining 

high standards of patient safety. 3 

has increased to 21 per month. Less desirable 

options, which we have not implemented, include ACKNOWLEDGMENTS 

increasing the length of residency, decreasing the The authors thank Kristin Kraus for her assistance in preparing 

research training period, or having chief residents this manuscript for submission and publication. 

. . . . . . 

REFERENCES 

1. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ 3rd: 

Effects of limited work hours on surgical training. J Am Coll 

Surg 195(4):531–538, 2002 

2. Brasel KJ, Pierre AL, Weigelt JA: Resident work hours: what they 

are really doing. Arch Surg 139(5):490-493; discussion 493–494, 

2004 

3. Chandra RK: The resident 80-hour work week: how has it 

affected surgical specialties Laryngoscope 114(8):1394–1398; 

discussion 1319, 2004 


Resident duty hour reform: results of a national survey of the 


Neurosurgery 56(2):398–402, 2005 

5. Conyers JR: Patient and Physician Safety and Protection Act of 

2001. H.R. 3236, 2001 

6. Corzine JS: Patient and Physician Safety and Protection Act of 

2002. S. 2614, 2002 

7. Friedman WA: Resident duty hours in American neurosurgery. 


8. Niederee MJ, Knudtson JL, Byrnes MC, Helmer SD, Smith RS: A 

survey of residents and faculty regarding work hour limitations 

in surgical training programs. Arch Surg 138(6):663-669; discussion 

669–671, 2003 

9. Underwood W, Boyd AJ, Fletcher KE, Lypson ML: Viewpoints 

from generation X: a survey of candidate and associate viewpoints 

on resident duty-hour regulations. J Am Coll Surg 

198(6):989–993, 2004 

10. Whang EE, Perez A, Ito H, Mello MM, Ashley SW, Zinner MJ: 

Work hours reform: perceptions and desires of contemporary 

surgical residents. J Am Coll Surg 197(4):624–630, 2003 


Restrictions Get Reality Check 

Assessing the Past, Present and Future of Resident 

Work Hour Restrictions 

PERSPECTIVE 

DEBORAH L. BENZIL,MD 

Listening to colleagues across the country discuss 

their perceptions of the post-July 2003 environment, 

I hear hauntingly familiar refrains, the same ones that 

echoed throughout New York more than 10 years ago 

when the state began to enforce its own resident work 

hour restrictions. Because academicians, including 

neurosurgeons, learned little from the New York 

experience, many will be doomed to repeat the failures 

of others, perhaps at the expense of resident satisfaction, 

faculty attrition, and sadly, quality of care 

for our patients. 

Perhaps the most common refrain is that the new 

resident work hour restrictions, which were mandated 

nationally by the Accreditation Council for Graduate 

Medical Education, will debase the profession of 

medicine resulting in a “shift-worker mentality” 

attended by failure to commit to the best care for our 

patients. Anecdotes abound of residents leaving in the 

middle of cardiac arrest codes, showing up late for 

rounds because they were entitled to their required 

time off, and similar behaviors. But these remain 

anecdotes, less valid scientifically than case reports, 

and the new reality has yet to be assessed. 

It is likely that the full impact of the ACGME resident 

work hour restrictions will not be understood 

for a generation, when the residents training under 

this new system gain seniority and assume roles as 

program directors and chairs of departments. At this 

time, two years into national implementation of the 

80-hour resident workweek, a brief look at the history 

of this reform and at how the future success or failure 

of this change will be assessed may be instructive. 

Into the Past 

Resident work hour restrictions, arguably medical 

education’s most sweeping reform in this century, 

evolved following the death of Libby Zion at a New 

York Hospital in March 1984. A junior resident 

admitted her with fever, chills and dehydration; by the 

next morning, she had died. While the exact cause of 

her death has never been determined, a New York 

grand jury investigation in 1986 found that the death 

was related to 36-hour 

sleepless resident shifts 

and inadequate supervision 

by attending 

physicians. 

Sidney Zion, Libby 

Zion’s father and also a 

newspaper columnist 

and attorney, sued New 

York Hospital and the 

physicians for malpractice. 

More than the 

malpractice case, he 

began a crusade against the system, targeting the long 

resident work hours and poor supervision that he felt 

had contributed to his daughter’s wrongful death. 

The publicity surrounding this case led the New 

York Health Commissioner in 1987 to form an ad hoc 

advisory committee chaired by Bertrand Bell, a professor 

of medicine at Albert Einstein College of Medicine. 

The committee’s strong recommendation to 

restrict resident work hours led to New York State 

health code legislation enacted July 1, 1989, commonly 

known as the 405 Regulations. Sidney Zion, 

however, continued to campaign, claiming that many 

hospitals were wantonly ignoring the code. In 1998, 

stiff hospital penalties were added. Initial violations 

could be fined up to $6,000 per violation with followup 

violations escalating to $25,000 and then $50,000. 

While New York hospitals were struggling with the 

405 Regulations, the push to implement national 

work hour restrictions began. In 2002 the ACGME 

announced its intention to impose national duty 

hour regulations effective July 1, 2003. 

A Look at the Present 

Assessment of the effect of the 80-hour resident 

workweek within much of surgery has emphasized 

the loss of surgical case volume and the dilution of the 

surgical training experience (3,11,13). The two studies 

published in this issue of the AANS Bulletin 

demonstrate the reduced number of cases in which 





neurosurgical residents are participating following 

implementation of the work hour restrictions. Unfortunately, 

little is known about how many procedures 

a resident must do to achieve competence or to attain 

the necessary balance of didactics, patient care, and 

technical training. Clearly individual residents follow 

very different learning curves. Surgical simulators, 

which increasingly are being used for both training 

and assessment of technical skills (6,7,9,15), may at 

least partially fill the gap in operative experience 

opened by the restrictions and also provide additional 

exposure to particular techniques. Some have even 

suggested applying the model of flight training to resident 

education, requiring residents to have simulation 

experience before they are awarded any patient 

responsibility (12). 

While volume of surgical cases always will be an 

important factor in technical training, many other 

factors may also be crucial to achieving technical 

proficiency. At the same time, fatigue, the technical 

and supervisory skill of the attending surgeon and 

the resident’s own preparation all may affect the 

ability to learn surgical technique. Increasing evidence 

has emerged about the effect of fatigue on 

medical errors (4,16), resident safety (1), and resident 

burnout (14). The impact of this research on 

the public is far greater than the multitude of more 

descriptive studies on attitudes and perceptions. To 

date, few studies have even tried to assess the impact 

of resident work hour restrictions on quality of 

patient care (2). Several studies have raised the concern 

of continuity of care but without clear evidence 

that it has been compromised by the 

restrictions (10,17). Just one study has addressed 

the issue of patient satisfaction and physician 

fatigue, finding that rested residents received consistently 

higher ratings from patients (8). 

Attention also has been given to resident attitudes 

and the increasing time and responsibility on attending 

physicians (5,14,20). At least one study failed to 

document increased faculty hours (19). Most studies 

of resident attitudes and perceptions are most notable 

for the differences expressed by senior and junior residents, 

with junior residents generally more likely to 

view the 80-hour workweek positively (10,17,18). 

This may be a reflection of the longer hours junior 

residents typically work or of a wider acceptance of 

the new paradigm of training permeating medical 

schools. This dichotomy of attitudes supports the idea 

that assessing the full impact of these changes may 

take many years, perhaps a “training generation.” 

A Note on Cost 

To date, little public consideration has been given to 

the cost of this mandate. When penalties were instituted 

for violation of New York’s 405 Regulations, 

the state provided significant funding to hospitals to 

balance the new costs. Unfortunately, over time 

these added monies were withdrawn, though the 

higher costs remain in place and new funding was 

not appropriated with the institution of the national 

ACGME regulations. 

At my own institution, three full-time nurse 

practitioners were hired in the neurosurgery 

department at a cost of $375,000 per year to cover 

120 hours of “lost” resident time, and conference 

time for neurosurgery residents declined by 25 percent. 

To compensate for its own loss of 120 hours of 

resident time, the orthopedics department hired 

five physician extenders at an annual cost of 

$520,000 and recalled two “away” residents to the 

primary institution. The hospital also hired a compliance 

officer, initially half time, then full time at a 

cost of $80,000 per year, as well as ancillary staff at 

an estimated cost of $250,000 per year. These hospital-wide 

costs were shared by the neurosurgery 

and orthopedics departments, bringing the annual 

cost of the work hour restrictions for just two surgical 

specialties at one hospital to nearly $1 million. 

Implementation of the work hour restrictions 

also has coincided with that of several other 

unfunded mandates: maintenance of certification, 

ACGME Core Competency Assessments, and the 

Health Insurance Portability and Accountability 

Act—all hitting at a time when most medical institutions 

have little operating surplus. While few in 

organized medicine argue with the concepts of 

maintaining patient confidentiality, error reduction, 

provision of quality care, and developing 

sound resident education and evaluation, the 

accompanying cost makes embracing these programs 

more difficult. At least some of the funding 

for these mandates has negatively impacted physician 

salaries. How this will impact retention and 

recruitment of faculty into academic programs 

remains to be seen. 

The Prospective Reality 

In the future, will expectation of a more reasonable 


workweek make entering medical school more 

appealing to a wider range of applicants Will traditionally 

time-demanding subspecialties like neurosurgery 

become more appealing by leveling the time 

component of the playing field Medical students 

entering new residencies in 2006 will have started 

medical school knowing of the 80-hour restriction. 

Soon after, we can more fully understand how the 

new landscape will be shaped. 

It has always been surprising to me that once 

neurosurgeons leave residency, they have the magical 

ability not only to forget the physical and mental 

stress of those years but to look back on them as the 

best years of their lives! Many who then enter academic 

medicine find it difficult to fathom another system 

that could successfully train competent neurosurgeons. 

However, rather than resisting the restrictions 

that already are in place, perhaps neurosurgery 

would be better served by participating in a concerted 

effort to assess the success or failure of this major 

paradigm shift on the quality of resident education 

and patient care. By understanding the critical factors 

that contribute to successful resident education and 

technical training, including work schedules, we will 

meet the goals of medical education. 3 

Deborah L. Benzil, MD, is associate professor at New York 

Medical College, Valhalla, N.Y., and a neurosurgeon at 

Westchester Spine and Brain Surgery PLLC, Hartsdale, N.Y. 

Avinash Mohan, MD, a resident at New York Medical College, 

contributed to this article. 

REFERENCES 

1. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA: Neurobehavioral 

performance of residents after heavy night call vs. 

after alcohol ingestion. JAMA 294(9):1025-33, 2005 

2. Bailit JL, Blanchard MH: The effect of house staff working 

hours on the quality of obstetric and gynecologic care. Obstet 

Gynecol 103(4):613-6, 2004 

3. Blanchard MH, Amini SB, Frank TM: Impact of work hour 

restrictions on resident case experience in an obstetrics and 

gynecology residency program. Am J Obstet Gynecol 

191(5):1746-51, 2004 

4. Boult M: Patient safety. The fatigue factor. Health Serv J 

115(5962):34-5, 2005 


Resident duty hours reform: results of a national survey of the 


Neurosurgery 56(2):398-403; discussion 398-403, 2005 

6. Dupuis O, Silveira R, Zentner A, Dittmar A, Gaucherand P, 

Cucherat M, et al.: Birth simulator: reliability of transvaginal 

assessment of fetal head station as defined by the American College 

of Obstetricians and Gynecologists classification. Am J 

Obstet Gynecol 192(3):868-74, 2005 

7. Fichera A, Prachand V, Kives S, Levine R, Hasson H: Physical 

reality simulation for training of laparoscopists in the 21st century. 

A multispecialty, multi-institutional study. JSLS 9(2):125-9, 

2005 

8. Hoellein AR, Feddock CA, Griffith CH 3rd, Wilson JF, Barnett 

DR, Bass PF 3rd, Caudill ST: Are continuity clinic patients less 

satisfied when the resident is postcall J Gen Intern Med 19(5 Pt 

2):562-5, 2004 

9. Korndorffer JR Jr, Dunne JB, Sierra R, Stefanidis D, Touchard 

CL, Scott DJ: Simulator training for laparoscopic suturing using 

performance goals translates to the operating room. J Am Coll 

Surg 201(1):23-9, 2005 

10. Kort KC, Pavone LA, Jensen E, Haque E, Newman N, Kittur D: Resident 

perceptions of the impact of work-hour restrictions on health 

care delivery and surgical education: time for transformational 

change. Surgery 136(4):861-71, 2004 

11. McElearney ST, Saalwachter AR, Hedrick TL, Pruett TL, Sanfey HA, 

Sawyer RG: Effect of the 80-hour work week on cases performed by 

general surgery residents. Am Surg 71(7):552-5; discussion 555-6, 

2005 

12. Sexton JB, Thomas EJ, Helmreich RL: Error, stress, and teamwork in 

medicine and aviation: cross sectional surveys. BMJ 320(7237):745 

9, 2000 

13. Spencer AU, Teitelbaum DH: Impact of work-hour restrictions on 

residents’ operative volume on a subspecialty surgical service. J Am 

Coll Surg 200(5):670-6, 2005 

14. Stamp T, Termuhlen P, Miller S, Nolan D, Hutzel P, Gilchrist J, Johnson 

RM: Before and after resident work hour limitations: an objective 

assessment of the well-being of surgical residents. Curr Surg 

62(1):117-21, 2005 

15. Stefanidis D, Korndorffer JR Jr, Sierra R, Touchard C, Dunne JB, 

Scott DJ: Skill retention following proficiency-based laparoscopic 

simulator training. Surgery 138(2):165-70, 2005 

16. Veasey S, Rosen R, Barzansky B, Rosen I, Owens J: Sleep loss and 

fatigue in residency training: a reappraisal. JAMA 288(9):1116-24, 

2002 

17. Whang EE, Mello MM, Ashley SW, Zinner MJ: Implementing resident 

work hour limitations: lessons from the New York State experience. 

Ann Surg 237(4):449-55, 2003 

18. Whang EE, Perez A, Ito H, Mello MM, Ashley SW, Zinner MJ: Work 

hours reform: perceptions and desires of contemporary surgical residents. 

J Am Coll Surg 197(4):624-30, 2003 

19. Winslow ER, Berger L, Klingensmith ME: Has the 80-hour work 

week increased faculty hours Curr Surg 61(6):602-8, 2004 

20. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P: The early 

effects of code 405 work rules on attitudes of orthopaedic residents 

and attending surgeons. J Bone Joint Surg Am 87(4):903-8, 2005 


The PE Potential 

New AANS Study Shows Snapshot of Physician Extenders in Neurosurgical Practices 

KATHLEEN T. CRAIG 

Neurosurgeons recently have expressed great concern over 

workforce issues. While the need for neurosurgical care 

has increased, the supply of neurosurgeons to deliver 

that care has remained the same or declined, particularly 

in areas of the country outside urban centers and in 

states experiencing a medical liability crisis. 

“The growth of America’s population and the increasing 

longevity of its citizens are being met with a decreasing number of 

neurosurgeons to provide care for them,” said AANS President Fremont 

P. Wirth, MD.“Recently, there has been significant discussion 

regarding the use of physician extenders in neurosurgery, and how 

they could be used to alleviate the current strain.” 

Physician extenders, a collective term for nurse practitioners and 

physician assistants, also have become increasingly important to 

training programs in order to help compensate for lost resident 

time related to work hour restrictions. Similarly, physician extenders 

appear to be playing an increasingly important role in the practice 

of neurosurgery by helping to facilitate the efficient use of 

neurosurgeons’ time. 

In fall 2005 the AANS surveyed members in the Active and 

Active Provisional categories, specifically addressing: 

WHY EMPLOY PHYSICIAN EXTENDERS 

26.3% 

Other 

29.2% 

Ease demands of 

ER coverage 

28.6% 

Satisfy resident 

work hours rules 

34.9% 

Help residents 

manage their 

responsibilities 

74.2% 

Increase 

patient volume 

in the office 

69.5% 

Assist in the OR 

In the 2005 AANS Physician Extender Survey, respondents who currently employ physician 

extenders were asked how they are using PEs, and those not currently employing 

PEs were asked how their practices would like to use them. Because respondents 

could check any option that applied, results do not sum to 100 percent. 

3 how members use or would like to use, physician extenders in 

their practices; 

3 which neurosurgical procedures physician extenders should be 

trained to perform; 

3 how physician extenders currently are trained in neurosurgical 

procedures and how members would like them to be trained in the 

future; and 

3 which educational resources the AANS currently offers that 

might meet physician extender needs, and what should be developed 

in the future. 

Charles J. Hodge Jr., MD, the AANS vice president during fiscal 

2005 and the head of the Physician Extenders Task Force, led the 

survey project, which ultimately was administered by a contracted 

research firm. The online survey garnered 524 responses and a 

robust sample size of 380 or more for most questions. Therefore, 

researchers are 95 percent confident that results presented in the 

survey report have accuracy of plus-or-minus 5 percent or better, 

which essentially means that if the survey was implemented one 

hundred times, the results would be the same 95 times. 

The survey results are being used by the AANS Long Range 

Planning Committee and the AANS Physician Extenders Task Force 

in their planning. The first of the resulting initiatives will be 

launched during the 2006 AANS Annual Meeting in San Francisco. 

Respondent Profile 

About half of the respondents were from private practices. Another 

28 percent were full-time academicians. Forty percent of respondents 

indicated that their practice settings were small (two-to-five 

neurosurgeons), and 24 percent selected medium (six-to-20 neurosurgeons 

and neurosurgical groups). These figures are consistent 

with the AANS Member Needs survey taken in 2004, and demonstrate 

a representative sample of membership. 

Use of Physician Extenders 

Seventy-four percent of respondents indicated that they employ 

physician extenders. Of these, just over half have been using physician 

extenders for more than five years. Another 40 percent have 

been using them for two-to-five years. When physicians in university 

settings were asked with whom extenders primarily work, 76 

percent responded “attendings,” and 18 percent, “residents.” 

The AANS also asked members if they felt their practices were 


in need of physician extenders (regardless of whether they currently 

employ them). A slight majority of respondents, 53 percent, 

said that their practices are in need of physician extender assistance 

compared with 47 percent who did not. 

Survey respondents who currently employ physician extenders 

were asked how they are using PEs, and those not currently 

employing PEs were asked how their practices would like to use 

them. Respondents could check any option that applied (multiple 

options). 

Most respondents identified “hospital based patient evaluation 

and management” (74 percent) and “office patient evaluation and 

management” (73 percent) as among the duties for physician extenders. 

The selection “phone call returns/administrative duties (letters 

of appeals)” generated 70 percent of responses, and 64 percent 

selected “first assist in the operating room.”When asked specifically 

about which invasive procedures they would like physician extenders 

to perform, top choices were suturing (58 percent) and lumbar 

punctures (36 percent). 

The pie chart on page 26 illustrates reasons for employing physician 

extenders. As shown, most respondents selected to “increase 

patient volume in the office” (74 percent) and to “assist in the operating 

room” (70 percent). 

Long range plans under consideration 

include developing a physician 

extender curriculum for competency 

in neurosurgery, developing advanced 

curriculum for continued education, 

and investigating Web-based modules 

for a formal training program. 

Neurosurgical Training for Physician Extenders 

The majority of respondents, 81 percent, indicated that “on the job 

training” best describes the method of physician extenders’ neurosurgical 

training. Sixteen percent reported that extenders were 

trained in a formal training program. Only 2 percent indicated they 

were trained in the military. The majority of respondents (60 percent) 

also indicated that their physician extenders received training 

at a university hospital. 

When asked how long the neurosurgical training period was, 

the majority of respondents, 57 percent, indicated that their physician 

extenders received training for six months or less and 21 percent 

indicated one year. 

More than 77 percent of respondents reported that the establishment 

of formal training programs for physician extenders in neurosurgery 

would be useful. When asked how long this training period 

should be to gain competence in the tasks that neurosurgeons expect 

a physician extender to accomplish, over half, 52 percent, selected six 

months of neurosurgical training. Thirty-seven percent selected one 

year. The participants were equally divided on who should be paying 

for the training: 40 percent said the physician extender, and 40 percent 

said the future or current employer. About 57 percent indicated 

that they expect the physician extender to receive a salary while 

attending an extended training program in neurosurgery. 

Working With the AANS 

When asked: “which of the following AANS offerings would best 

help meet the educational needs of physician extenders,” 62 percent 

selected “AANS annual meeting practical clinics or breakfast seminars.” 

Fifty-three percent of respondents selected “AANS instructional 

DVDs, publications or online offerings,” and 36 percent 

selected the “AANS Master Series courses taught in educational/ 

research facilities offering lab work using cadaver material.” (Multiple 

selections were allowed.) 

“Survey participants also identified many topics and types of 

educational experiences they would like extenders to receive from 

the AANS,” said Dr. Hodge. “Leadership reviewed a summary of 

write-in recommendations.” 

Moving Forward 

With survey results in hand as well as input from the task force, the 

Long Range Planning Committee began to address the issue of 

using of physician extenders as one of many solutions to workforce 

shortages. 

“Initially, training courses for physician extenders will be offered 

during the 2006 AANS Annual Meeting in San Francisco,” said Dr. 

Hodge. “Short-range plans focus on identifying funding for additional 

physician extender neurosurgical training and expanding 

AANS offerings for physician extenders. Long range plans under 

consideration include developing a physician extender curriculum 

for competency in neurosurgery, developing advanced curriculum 

for continued education, and investigating Web-based modules for 

a formal training program.” 

Addressing workforce issues has been a priority for Dr. Wirth 

during his presidential year. 

“It is clear that there is tremendous potential for physician 

extenders to help alleviate neurosurgical workforce shortages,” said 

Dr. Wirth.“We are considering all the recommendations of the task 

force and are working closely with nurse practitioner and physician 

assistant organizations to investigate which avenues will result in 

optimal benefit to our patients.” 3 

Kathleen T. Craig is AANS director of marketing. 


P ATIENTS AFETY A RNOLD A. ZEAL, M D 

Error Results in Doctor’s Paradigm Shift 

Protocols, Team Approach and Site Marking Increase Patient Safety 

As a board-certified neurosurgeon in 

practice for nearly 30 years, I have 

served as chair of the neurosurgery 

section at a major medical center 

and as vice chair of the entire surgery 

department for a number of years. As vice 

chair of the surgery department, I was also 

chair of the department’s Quality Assurance 

Committee, and I additionally served 

as a sitting member of that committee for 

eight years. 

During my tenure in these positions, I 

was faced with several instances of medical 

errors involving colleagues, including 

wrong-site surgery. I listened to surgeons 

describe how their errors occurred and 

always found myself very unsympathetic. I 

could not imagine how conscientious surgeons 

could make such errors and could 

not, in my wildest dreams, imagine it happening 

to me. I am one of those compulsive 

surgeons who checks, double-checks, and 

even sometimes triple-checks things during 

surgery to the extent that my partner and 

operating room staff often tease me about 

being so obsessive-compulsive. 

Then it happened to me. I learned that 

we all make mistakes. It is easy. We are 

human. In fact, when I was forced to 

review the literature to produce a lecture 

on this topic, I discovered that the numbers 

of medical errors and wrong-site 

surgeries and the injuries they cause are 

unbelievable. 

I became a convert, and in 2003 I was 

one of the surgeons and other health professionals 

and organizations standing with 

the Joint Commission on Accreditation of 

Healthcare Organizations strongly advocating 

and promoting the Universal Protocol 

for Preventing Wrong Site, Wrong Procedure, 

Wrong Person Surgery. The following 

account describes how I came to be there 

and what I learned along the way. 

Anatomy of a Medical Mistake 

In December 2000, a former partner of 

mine referred his best friend to me for 

treatment of an L3–4 disc herniation. The 

patient, an internist, was well known to me. 

Examination revealed a mild right footdrop. 

A magnetic resonance image demonstrated 

a moderately large, very central 

herniated nucleus pulposus at L3–4, plus a 

very small extruded fragment on the right. 

The patient was scheduled for surgery a few 

days later, on a Monday. 

The weekend before the surgery was 

particularly memorable for me, with several 

exciting events transpiring. When I came 

to the OR, I enjoyed telling everyone the 

weekend’s exciting details during the case. 

In addition, to accommodate the patient, I 

had elected to perform the surgery in the 

hospital where he practices, an excellent 

institution where I rarely perform elective 

surgery, although I do assist my colleagues 

in covering this facility. At my usual hospital, 

the rooms are rectangular and the 

operating table is always set up parallel to 

the long axis of the room in a grid-like 

fashion, whereas in this hospital, the operating 

table is frequently on a diagonal. 

My usual routine 

is to scrub my hands, 

enter the room, 

check the X-rays and 

magnetic resonance 

images, then go to 

the side of the patient 

on which I intend to 

operate and finish 

prepping the skin 

with the antiseptic. 

At this hospital, the 

doctors are not permitted 

to prep the 

skin, so I had to 

enter, mark the site 

and help drape from the most accessible 

side of the patient. Aside from having a 

minimal acquaintance with the anesthesiologist, 

I knew no one else in the room, and 

as the case proceeded, I realized they also 

were inexperienced regarding my particular 

techniques. 

I started the case standing on the 

patient’s left side because, as I entered the 

room with the table somewhat askew, I 

stood there to help drape. I took an X-ray 

to confirm my level, L3–4, as I exposed the 

lamina. I then proceeded with the laminotomy. 

I was easily able to identify a large 

central disc herniation, but no free fragment. 

A second X-ray was taken to confirm 

the level, and then I extended the small 

laminotomy cranially and caudally looking 

for the free fragment. A third X-ray confirmed 

that I was at the L3–4 level as 

intended. Eventually I incised into the large 

herniated disc and performed a discectomy. 

The small extruded fragment was not 

located, but I had long since learned that 

sometimes findings are not exactly as 

expected. I did detect and remove a large 

herniation, decompressing the thecal sac 

and nerve roots. 


Exiting the OR, I discussed the case with 

my former partner, the referring physician, 

including my concern regarding not finding 

the extruded fragment. When dictating 

the operative report, as soon as I stated the 

preoperative diagnosis of “large central disc 

herniation with small right extruded fragment,” 

I realized that I had been on the 

patient’s left side. When I explained my 

concerns to the OR technicians, they reassured 

me that I must have been in the correct 

place because I had uncovered and 

removed a large disc herniation and had 

checked and rechecked the X-rays. I debated 

the pros and cons of returning to 

surgery, with the thought that the significant 

decompression and excision of the 

large central disc probably would accomplish 

the desired goal of alleviating his 

radiculopathy. However, compelled by my 

conscience to return to the OR, eventually 

I convinced everyone that we needed to 

return to explore the patient’s right side. I 

discussed the situation with the patient’s 

wife as well as with the awakening patient 

himself; this was incredibly uncomfortable. 

Back in the OR, I explored the right side 

at L3–4 through the same incision and 

located and removed the extruded fragment. 

My former partner called me a few 

hours later to advise me that the patient’s 

foot-drop had already significantly improved 

and he was doing great. The next 

morning the patient had no residual footdrop, 

was comfortable, and was discharged. 

Two weeks after the operation he 

covered call for his colleagues during the 

holidays and was playing tennis within a 

few months. He greeted me as a friend 

whenever I saw him in the hospital, but I 

always felt too embarrassed to talk with 

him, other than simply to say hello. 

Despite those facts, the patient did file 

a malpractice suit and the case was referred 

to the state board of medicine, as is appropriate 

for such cases. Those issues were a 

concern, but my greatest concern was simply 

the fact that I could make such a mistake. 

I was devastated. I started searching 

for answers to how this mistake could happen 

and how similar incidents can be prevented 

from ever occurring. Literature 

reviews revealed that many other instances 

of surgical errors have the same or very 

similar factors contributing to the errors. 

In almost all cases, there is a “systems 

breakdown” in which everyone participating 

in the case holds some responsibility. 

Several factors contributed to my error. 

First, the case was not performed at my 

usual hospital. Second, the room setup was 

unfamiliar to me. Third, the OR staff was 

unfamiliar to me. Fourth, I was not able to 

prep the skin myself, which disrupted my 

usual routine. Fifth, I was distracted by the 

exciting events of the preceding weekend. 

Lastly, I knew something was wrong and 

felt I was in the wrong place but could not 

recognize that I had exposed the unintended 

side—what I call “oblivious to the 

obvious.” Later, recognizing these factors 

made me even more distressed at how easily 

such errors happen, and searching the 

literature and recognizing the frequency of 

these errors was an absolute eye-opener. 

Despite the fact that my patient made a 

rapid and excellent recovery, I still have 

nightmares about this case. 

Toward a New Ideology and Culture 

I decided that we must develop a new ideology 

and culture to recognize how such 

errors occur and to prevent them from 

happening again. This was further reinforced 

by listening, in horror, to some of 

the disastrous cases of wrong-site and even 

wrong-patient surgery presented at the 

board of medicine meeting I attended. 

My recommendations, as presented at 

two national JCAHO conferences, are the 

following: 

1. We must do a better job of communicating 

between members of the OR team, 

and should involve the patients. 

2. The surgeon is no longer autonomous. 

3. We must emphasize teamwork and 

“systems” to succeed safely. 

4. There must be protocols and checklists. 

5. The surgeon must participate in development 

of new ideas to promote teamwork 

and safety. 

6. The OR staff is there to protect the 

patient. 

7. Our culture must change, and the goal 

and expectation must be perfection. 

The protocols and checklists should 

include: 

1. Cases stating site and side should be 

posted in the OR and listed on the OR 

schedule. 

2. Consent forms should identify site and 

side specifics. 

3. The surgeon should visit the patient 

immediately before the surgery to reconfirm 

site and side and note it in the chart. 

4. When possible, the surgeon should mark 

the site and side (in the surgical field). 

5. OR staff should reconfirm the intended 

procedure and site and side immediately 

before surgery. 

6. Appropriate studies—X-rays, scans and 

data—must be available in the OR, plus 

confirmed by the OR staff to represent the 

appropriate patient. 

Everyone in the OR is a part of a team. 

The individual team members are important, 

responsible parties who must communicate 

and interrelate in the OR in the 

interest of the patient. This must be a “systems 

approach.” We must focus on quality 

and accountability. Safety represents quality, 

and freedom from errors equates with 

good results. 

Humans are fallible, but mistakes are 

preventable. We must devote more time 

and resources to developing teams of varying 

expertise within the operating room 

environment to work together toward the 

common goal of error-free surgery. Surgical 

errors are devastating for the surgeon 

just as they are for the patient and must be 

prevented. 3 

Arnold A. Zeal, MD, FACS, FAHA, is chief of neurosurgery 

at Baptist Health System in Jacksonville, Fla. 


When Neurosurgeons Drop 

What Role Might Microeconomics Play in Their Decision 

RICHARD N.W. WOHNS,MD,MBA 

Although neurosurgeons are popularly known as “brain” 

surgeons, anecdotal evidence and some studies suggest that 

at least a small number of neurosurgeons are relinquishing 

cranial surgery privileges. A result of taking such action is 

that the neurosurgeon involved no longer can cover emergency 

call. While cranial surgery and emergency call long have been 

accepted tenets of the neurosurgical profession, relinquishing cranial 

surgery privileges is commonly thought to limit liability and 

help control rising medical liability insurance costs, as well as ease 

the surgeon’s demanding schedule. 

However, the underlying reason why a neurosurgeon might 

relinquish cranial surgery privileges may be because the microeconomics 

of neurosurgical practice has changed. Diminished reimbursement, 

particularly in the face of escalating overhead affected 

by high medical liability insurance premiums, means that cranial 

procedures now may consume more practice dollars than they generate. 

To illuminate the issues underlying the contentious topic of 

dropping cranial surgery privileges, a business perspective and 

analysis can be applied. 

Devaluation and Decline of Neurosurgical Reimbursement 

Reimbursement for neurosurgical procedures has experienced an 

overall decline in recent years. After reimbursement values reached 

their maximum in 1997, cranial surgery values fell about 25 percent 

and spinal surgery values, about 30 percent. The reimbursement 

reductions primarily were due to Medicare’s transition to the 

resource-based relative value scale between 1999 and 2002. 

Since 1992, reimbursement for spinal procedures fell more than 

for cranial procedures in most cases. An example of the reimbursement 

decline for spinal procedures is the 30 percent reduction for 

code 63047 (lumbar laminectomy) from $1,408 in 1992 to $1,010 

in 2003. (Code 22612 for posterolateral fusion is an exception. 

Reimbursement for this code increased from $1,255 in 1992 to 

$1,372 in 2004.) Cranial surgery reimbursement remained 

unchanged or even increased slightly from 1992 to 2004, but there 

was a significant reduction in the real dollar value. This is due to 

lack of any adjustment for inflation, cost of living or practice overhead 

increase. Several examples of reimbursement for cranial procedures 

per Current Procedural Terminology Code are: code 61313 

(craniotomy for intracranial hemorrhage)—$1,600 in 1992, and 

$1,662 in 2003; code 61312 (craniotomy for subdural hematoma)— 

$1,605 in 1992, and $1,654 in 2004; and code 61512 (craniotomy for 

meningioma)—$1,913 in 1992, and $2,315 in 2003. 

The Cost of Lost Opportunity 

In addition to the rate of reimbursement, the time and expense 

involved in performing each surgical procedure must be assessed. 

The time and expense spent in the total provision of cranial surgery 

exceeds that spent in spinal surgery. Therefore, when neurosurgeons 

forego the revenues generated from spinal surgeries to perform cranial 

surgeries, they are experiencing the phenomenon of “opportunity 

cost.” This particularly is the experience when emergency 

cranial surgeries cause cancellation of elective spinal surgeries. 

A neurosurgical practice that primarily focuses on spinal surgery 

not only is efficient, but there also is very little adverse impact on 

the profitability of a practice that does not include brain surgery 

and emergency coverage. An analysis of the opportunity cost and 

microeconomics of neurosurgical practice illustrates the contrast in 

profitability between cranial and spinal surgery. 

Marginal Revenue, Marginal Cost, and Profit Maximization 

When businesses have a product with diminishing profitability and 

other products with greater profitability, the decision often is made 

to drop the less profitable product. The decision hinges on the marginal 

revenue of the product, whether the business is running at 

capacity, and the supply and demand for products. If the business 

is not running at capacity and the devalued product helps to cover 

fixed expenses, then good business practice supports continuing 

with that product line. However, if the business is running at capacity 

and there is strong demand for the products, then good business 

practice supports dropping the less profitable product. 

As the business increases its level of output, each additional unit 

adds to the total revenue of the business. The additional revenue 

attributable to producing one more unit of output is called marginal 

revenue. As the business increases its level of output, each unit 

increase in output increases the business’s total cost. The additional 

cost of producing one more unit of output is called marginal cost. 

In the special case in which the price of the commodity is given to 

the business by the market, marginal revenue equals price. For 

example, if the business produces plywood, and the market price of 

plywood is $300 per 1,000 square feet, the marginal revenue from 

each additional thousand square feet is $300. The business would 

increase plywood production—and maximize profit—as long as 

the marginal cost of each additional thousand square feet is less 

than $300. The business would not increase production if cost of 

each additional thousand square feet is more than $300 to produce. 

The principle of profit maximization is germane to a neurosurgical 

practice. The reasoning used by businesses that choose 


Cranial Surgery Privileges 

output to maximize profit, described by Maurice and Thomas in 

their 1995 book Managerial Economics, can be applied to neurosurgical 

practice thusly: If neurosurgeons consider surgery as their 

product, the means to maximizing profit is to choose the level of 

the activity, or surgery, at which the additional revenue just equals 

the additional cost. 

If a neurosurgical practice produces craniotomies and the market 

price of craniotomies is $1,500, the marginal revenue from each 

additional craniotomy is $1,500. The neurosurgeon would increase 

craniotomy production as long as the marginal cost of each additional 

craniotomy is less than $1,500. The neurosurgeon would not 

increase production if the cost of each additional craniotomy is 

more than $1,500 to produce. 

The marginal cost of producing craniotomies has steadily 

increased due to escalating practice overhead, including the cost 

of medical liability insurance. The marginal revenue has steadily 

decreased due to diminishing insurance reimbursements. In 

addition, there is the previously discussed phenomenon of opportunity 

cost wherein neurosurgeons forego the revenues generated 

from additional spinal surgeries by performing craniotomies, 

particularly in emergency cases. 

Purely from an economic perspective, a neurosurgeon would 

decrease the output of craniotomies when marginal cost is greater 

than marginal revenue. A neurosurgeon would increase the number 

of craniotomies when the added revenue from the expansion 

(marginal revenue) is greater than the added cost of the expansion 

(marginal cost). In order to maximize profit, the neurosurgeon 

would choose to produce the level of output for which marginal 

revenue equals marginal cost. 

Neurosurgery, of course, is not solely an economic enterprise. 

Some services are offered which, while less profitable, are considered 

part of the full array of neurosurgical services, and these services 

are subsidized by other more profitable services. However, 

when margins run thin and subsidies disappear, the less profitable 

services such as cranial surgery may be dropped. 

When deciding on the value of neurosurgical services offered, 

neurosurgeons might heed the wisdom of Jim Collins, author of 

business books Built to Last and Good to Great: 

Our study clearly shows that a company does not need to be in a 

great industry to become a great company. Each good-to-great company 

built a fabulous economic engine, regardless of the industry. 

They were able to do this because they attained profound insights 

into their economics. 

Neurosurgical practices are, at least in part, economic enterprises, 

and neurosurgeons undoubtedly can benefit from the 

insights that economic analysis can yield. 3 

Richard N.W. Wohns, MD, MBA, is chair of the AANS Professional Liability 

Committee and chair of the CSNS Northwest Quadrant. He is president and founder 

of South Sound Neurosurgery, PLLC, in the Puget Sound region of Washington. 

Surgeons Link Ad 

PU Fall 2005 

The Benefit of Economic Insight 

The phenomenon of decreasing the output of craniotomies, 

that is, giving up cranial surgery privileges, may actually be an 

attempt by neurosurgeons, with or without formal economic 

analysis, to establish at least a short-term microeconomic competitive 

equilibrium. Whether this will become a more prevalent 

long-term strategy for neurosurgeons, for whatever reason, is yet 

to be determined. 


M EDICOLEGALU PDATE J EFFREY S EGAL, MD, AND M ICHAEL J . S A COPULOS, JD 

Can Contracts Preclude Frivolous Lawsuits 

Precedent Suggests Yes, When Carefully Crafted and Introduced 

Frivolous malpractice claims are expensive 

and time-consuming. What 

remedies are available to physicians 

who fall prey to such lawsuits 

One remedy is to file a suit against the 

plaintiff and his or her attorney using the 

tort of malicious prosecution. However, a 

key element for prevailing is proving that 

the attorney filed the case with malice, 

which is difficult to do. In addition, courts 

generally grant plaintiffs and attorneys 

wide latitude in pursuing claims of malpractice. 

Hence, malicious prosecution is a 

remedy rarely used. 

Contract law, which is separate from 

tort law, is another avenue of redress for 

physicians to investigate. This article will 

explore the ability of contract law to protect 

physicians from frivolous lawsuits. 

Making Contracts Enforceable 

To help explain what should work, it is first 

useful to describe what will not work. Asking 

a patient to forego all remedies is not a 

workable solution. For example, demanding 

that a patient not sue for any reason will 

not be enforceable. Public policy dictates 

that patients must have some remedy for 

negligence. That remedy is usually through 

the courts, although arbitration is another 

viable option. Having a patient sign a blanket 

release would be considered an “abuse 

of power,” and courts routinely have dismissed 

such agreements. 

If, however, the demands of a contract 

are narrower, the contract should withstand 

challenges to enforceability. The 

contract defines expectations regarding 

resolution of concerns, specifically that 

the physician cannot be sued for a frivolous 

reason and that should there be a dispute, 

each side will use experts who follow 

the code of ethics of the physician’s specialty 

society. 

The following considerations for the 

patient-physician contract are suggested: 

3 Be clear on the mutuality of agreement. 

3 Do not make any attempt to change the 

physician’s duty to the patient within the 

agreement. 

3 Call the patient’s attention to contractual 

provisions. 

3 Allow the patient the opportunity to 

think about the contract and its consequences 

and to ask questions. 

3 Do not seek the patient’s agreement 

when care is needed urgently or emergently. 

A better approach is to obtain agreement 

later (for example, in a post-hospitalization 

office visit) and to make the agreement 

retroactive—as long as the effective date of 

the agreement is clearly reflected. 

3 Do not condition the patient’s treatment 

on signing the agreement. 

Tests of Enforceability Under 

Case Law 

One test determining enforceability is 

whether the document is a contract of 

adhesion. An adhesion contract, as defined 

in Sanford v. Castleton Health Care 

Center, is “a standardized contract, which, 

imposed and drafted by the party of superior 

bargaining strength, relegates to the 

subscribing party only the opportunity to 

adhere to the contract or reject it.” While 

“adhesion contract” is usually viewed as a 

pejorative label, one court, in Ingles v. 

State Farm Mutual Insurance, has recognized 

the basic truth that most contracts 

fit that description. As the Ingles court 

noted, however, the important task is to 

distinguish which adhesion contracts are 

appropriate and therefore enforceable, 

and which are not. 

The usual term to describe the unenforceable 

adhesion contract is “unconscionable.” 

The court in Sanford v. 

Castleton wrote that “a contract is unconscionable 

if a great disparity in bargaining 

power exists between the parties, such that 

the weaker party is made to sign a contract 

unwillingly or without being aware of its 

terms.” The court proceeded to cite the 

definition of “unconscionable” according 

to a 1989 Indiana appellate court opinion: 

“The contract must be such as no sensible 

man not under delusion, duress, or in distress 

would make, and such as no honest 

and fair man would accept.” 

Unconscionability is a fact-sensitive, 

case-by-case issue. As addressed by the 

court in Sosa v. Paulos, there are two aspects 

to unconscionability: procedural and substantive. 

The procedural aspect addresses 

the way the contract is reached. The substantive 

aspect refers to the actual terms. 

Two provisions of agreement that likely 

would not be considered unconscionable 


are first the promise not to bring a frivolous 

lawsuit and second the mutual promise to 

use only experts who follow the code of 

ethics for the physician’s specialty society. 

The first promise could be “unconscionable” 

only if the court concludes that 

it is intended to have a chilling effect on 

bringing lawsuits, which, the argument 

would state, is against public policy. Such a 

promise, however, is nothing more than an 

obligation already imposed on litigants. 

People are not supposed to file frivolous 

lawsuits. This principle is reflected in 

numerous statutes. For example, an Indiana 

statute permits the winning party to 

recover attorney fees if the losing party’s 

lawsuit was frivolous. 

The second promise focuses on how 

evidence may be brought forward. The 

well-reputed treatise on contract law, 

Williston on Contracts, Fourth Edition, 

states: “There is a growing tendency for 

courts to uphold the right of parties to prescribe 

certain rules of evidence should a 

lawsuit arise out of the bargain between 

them, so long as it does not unduly interfere 

with the inherent power and right of 

the court to consider relevant evidence.” 

As to the option of arbitration, it is 

well established that patients and physicians 

can contractually use arbitration. 

Arbitration asks the plaintiffs to forego 

their right to trial by judge or jury. Yet 

imposing reasonable conditions on expert 

witness behavior is clearly less restrictive 

than arbitration. Agreements to arbitrate 

are a far greater intrusion into the traditional 

judicial system. 

Recent cases on arbitration are split 

among jurisdictions. However, close analysis 

suggests that the cases in which arbitration 

was not enforced were so decided 

because the way the contract was reached 

was unconscionable, not because arbitration 

was unconscionable in and of itself. In 

Sosa v. Paulos, an agreement to arbitrate 

was presented to the patient immediately 

before knee surgery, after the plaintiff was 

in his surgical gown, and the agreement 

was presented for signature without explanation. 

Neither was there any explanation 

of the documents at any postoperative visits. 

The Utah Supreme Court found this 

agreement unconscionable because of the 

way the patient was asked to make the 

agreement. When, however, the troublesome 

facts reflected in Sosa v. Paulos have 

not been present, agreements to arbitrate 

have been held to be not unconscionable 

and, therefore, enforceable. 

In the Buraczynsky v. Eyring and Sanford 

v. Castleton cases, the courts relied on 

several factors to find that the contracts 

were not unconscionable and therefore 

were enforceable. Those factors included: 

3 Contractual provisions were not hidden, 

but highlighted. 

3 There was opportunity to read the contract 

unrushed and to ask questions. 

3 The language was easy to read and 

understand. 

3 The language did not change the physician’s 

duty to use reasonable care. 

3 The contract did not limit liability of the 

provider to the patient. 

Contract Enforceability for Nonsignatory 

Parties 

A contract can mandate that any attorney a 

patient-plaintiff hires follows the same 

rules. Further, falling back on the arbitration 

analogy, there are precedents for holding 

nonsignatory parties to agreements. 

A minor child can be bound by the 

mother in an agreement to arbitrate made 

during the prenatal period. The court in 

Wilson v. Kaiser Foundation Hospitals 

interpreted the arbitration clause to apply 

to any claim arising from services under the 

agreement, even though the plaintiff had 

not been born when the agreement was 

signed. In Gross v. Recabaren, the spouse of 

a contract signatory filed a lawsuit for loss 

of consortium because of a physician’s 

negligence. The court found that when a 

patient contracts to arbitrate claims of negligence, 

all claims arising from the alleged 

malpractice must be arbitrated. Similarly, 

in Herbert v. Superior Court, heirs in a 

wrongful death action were found to be 

bound by the decedent’s agreement to 

arbitrate because the contract required 

claims by the “member’s heir or personal 

representative” to be arbitrated. 

A note on retroactive enforcement: 

Physicians often have long-term relationships 

with patients. Is it possible to script 

a new contract to address past actions 

The answer is maybe. In California the 

Coon v. Nicola ruling provided precedent 

for retroactive activation of an arbitration 

agreement. 

What Is “Frivolous” 

The fact remains that what is frivolous to 

one person might be entirely legitimate to 

another. How can the definition be tightened 

to make a contract to avoid pursuing 

a frivolous case meaningful 

One solution is to focus on frivolous 

testimony as a determinant of breach. For 

example, a conclusion by the professional 

conduct committee of an organization 

such as the AANS might serve as the basis 

that the expert testimony was indeed frivolous. 

Labeling definitions and rules of 

procedure are often embedded in contracts. 

Hence, the definition of frivolous or 

the process for determining if testimony is 

frivolous could likewise be incorporated 

into a contract. 

In summary, contracts can be used with 

patients to decrease the likelihood that the 

physician will be sued for a frivolous reason. 

There is ample precedent with arbitration 

contracts to believe that such 

contracts can be enforced. However, proper 

attention must be paid to the content 

and the procedure used for obtaining 

agreement. Given that tort reform may not 

be the best tool to deal specifically with 

frivolous lawsuits, contract law should help 

to fill the gaps. 3 

Jeffrey Segal, MD, FACS, is a neurosurgeon and 

founder and chief executive officer of Medical Justice 

Services Inc. Michael J. Sacopulos, JD, is a partner 

of Sacopulos, Johnson and Sacopulos. 


Wisconsin 

St. Vincent 

COUNSEL AND EDUCATE PATIENTS AND THEIR FAMILIES 

A PATIENT’S GUIDE 

Often patients see you when they are in pain, frustrated by a prolonged condition, or 

overwhelmed with information they’ve received from friends, the Internet or other physicians. 

No matter how much time you spend with a patient, inevitably they feel better having 

something from you to take home. 

AANS Patient Education Brochure Series 

Visit the AANS Online Marketplace at www.AANS.org. 


C OMPUTERE ASE J OEL D. MACD ONALD, M D 

Computers in Neurosurgical Education 

Online Learning and Performance-Assessment Tools Are Evolving 

Throughout a physician’s career, 

computer-assisted learning offers 

several advantages over traditional 

educational vehicles. Search and retrieval 

of information is more rapid and comprehensive. 

Content is dynamic and can 

be quickly and easily updated. Digital 

documents can incorporate multimedia 

elements. Resource information can be 

stored more efficiently and economically 

in digital format. From a cost standpoint, 

computers require a high initial investment 

but that expense would ultimately 

be exceeded by the alternative of accumulating 

an extensive hardbound library. 

Neurosurgery is highly dependent on 

computer technology. Diagnostic imaging 

and surgical navigation demand substantial 

computer facility. Neurosurgeons’ 

familiarity with computers enables the 

specialty as a whole to take advantage of 

the numerous opportunities that computers 

offer for medical education—opportunities 

that will continue to evolve. 

Computers can be used for education in 

two main ways. The first involves directed 

learning via computers, whereas the second 

involves learning through the day-to-day 

use of computers. As time passes, the latter 

model will gradually supersede the first, 

allowing surgeons to take care of patients 

and simultaneously learn through selfevaluation 

and competency maintenance. 

Under the older model, computers are 

used to deliver educational content and 

assess performance. Most of the educational 

content currently available online follows 

this paradigm. The most common example 

of this type of computer-assisted learning is 

online continuing medical education. A 

wide variety of CME activities covering the 

spectrum of clinical topics are now available 

online. These activities have many 

advantages for busy clinicians. First and 

foremost, they can be conducted at the 

convenience of the learner. They usually 

provide immediate feedback and a selfevaluation 

process, as well as immediate 

validation of earned credit. Typically, the 

materials are updated frequently and cost 

per credit is low. 

The self-assessment test for neurological 

surgery, known as SANS Wired, is a 

good example of a computer-based tool 

that provides a mechanism for periodic 

knowledge assessment and learner-driven 

study. Each SANS question provides immediate 

feedback, with a detailed critique and 

hyperlinks to additional content on the 

Internet. Users can explore a given topic 

through the SANS examination using only 

a Web browser to broaden their reach to 

study materials. Learning occurs primarily 

through the process of investigating incorrect 

responses to practice test questions. 

The user can study entirely from the SANS 

Wired system without the need for textbooks. 

The system tracks the user’s 

progress and also permits the user to interrupt 

the study process at any time. Yet even 

though the SANS experience is flexible and 

“termless,” the content is structured and 

based on defined learning objectives. 

The second way that computers can be 

used for education involves learning 

through the routine use of computers. By 

incorporating computers into clinical 

activity on a day-to-day basis, the learning 

process becomes perpetual and less well 

defined. For example, clinical expert systems 

and clinical decision support systems 

provide a vast potential for learning in a 

relatively unstructured fashion. Knowledge 

acquisition tends to be driven by the interest 

of the user or the need to solve a particular 

clinical problem. Under these 

circumstances, performance evaluation is 

more difficult because the learning objectives 

are not defined in advance. Furthermore, 

since not everyone is studying the 

same thing, cohort performance comparison 

is not possible. As computer-based clinical 

tools evolve, however, the routine-use 

realm will offer the most opportunity for 

expansion of educational activities. 

One specific type of learning that is of 

paramount importance to neurosurgeons, 

the mastery of technical skills, cannot be 

easily accomplished using computers. Virtual 

reality and simulation platforms for 

surgery are only in their infancy. There are 

a few simulators for exercises such as ventricular 

endoscopy and temporal bone 

drilling, but they are expensive and rudimentary 

and currently are not in widespread 

use. Ideally, the sophistication of 

these platforms will improve so that clinicians 

can use actual patient data for both 

surgical rehearsal and training. This would 

not only promote competency with technical 

skills but also improve safety for 

patients in future. 

As the capabilities of handheld computers 

expand and as data transfer 

improves, too, additional educational 

applications that work in conjunction with 

clinical tools will likely emerge. Indeed, 

young physicians routinely “Google” 

everything from drug doses to treatment 

recommendations, often using their cell 

phones or personal digital assistants. 

Computer-assisted learning is clearly an 

integral part of medical education 

throughout a physician’s clinical career. 

The body of knowledge has now expanded 

well beyond the ordinary physician’s 

capacity to carry adequate reference materials 

physically or to memorize information—and 

it will only expand more, 

necessitating further development of 

everyday opportunities for computerassisted 

education. 3 

Joel D. MacDonald, MD, is associate professor 

of neurosurgery at the University of Utah 

Medical Center. 


R ESIDENTS’ F ORUM K. MICHAEL W EBB, M D, AND L AWRENCE S. CHIN, M D 

Evaluating a New Job 

Rank Your Priorities and Do Your Homework 

After many years of residency, the 

prospect of getting a job is very 

exciting. Unfortunately, that excitement 

can make it difficult to evaluate 

a potential practice rationally. During 

residency one learns little about the business 

side of neurosurgery, and there is no 

chapter in Greenberg to help you out. 

Guidance for evaluating job opportunities 

in both academic and private settings is the 

subject of this Residents’ Forum. 

The first step in looking for a job is to 

determine what is most important to you 

and your family. The main factors to consider 

are the practice’s location, income 

potential and financial strength, as well as 

your interest in a subspecialty and 

research opportunities. Rank these factors 

in order of importance, but remember 

that every job requires some compromise. 

To decide what is negotiable, you must 

know your priorities. 

Location 

Location may be of primary importance, 

particularly if you have a family. Most 

hospitals, offices and operating rooms 

look the same, and you will spend most of 

your time there. Your family, however, 

will need to deal with jobs elsewhere as 

well as with schools, new neighbors and 

friends, and the like. Talk to people who 

know the area well, and make sure that 

you spend at least a few days exploring 

the area on your own to examine commute 

times, access to shopping and recreation, 

and other things that are important 

to your life outside of work. 

Income Potential 

Of the 800 neurosurgical job openings 

each year, approximately 5 percent to 10 

percent are academic jobs. Of approximately 

150 residents graduating each 

year, about 50 go on to fellowships, 

research or military positions, leaving 100 

residents entering the job market. At an 8 

1 ratio of jobs to graduates, the odds favor 

you heavily. Regardless of your academic 

interests and research prowess, remember 

that your income will largely be determined 

by your clinical activity. Additional 

training such as an endovascular or 

spine fellowship will allow you to command 

a premium salary. 

Because it is a job-seeker’s market, academic 

practices have increased their starting 

salaries to be more competitive with 

private practices. However, this relative 

equality ends after a few years, as private 

practitioners become partners in their 

practices. Compensation of private practitioners 

is on average 20 percent to 50 

percent higher than that of their academic 

counterparts. So if you are considering 

joining a private practice, ask about the 

path toward partner status (for example, 

time frame and board certification), but 

remember, everything is negotiable. Practices 

with large assets such as office buildings 

or surgery centers may require a 

buy-in—but be wary if the assets are not 

easily valued. 

Academic compensation is frequently 

tied to rank. Be aware that the salary differential 

between a full professor and a partner 

in private practice may be less than anticipated, 

particularly when you factor in benefits 

such as travel compensation, insurance 

benefits and malpractice coverage. 

Financial Strength 

Most academic practices associated with a 

medical school are either a department, 

which indicates more financial responsibility 

and direct reporting to the dean, or a 

division of general surgery where financial 

decisions are made in conjunction with the 

chair of surgery—though financial independence 

for divisions of neurosurgery is 

not uncommon. Obviously, a private practice 

is completely responsible for its 

finances. In addition to paying salaries, a 

practice must pay employee benefits, office 

rental, supplies, resident expenses and professional 

liability insurance. Any remaining 

money may be paid as a bonus or used for 

practice development. 

You should meet with the business manager 

to evaluate the practice’s financial condition. 

Let the manager know in advance 

what you want to learn, so this person can 

be prepared with the right information. On 

the income side, look for the amounts billed 

and collected, as well as income from alternate 

sources such as pain clinics, ambulatory 

surgical centers, office building rents and 

other sources. On the expense side, look at 

the “dean’s tax,” salaries and overhead. Also, 

ask if bonuses have been based on case 

numbers or relative value units and whether 



T IMELINE: N eurosurgery Through History 

When Their Residence Isn’t the Hospital 

What Do You Call Physician Trainees 

MICHAEL SCHULDER,MD 

Odd label, “residents,” for medical doctors who are preparing 

to be fully-trained surgical specialists charged with caring for 

patients who may be very ill, and who sometimes can do surgical 

procedures that their presumed teachers and supervisors 

cannot. The origin of this term sheds light on the long hours 

that residents have “traditionally” worked such that an 88-hour 

workweek is viewed as a veritable sinecure. 

Through the late 19th century, medical and surgical education 

followed a haphazard apprenticeship model. No formal education 

was required. Didactic learning was obtained through courses 

given by voluntary faculty lecturing in medical schools. Students 

bought tickets to attend, and when the time was right they 

attached themselves to a practitioner from whom they learned the 

art of medicine and/or surgery. When Harvey Cushing entered 

Harvard Medical School in 1891, he was nearly the only member 

of his class who had attended college. 

At about this time a movement was underway to improve the 

level of American medical education. William Osler, in particular 

fervently promoted the importance of formal bedside teaching for 

medical students and postgraduate trainees. To learn the most pos- 

Residents training to be 

neurosurgeons started 

out working in essence 

around the clock for 

almost no money. 

sible (and to do the 

work of caring for 

patients, much more 

of a burden in the 

developing world of 

scientific medicine 

and surgery—and 

still following an 

apprentice model), 

the young doctors 

were required to live in the hospital. Hence, they became known as 

resident physicians. 

Residents training to be neurosurgeons started out working in 

essence around the clock for almost no money. Over time they 

came to work incredibly hard, by most standards, for a living wage. 

Now organized neurosurgery has accepted the concept of strictly 

defined limitations on work hours. Residents still work long and 

hard but no longer have to fear that a sleepless night will be followed 

by a day without end. Some people may consider this a 

needless accommodation. Others might call it progress. 3 

Michael Schulder, MD, is associate professor in the Department of Neurological 

Surgery and director of image-guided neurosurgery at UMDNJ-New Jersey Medical 

School in Newark. 


teaching and research have been considered. 

Is there a business plan for increasing 

income and decreasing expenses Does the 

practice have certified coders Is it looking at 

alternative revenue sources Does it have a 

plan for expansion Don’t be shy in asking 

questions—a good practice will have nothing 

to hide. 

Subspecialization 

When considering your subspecialty interest, 

determine what cases you will be 

expected to do and what you will need to 

give up. More importantly, make sure the 

practice’s expectations are not at odds with 

the financial incentives. For example, there 

will be very little incentive to give up highbilling 

cases such as those with spinal 

instrumentation if the salary and bonus are 

determined by relative value units. If you 

are interested in subspecializing, will you be 

given the opportunity and resources for 

developing a new practice 

Research 

Starting a laboratory requires space, equipment, 

money, collaborators, a mentor and 

a lab technician. Meet with the neuroscience 

chair and other faculty who share 

your research interests. Determine if 

resources can be shared and if they are 

open to collaboration. Ask for a list of faculty 

members and their research support. 

Protected research time, start-up funds 

and a grace period in which your research 

will be supported by department funds are 

critical for the young investigator. Having 

an experienced mentor (preferably a 

neurosurgeon who will understand the 

unique demands on your time) is a common 

factor for clinician-investigators who 

become successful. 

The Bottom Line 

The most important piece of advice before 

signing with a new practice is to get the 

specifics in writing. A key corollary is that 

everything is negotiable. Be open and 

polite, but do not be afraid to ask the 

tough questions. In the end, you will be 

respected for your acumen and attention 

to detail. 3 

K. Michael Webb, MD, is a spine fellow at Barrow 

Neurosurgical Associates in Phoenix, Ariz. Lawrence 

S. Chin, MD, is professor of neurosurgery at the 

University of Maryland Medical Center in Baltimore. 


R ISKM ANAGEMENT M ICHAEL A. CHABRAJA, J D, AND M ONICA W EHBY, M D 

Surgeon’s Error or Jury’s Sympathy 

Patient Delays Surgery With Adverse Results 

When treating high-risk patients, 

the uncomfortable reality is that 

regardless of whether error is 

involved, juries often are swayed 

by severe outcomes. 

In this case, the defendant neurosurgeon 

had recommended surgery in June 

1994. Despite having received this recommendation, 

the patient elected to postpone 

the surgery until after his son’s 

wedding in October. The patient’s condition 

deteriorated rapidly after the wedding 

and somatosensory evoked potential 

monitoring performed prior to surgery 

failed to pick up any signals from his legs. 

The defendant neurosurgeon performed 

anterior cervical discectomy and fusion at 

C5–6 and C6–7 on the 57-year-old patient 

in October 1994 to remove two herniated 

discs and treat spinal stenosis caused by 

degenerative disc disease. Following surgery, 

the patient was paralyzed from the chest 

down. He remained a paraplegic with weakness 

of his arms and hands until he died 

from unrelated cancer approximately eight 

years later. 

The patient’s estate and his spouse sued 

the neurosurgeon and the hospital for malpractice. 

In addition to recovery of medical 

expenses, the estate sought damages for loss 

of normal life, pain and suffering and disfigurement. 

The spouse sought damages 

for loss of consortium and loss of services. 

The patient’s expert opined at trial that 

the postoperative films showed a disc fragment 

remaining in the spinal canal and 

pressing on the spinal cord, causing worse 

compression than the preoperative magnetic 

resonance images had revealed. The 

defense countered that the postoperative 

MR images showed that the spinal canal had 

been decompressed successfully. The 

defense further maintained that the patient’s 

spinal cord was so severely compromised 

prior to surgery that the cord could not 

withstand the normal trauma of surgery 

and the simple act of decompressing the 

stenotic spinal cord caused a spinal stroke. 

The evidence presented at trial demonstrated 

that in the weeks immediately preceding 

the surgery, the patient became 

numb from the waist down and had to use 

a wheelchair to get around. With regard to 

the issue of when the surgery took place, 

the defense introduced the neurosurgeon’s 

notes in the medical record documenting 

his discussion with the patient concerning 

the risks associated with delaying surgery. 

After deliberating for two days and 

twice reporting that it was deadlocked, the 

jury returned a verdict against the defendant 

neurosurgeon and in favor of the 

patient’s estate and his spouse in the 

amount of $2,269,034. The bulk of this 

sum, 1.5 million, was awarded to the estate 

and apportioned as $750,000 for loss of 

normal life, $500,000 for pain and suffering, 

and $250,000 for disfigurement. The 

remainder of $769,034 was awarded to the 

patient’s spouse, with $517,034 allotted for 

medical expenses, $150,000 for loss of consortium 

and $102,000 for loss of services. 

Notably, the defendant hospital had settled 

out prior to trial for $400,000. 

Outcome’s Severity 

The fact that the jury twice reported that it 

was deadlocked is evidence of its struggle to 

reach a decision on liability. Although the 

patient’s decision to delay his surgery may 

well have resulted in further compromising 

his spinal cord, the jury ultimately concluded 

that this was insufficient to relieve 

the defendant neurosurgeon of liability. 

An argument can be made that the 

defendant neurosurgeon should have documented 

more clearly in his notes that he had 

explained the risks of paralysis as well as the 

risk of delaying surgery with the patient. 

However, it is far from clear that this action 

would have been outcome determinative. 

The result in this case illustrates that the 

risk of an adverse verdict is sometimes 

directly related to the severity of the outcome 

rather than to the actions taken by a 

surgeon. A 2002 study conducted by 

Kessler and McClellan underscores this 

conclusion and demonstrates its frequency. 

The study revealed that evidence of medical 

negligence was found in less than 20 

percent of cases in which a patient received 

some form of compensation from a medical 

provider and further that only one in 

every 15 patients who were found to have 

sustained an injury due to medical negligence 

received any sort of compensation. 

This evident lack of relationship 

between medical liability award and medical 

negligence compounds the risk of liability 

for specialists treating high-risk 

patients. Data maintained by medical liability 

insurance provider The Doctors 

Company shows that neurosurgeons frequently 

sustain claims, averaging a claim 

every 18 months. Thus, high-risk specialists 

such as neurosurgeons are sued more often, 

not because of medical negligence, but 

because of the risk of the medical condition 

and the severity of the adverse outcome. 3 

Michael A. Chabraja, JD, is a partner with 

McGuireWoods LLP in Chicago, Ill. Monica Wehby, 

MD, is a neurosurgeon with Microneurosurgical 

Consultants P.C. in Portland, Ore. 

Suggestions By exploring closed 

medical liability cases, Risk Management 

aims to help neurosurgeons identify 

and avoid areas of legal peril. If you 

would like to see a particular topic 

covered, please send your idea to 

Monica Wehby, MD, Risk Management 

editor, mcwehby@yahoo.com. 


NREF 

M ICHELE S. G REGORY 

A Match Made in Science 

NREF Gives and Receives in Name of Medical Research 

It is easy to understand why a relationship 

works between the Neurosurgery 

Research and Education Foundation 

and Kyphon Inc., a medical device company 

that develops and markets minimally 

invasive technology designed to restore 

spinal anatomy. Both organizations are 

trying to do the same thing: improve 

patient care and quality of life through 

research and the development of advanced 

medical technology. 

The AANS founded the NREF, its 

research division, in 1981 in response to a 

rapid decline in federal and private funding 

for medical research. The membership 

was supportive; however, the annual contributions 

were not enough to sustain the 

level of funding necessary to pursue quality 

research into neurosurgical diseases. 

Consequently, to enhance the much needed 

grant support, in the 1990s the NREF 

began partnering with pharmaceutical 

and medical device companies such as 

Kyphon Inc. 

Founded in 1994, Kyphon utilizes a 

proprietary balloon technology to repair 

spinal fractures with minimally invasive 

surgery. The company strives to remain 

true to its core values of loyalty, trust and 

respect for others, and to operate an organization 

based on honesty, integrity and 

commitment. 

Since 2003, Kyphon has been one of 

the many corporations investing in spine 

research through NREF research fellowships 

and young clinician investigator 

awards. Kyphon’s annual support of a oneor 

two-year grant has made a difference in 

the research careers of three clinicianscientists 

funded by these grants. 

“We are pleased to continue our support 

of the NREF and its research activities,” 

said Karen Talmadge, PhD, Kyphon’s 

executive vice president and chief science 

Pictured at the 2005 AANS Annual Meeting, NREF 

Chair Martin H. Weiss, MD, at right, presents Kyphon 

representative Karen Talmadge, PhD, with a token of 

appreciation for Kyphon’s 2004–2005 support of the 

AANS’ neurosurgical research and educational goals. 

Dr. Talmadge is Kyphon’s executive vice president 

and chief science officer. For more NREF information, 

visit www.AANS.org/research. For more about 

Kyphon, visit www.kyphon.com. 

officer. “Through our corporate sponsorship, 

we can support the foundation’s 

activities to realize our common mission 

of improving patient care and quality of 

life by advancing worthwhile neurosciences 

research.” 

Kyphon Matches Donations 

100 Percent 

Kyphon recently took its relationship with 

the NREF to yet another level, issuing a 

matching grant and a challenge to all 

AANS members. Kyphon generously 

agreed to match 100 percent of all donations 

to the NREF up to $25,000. Hence 

the donations made to NREF, either firsttime 

or renewed gifts, were doubled, thus 

enabling each contribution to have a 

greater impact on the overall research 

grant program. 

“We are proud to partner with Kyphon 

in this way,” commented NREF Chair Martin 

H. Weiss, MD, FACS. “Neurosurgery’s 

growth and expansion is dependent upon 

both technical evolution and the expansion 

of our understanding of the disease 

processes that confront us. Corporations 

like Kyphon are assisting us with this 

growth and expansion through their dedicated 

support of research.” 

It is a true match made in the name of 

science and medical research. Kyphon and 

the NREF are organizations working 

together toward a common good—making 

a difference in neurosurgery, one day and 

one dollar at a time. 

Silent Auction Donations 

Support Research 

In addition to corporate support, another 

avenue of NREF support will be evidenced 

at the 2006 AANS Annual Meeting 

April 22–27, when the Young Neurosurgeons 

Committee hosts the 2006 Annual 

Silent Auction benefiting the NREF. 

The committee, led by Edward Vates, 

MD, began procuring items for the eighth 

silent auction immediately following the 

2005 event, securing popular items such as 

vacation packages, electronic gadgets, 

sports memorabilia and medical books. 

Also welcomed are monetary donations, 

which will be used to purchase items in the 

name of the contributor or contributing 

company. This year’s fundraising goal for 

the auction is $30,000. 

Proceeds from the YNC-sponsored auction 

assist the NREF in its efforts to fund 

scientific investigations through research 

fellowships and young clinician awards. 

For more information about the 2006 

Annual Silent Auction, to make a donation 

or to learn more about the NREF grants 

program, visit www.AANS.org/research. 3 

Michele S. Gregory is AANS director of development. 


B OOKSHELF G ARY V ANDER A RK, M D 

A Tale of Neurosurgery’s Founder 

A Compelling Cushing Inspired a Specialty 

Harvey Cushing: 

A Life in Surgery, 

by Michael Bliss, 

2005, Oxford 

University Press, 

591 pp., $40 

($26.40 for AANS 

members). 

Canadian historian Michael Bliss, 

MD, author of William Osler: A Life 

in Medicine, has written a new book 

about neurosurgery’s founder, Harvey 

Cushing. It is a book that everyone 

should read. 

Bliss based this book on a host of Cushing 

family papers unavailable to earlier 

biographers. As a result, this is a less constrained 

and more personal biography. 

Cushing still comes through as a daring 

innovator and icon, but he is also revealed 

as a real person with many foibles. 

Born in Cleveland in 1869, Cushing 

graduated from Yale in 1891 and Harvard 

Medical School in 1895, staying in Boston 

for an internship at Massachusetts General 

Hospital. Then Baltimore beckoned with 

its new, graciously endowed Johns Hopkins 

Hospital and Medical School. Halsted, 

Welch, Kelly and Osler all influenced Cushing, 

although during his training Cushing 

had limited contact with Halsted, but it was 

Osler who quickly became a surrogate 

father figure for the young surgical pioneer. 

A most significant part of Cushing’s 

development then followed in his “Wanderjahr” 

of 1900–01, when he visited Europe. 

There, Cushing was shocked by the lack of 

surgical asepsis, concern for the feelings of 

the patients and consistency of surgical 

techniques. He also did the research that led 

to elucidation of the “Cushing reflex.” 

The next year, Cushing married Kate 

Crowell and they moved into the house next to 

the Oslers in Baltimore. Cushing was declared 

the neurosurgical specialist among the Hopkins 

surgeons. His interest in brain surgery 

resulted from his ability to successfully treat 

trigeminal neuralgia by gasserian ganglionectomy. 

As a result, he began to do brain tumor 

operations, and in 1902 performed a successful 

nerve anastamosis. 

Before 1900 more than 500 general surgeons 

in the United States had done operations 

on the brain. Cushing, however, 

brought to the then-dismal field a highly 

developed set of techniques to control 

bleeding, crucial knowledge of and sensitivity 

to the problem of intracranial pressure, 

an awesome dexterity, and an equally 

He was the kind of man 

you would work with, 

admire and respect, but 

not one you would like. 

awesome combination of enthusiasm and 

determination to succeed. 

During the first decade of the 20th century, 

Cushing established neurosurgery as a 

specialty. He developed subtemporal decompression 

as his basic intracranial operation. It 

was his all-purpose response to any cerebral 

symptomology. Halsted is said to have commented 

during these years that he didn’t 

know whether to refer to “poor Cushing’s 

patients or Cushing’s poor patients.” 

But he also increasingly dedicated himself 

to the pituitary toward the end of that 

decade. By 1912 he had data on 48 patients 

and wrote The Pituitary Body and Its Disorders. 

It was not until many years later that he 

described the syndrome of hypersecretion 

due to a basophilic adenoma that came to be 

known as Cushing’s syndrome. 

Cushing is not presented in this book as the 

well-rounded person we would like our residents 

to become. He was not a good husband; 

he was an absentee father, and in the operating 

room he could be peevish and mean. One 

Hopkins resident said, “He was the kind of 

man you would work with, admire and 

respect, but not one you would like.” 

World War I, in which Cushing served 

two tours of duty, definitely took its toll. 

While in France he probably had the dreadful 

influenza and then post-flu Guillain- 

Barre syndrome. This, combined with 

Berger’s disease made worse by his smoking, 

resulted in significant pain and lower extremity 

disability. He also learned something 

from the war, however—how to operate 

more rapidly. By the time the war ended, he 

was able to do eight major cases in a day. 

I particularly enjoyed the portions of 

this book that deal with the relationship 

between Cushing and Osler. The book’s 

most moving scene is the death of Osler’s 

son, Revere, on the operating table in Flanders. 

William Osler himself died in December 

1919, and within a few months his 

widow asked Cushing to write his biography. 

Cushing responded by doubling his 

workload to write more than a million 

words about his mentor. The final work was 

edited down to the two-volume The Life of 

Sir William Osler, published in 1925. One 

year later Cushing was awarded the Pulitzer 

Prize in biography for this work. 

Bliss refers to Cushing as “the Babe Ruth 

of his game.” Interestingly, his subject 

enjoyed the athletic analogy, too. Cushing 

wrote to his oldest son, who was struggling 

with his studies, “Life all round is a kind of 

sporting event and the best any of us can do 

is to try continually to improve our game.” 

Reading this book will help you improve 

your own game. 3 

Gary Vander Ark, MD, is director of the Neurosurgery 

Residency Program at the University of Colorado. He is 

the 2001 recipient of the AANS Humanitarian Award. 


W ASHINGTONU PDATE 

2005 NPHCA Contributors 

Special Thanks to Neurosurgery’s Medical 

Liability Campaign Supporters 

This listing of 2005 contributors to Neurosurgeons to Preserve Health Care Access 

reflects donations at press time. The NPHCA is the AANS/CNS advocacy organization 

that funds Doctors for Medical Liability Reform, which in October 

launched a new interactive, nationwide grassroots education and advocacy campaign 

known as Protect Patients Now (www.protectpatientsnow.org). Additional 

NPHCA information is located at www.neuros2preservecare.org. Questions or concerns 

can be directed to Katie Orrico, NPHCA director, at (202) 628-2883. 

Alabama 

Neurosurgical Society of Alabama 

Robert H. Bradley Jr., MD 

Thomas L. Francavilla, MD 

Paul G. Matz, MD 

Richard B. Morawetz, MD 

Thomas W. Rigsby, MD 

Patrick G. Ryan, MD 

Nicholas F. Voss, MD 

Thomas A. S. Wilson Jr., MD 

D. Bruce Woodham, MD 

H. Evan Zeiger, MD 

Alaska 

None 

Arizona 

Hillel Baldwin, MD 

L. Philip Carter, MD 

Curtis A. Dickman, MD 

Paul M. Francis, MD 

Gabriel A. Gonzales-Portillo, MD 

Barry A. Kriegsfeld, MD 

Paul W. LaPrade Jr., MD 

Bradley R. Nicol, MD 

Stephen M. Papadopoulos, MD 

Randall W. Porter, MD 

Abhay Sanan, MD 

Thomas B. Scully, MD 

Kris A. Smith, MD 

Volker K. H. Sonntag, MD 

Robert F. Spetzler, MD 

Harvey G. Thomas, MD 

Carrie L. Walters, MD 

Arkansas 

Rebecca J. Barret-Tuck 

James Blair Blankenship, MD 

George T. Burson, MD 

Arthur M. Johnson, MD 

Ali F. Krisht, MD 

Jeffrey Alan Kornblum, MD 

Gregory F. Ricca, MD 

Tresa Sauthier 

Pervie Simpson Jr., MD 

Kenneth Tonymon, MD 

California 

Moustapha Abou-Samra, MD 

Laurie Lynn Ackerman, MD 

Mark E. Anderson, MD 

Brian T. Andrews, MD 

James I. Ausman, MD, PhD 

Mitchel S. Berger, MD 

David B. Bybee, MD 

Steven D. Chang, MD 

E. Thomas Chappell, MD 

SooHo Choi, MD 

Tony F. Feuerman, MD 

Igor Fineman, MD 

Sanjay Ghosh, MD 

William Hitselberger, MD 

Robert John Jackson, MD 

J. Patrick Johnson, MD 

John A. Kusske, MD 

David I. Levy, MD 

Mark A. Liker, MD 

Mark E. Linskey, MD 

Amir S. Makoui, MD 

Michael W. McDermott, MD 

Jenny Jasbir Multani, MD 

Kimberly A. Page, MD 

Mahmoud Rashidi, MD 

Benjamin J. Remington, MD 

Roderick G. Sanden, MD 

Marc S. Schwartz, MD 

Randal W. Smith, MD 

Melvin Snyder, MD 

Philip A. Starr, MD, PhD 

Peter P. Sun, MD 

Asher H. Taban, MD 

Peyman R. Tabrizi, MD 

Scott Patrick Wachhorst, MD 

Daniel Vernon White, MD 

Daniel Won, MD 

Kevin Yoo, MD 

Colorado 

Giancarlo Barolat, MD 

Hans C. Coester, MD 

Andrew T. Dailey, MD 

John Diaz Day, MD 

J. Paul Elliott, MD 

Timothy M. Fullagar, MD 

David Hall, MD 

John H. McVicker, MD 

Lloyd W. Mobley III, MD 

J. Adair Prall, MD 

Chad J. Prusmack, MD 

Carson J. Thompson, MD 

Larry D. Tice, MD 

Donn Martin Turner, MD 

Brian H. Wieder, MD 

Timothy C. Wirt, MD 

Connecticut 

Gary M. Bloomgarden, MD 

Abraham Mintz, MD 

Patrick R Tomak, MD 

Stephen A. Torrey, MD 

Andrew E. Wakefield, MD 

Delaware 

Magdy I. Boulos, MD 

Michael G. Sugarman, MD 

District of Columbia 

Bruce J. Ammerman, MD 

Katie Orrico, JD 

Florida 

John K. B. Afshar, MD 

Anthony M. Alberico, MD 

Christopher J. Baker, MD 

Kaveh Barami, MD, PhD 

John Scott Boggs, MD 

Kevin L. Boyer, MD 

Joseph C. Cauthen, MD 

Harold J. Colbassani Jr., MD 

Gary P. Colon, MD 

Gary J. Correnti, MD 

Mark James Cuffe, MD 

Paul D. Dernbach, MD 

William O. DeWeese, MD 

Antonio DiSclafani II, MD 

Andrew D. Fine, MD 

Duane B. Gainsburg, MD 

Mark B. Gerber, MD 

F. Gary Gieseke, MD 

Jordan C. Grabel, MD 

Cesar Guerrero, MD 

Philip Henkin, MD 

Roberto C. Heros, MD 

Hector E. James, MD 

Dale K. Johns, MD 

I. Basil Keller, MD 

Rakesh Kumar, MD 

Albert S. Lee, MD 

Dean C. Lohse, MD 

Lucy Carole Love, MD 

Lloyd I. Maliner, MD 

Fairuz Matuk, MD 

Peter L. Mayer, MD 

Christie M. McMorrow, MD 

Muhammed Y. Memon, MD 

Paulo Monteiro, MD 

Brett A. Osborn, DO 

Guillermo A. Pasarin, MD 

Antonio R. Prats, MD 

Christopher S. Rumana, MD 

John S. Sarzier, MD 

Douglas F. Savage, MD 

Andrew E. Sloan, MD 

Mark A. Spatola, MD 

John C. Stevenson, MD 

Amos Stoll, MD 

Philip W. Tally, MD 

Troy M. Tippett, MD 

Jed P. Weber, MD 

Aizik L. Wolf, MD 

Georgia 

Michael A. Amaral, MD 

Roy Powell Baker, MD 

Kimberly S. Brown, MD 

Cliff Cannon Jr., MD 

C. Michael Cawley, MD 

Marc S. Goldman, MD 

Regis W. Haid Jr., MD 

Peter Osborne Holliday III, MD 

Timothy B. Mapstone, MD 

Praveen V. Mummaneni, MD 

Bruce J. Nixon, MD, PhD 

Gregory M. Oetting, MD 

Jeffrey J. Olson, MD 

Nelson M. Oyesiku, MD, PhD 

Gerald E. Rodts Jr., MD 

Karl D. Schultz Jr., MD 

David Louis Semenoff, MD 

John M. Shutack, MD 

Ildemaro J. Volcan, MD 

Fremont P. Wirth, MD 

Hawaii 

Jon F. Graham, MD 

Warren Y. Ishida, MD 

Leon K. Liem, MD 

Michon Morita, MD 

Idaho 

Roy Tyler Frizzell, MD 

William F. Ganz, MD 

Douglas E. Smith, MD 


Illinois 

Todd D. Alexander, MD 

Nesher G. Asner, MD 

H. Hunt Batjer, MD 

Jerry Bauer, MD 

Central Illinois Neuro 

Health Science 

Byong Uk Uk Chung, MD 

Jeffrey Warren Cozzens, MD 

Oliver N. R. Dold, MD 

Jose A. Espinosa, MD 

Richard G. Fessler, MD, PhD 

Aruna Ganju, MD 

Kenneth S. Heiferman, MD 

Thomas Richard Hurley, MD 

Russ P. Nockels, MD 

Vikram C. Prabhu, MD 

John Kevin Ratliff, MD 

Arden F. Reynolds Jr., MD 

Robert Richardson, MD 

Gail L. Rosseau, MD 

Sean A. Salehi, MD 

James L. Stone, MD, SC 

Dennis Yung K. Wen, MD 

Indiana 

Jose M. Arias, MD 

Michael R. Burt, MD 

Henry Feuer, MD 

Peter G. Gianaris, MD 

Julius M. Goodman, MD 

Terry Horner, MD 

Steven M. James, MD 

Wayel Kaakaji, MD 

Jeffrey K. Kachmann, MD 

Saad Abul Khairi, MD 

Thomas J. Leipzig, MD 

Jean-Pierre Mobasser, MD 

Troy D. Payner, MD 

Eric A. Potts, MD 

M. Hytham Rifai, MD 

J. Sartorius, MD 

Daria D. Schooler, MD 

Mitesh V. Shah, MD 

Erick Stephanian, MD 

Michael S. Turner, MD 

Ronald LeRoy Young, MD 

Iowa 

David W. Beck, MD 

Thomas A. Carlstrom, MD 

Matthew A. Howard III, MD 

Darren S. Lovick, MD 

Todd R. Ridenour, MD 

Vincent C. Traynelis, MD 

Sabrina M. Walski-Easton, MD 

Kansas 

Paul M. Arnold, MD 

John D. Ebeling, MD 

Clifford M. Gall, MD 

Raymond W. Grundmeyer III, MD 

Kentucky 

Steven C. Bailey, MD 

James R. Bean, MD 

William H. Brooks, MD 

Steven P. Kiefer, MD 

Bradley G. Mullen, MD 

Srinivasan Periyanayagam, MD 

David A. Petruska, MD 

Steven J. Reiss, MD 

Andrew Scott, MD 

Bradbury A. Skidmore, MD 

Karin R. Swartz, MD 

Wayne G. Villanueva, MD 

Louisiana 

David Cavanaugh, MD 

John Robert Clifford, MD 

Lawrence Drerup, MD 

Thomas B. Flynn, MD 

David G. Kline, MD 

Ricardo R. Leoni, MD 

Horace L. Mitchell, MD 

Stefan G. Pribil, MD 

Troy M. Vaughn, MD 

Rand M. Voorhies, MD 

Erich W. Wolf II, MD, PhD 

Maine 

Konrad (Max) N. M. Barth, MD 

Joel I. Franck, MD, PA 

Patricio Hernan Mujica, MD 

Lee L. Thibodeau, MD 

Maryland 

Bizhan Aarabi, MD 

Kheder Ashker, MD 

Hugo E. Benalcazar, MD 

Henry Brem, MD 

John R. Caruso, MD 

Lawrence S. Chin, MD 

Gary A. Dix, MD 

Howard M. Eisenberg, MD 

Augusto F. Figueroa Jr., MD 

Raymond I. Haroun, MD 

Jeff Jacobson, MD 

Saied Jamshidi, MD 

Jacek Marian Malik, MD, PhD 

William T. Monacci, MD 

Swami Nathan, MD 

Daniele Rigamonti, MD 

Henry M. Shuey Jr., MD 

J. Sullivan, MD 

Dennis D. Winters, MD 

Ravi Yalamanchili, MD 

Massachusetts 

Christopher H. Comey, MD 

Arthur L. Day, MD 

Peter K. Dempsey, MD 

Michael H. Freed, MD 

Marc H. Friedberg, MD, PhD 

Howard M. Gardner, MD 

Carl Barnes Heilman, MD 

Kamal K. Kalia, MD 

Michael Dean Medlock, MD 

Savvas Papazoglou, MD 

Ronald K. Warren, MD 

Michigan 

Christopher J. Abood, MD 

Charles H. Bill II, MD, PhD 

Paul D. Croissant, MD 

Fernando G. Diaz, MD, PhD 

Alain Y. Fabi, MD 

Phillip Friedman, MD 

David A. Herz, MD 

Julian T. Hoff, MD 

Vivekanand Palavali, MD 

Miguel Lis-Planells, MD 

Mick J. Perez-Cruet, MD 

Norbert Roosen, MD 

Donald M. Seyfried, MD 

John E. Stevenson, MD 

Sherry L. Taylor, MD 

Geoffrey M. Thomas, MD 

Minnesota 

Hector W. Ho, MD 

Cornelius H. Lam, MD 

David George Piepgras, MD 

Corey Raffel, MD, PhD 

Mississippi 

W. Craig Clark, MD, PhD 

E. Thomas Cullom III, MD 

John J. McCloskey, MD 

Andrew D. Parent, MD 

Missouri 

Robert J. Backer, MD 

Charles Palmer Bondurant, MD 

Arthur Steven Daus, MD 

Thomas R. Forget Jr., MD 

Robert L. Grubb Jr., MD 

J. Alexander Marchosky, MD 

Midwest Neurosurgery Associates 

M. Ellen Nichols, MD 

Nebraska 

Kenneth A. Follett, MD, PhD 

Benjamin R. Gelber, MD 

Leslie C. Hellbusch, MD 

Lyal G. Leibrock, MD 

Douglas J. Long, MD 

A. Angelo Patil, MD 

William E. Thorell, MD 

Nevada 

John A. Anson, MD 

Gary Flangas, MD 

Randal Peoples, MD 

Dante F. Vacca, MD 

New Hampshire 

Jonathan A. Friedman, MD 

Nigel Ross Jenkins, MD 

New Jersey 

Peter W. Carmel, MD 

Duncan B. Carpenter, MD 

Jeffrey E. Catrambone, MD 

James M. Chimenti, MD 

Roderick J. Clemente, MD 

Michael P. Feely, MD 

Allan L. Gardner, MD 

Robert F. Heary, MD 

Frank M. Moore, MD 

Jay More, MD 

Francis J. Pizzi, MD 

Elisabeth M. Post, MD 

Bruce R. Rosenblum, MD 

Catherine A. Ruebenacker- 

Mazzola, MD 

Michael Schulder, MD 

Richard C. Strauss, MD 

New Mexico 

Hal L. Hankinson, MD 

Andrew K. Metzger, MD 

New York 

Rick Abbott, MD 

Rafael Allende, MD 

Ron L. Alterman, MD 

Ashok Anant, MD 

Marc S. Arginteanu, MD 

Saeed Bajwa, MD 

Ethan A. Benardete, MD, PhD 

Alan S. Boulos, MD 

Jeffrey N. Bruce, MD 

Michael H. C. Cho, MD 

Paul R. Cooper, MD 

Kaushik Das, MD 

Anthony K. Frempong-Boadu, MD 

Daniel D. Galyon, MD 

Francis W. Gamache Jr., MD 

Isabelle M. Germano, MD 

John G. Golfinos, MD 

Robert Goodman, MD 

Alan D. Hirschfeld, MD 

L. N. Hopkins III, MD 

Paul P. Huang, MD 

Jafar Jewad Jafar, MD 

Patrick J. Kelly, MD 

Ezriel Edward Kornel, MD 

David C. Y. Kung, MD 

Ranjit Kumar Laha, MD 

Michael K. Landi, MD 

Michael H. Lavyne, MD 

Steven P. Leon, MD 

P. Jeffrey Lewis, MD 

Veetai Li, MD 

Paul C. McCormick, MD 

Raj Murali, MD 

Stephen T. Onesti, MD 

Robert J. Plunkett, MD 

A. John Popp, MD 

Kalmon D. Post, MD 

Donald O. Quest, MD 

Sumeer Sathi, MD 

Steven J. Schneider, MD 

Theodore H. Schwartz, MD 

Daniel E. Spitzer, MD 

Jack Stern, MD, PhD 

Loubert Steven Suddaby, MD 

Jeffrey H. Wisoff, MD 

Seth M. Zeidman, MD 

North Carolina 

Tim E. Adamson, MD 

Anthony Asher, MD 

Joe D. Bernard Jr., MD 

Adam P. Brown, MD 

Domagoj Coric, MD 

Vinay Deshmukh, MD 



W ASHINGTONU PDATE 


E. Hunter Dyer, MD 

Frederick E. Finger III, MD 

Michael D. Heafner, MD 

Martin M. Henegar, MD 

Stephen W. Hipp, MD 

Bruce P. Jaufmann, MD 

F. Douglas Jones, MD 

Barry Katz, MD 

Robin Koeleveld, MD 

Kim Eng Koo, MD 

Robert Lacin, MD 

Clinton Edward Massey, MD 

C. Scott McLanahan, MD 

Henry Moyle, MD 

Victoria Neave, MD 

Richard K. Osenbach, MD 

Christopher G. Paramore, MD 

Mark P. Redding, MD 

Eric Loren Rhoton, MD 

Malcolm Shupeck, MD 

Pat Smith, MD 

Victor G. Sonnino, MD 

Craig Andrew Van Der Veer, MD 

Carol M. Wadon, MD 

North Dakota 

John W. Hutchison, MD 

Ohio 

Cynthia Zane Africk, MD 

Arthur G. Arand, MD 

Janet W. Bay, MD 

William E. Bingaman Jr., MD 

Robert J. Bohinski, MD, PhD 

Louis P. Caragine Jr., MD, PhD 

A. Lee Greiner, MD 

Edward J. Kosnik, MD 

Charles Kuntz IV, MD 

George T. Mandybur, MD 

Dennis E. McClure, MD 

John M. McGregor, MD 

Azedine Medhkour, MD 

Raj K. Narayan, MD 

Morris Wade Pulliam, MD 

Robert Ratcheson, MD 

Andrew J. Ringer, MD 

E. Salinas, MD 

Thomas G. Saul, MD 

P. Robert Schwetschenau, MD 

Mario M. Sertich, MD 

Michael B. Shannon, MD 

Joel D. Siegal, MD 

Lawrence M. Spetka, MD 

Jean-Claude M. Tabet, MD 

John M. Tew Jr., MD 

Philip V. Theodosopoulos, MD 

William D. Tobler, MD 

Ronald E. Warnick, MD 

Hwa-shain Yeh, MD 

Bo H. Yoo, MD 

Ahmad Zakeri, MD 

Mario Zuccarello, MD 

Oklahoma 

Christopher Covington, MD 

Karl N. Detwiler, MD 

Charles F. Engles, MD 

Douglas R. Koontz, MD, PC 

Jeffrey Paul Nees, MD 

Neuroscience Specialists 

Don F. Rhinehart, MD 

James A. Rodgers, MD 

Oklahoma Spine Hospital 

Stan Pelofsky, MD 

Bruce Pendleton, MD 

Stewart C. Smith, MD 

Oregon 

Mark G. Belza, MD 

Kim J. Burchiel, MD 

Maurice Collada Jr., MD 

Michael Dorsen, MD 

Jerry L. Hubbard, MD 

Andrew J. Kokkino, MD 

Michael W. Potter, MD 

Donald A. Ross, MD 

Nathan R. Selden, PhD, MD 

Francisco X. Soldevilla, MD 

Pennsylvania 

P. David Adelson, MD 

Perry Argires, MD 

Kimberly S. Harbaugh, MD 

Robert E. Harbaugh, MD 

James S. Harrop, MD 

Philip J. Hlavac, MD 

Christopher D. Kager, MD 

James A. Kenning, MD 

Douglas S. Kondziolka, MD 

Keith R. Kuhlengel, MD 

Daniel V. Loesch, MD 

L. Dade Lunsford, MD 

Joseph Charles Maroon, MD 

Mark R. McLaughlin, MD 

David R. Oliver-Smith, MD 

Carroll Prentis Osgood, MD 

Roger H. Ostdahl, MD 

Robert H. Rosenwasser, MD 

Frederick Anthony Simeone, MD 

Richard M. Spiro, MD 

Michael I. Stanley, MD 

Hani J. Tuffaha, MD 

Kevin Walter, MD 

William C. Welch, MD 

Joel W. Winer, MD 

Rhode Island 

Curtis E. Doberstein, MD 

J. Frederick Harrington Jr., MD 

South Carolina 

Michael A. Cowan, MD 

Brian G. Cuddy, MD 

David B. Kee Jr., MD 

Aaron Curtis MacDonald, MD 

William M. Rambo Jr., MD 

Andrew Rhea, MD 

South Dakota 

Quentin John Durward, MD 

Marc E. Eichler, MD 

Mark W. Fox, MD, PC 

Michael J. Giordano, MD 

Thorir S. Ragnarsson, MD 

Tennessee 

Tennessee Neurosurgical Society 

Kenan Arnautovic, MD 

H. Glenn Barnett II, MD 

Frederick A. Boop, MD 

Allen S. Boyd Jr., MD 

John A. Campbell, MD 

Gregory Corradino, MD 

David L. Cunningham, MD 

Sanat Dixit, MD 

Stephanie L. Einhaus, MD 

Jerry Engelberg, MD 

Claudio Andres Feler, MD 

Kevin T. Foley, MD 

Thomas Duane Fulbright, MD 

John J. Kruse, DMD, MD 

Michael S. Muhlbauer, MD 

John W. Neblett, MD 

Rodney Glen Olinger, MD 

Morris William Ray, MD 

Jon H. Robertson, MD 

Allen K. Sills Jr., MD 

Maurice M. Smith, MD 

Jeffrey M. Sorenson, MD 

Shelly D. Timmons, MD, PhD 

Eugenio F. Vargas, MD 

Clarence B. Watridge, MD 

Texas 

Alfonso Aldama-Luebbert, MD 

David W. Barnett, MD 

Jay M. Barrash, MD 

Michael James Burke, MD 

Tamerla D. Chavis, MD 

Jeffrey D. Cone, MD, FACS 

John S. Crutchfield, MD 

David J. Donahue, MD 

Luis E. Duarte, MD 

Bruce L. Ehni, MD 

Richard E. George Jr., MD 

Michael Gieger, MD 

Jeffrey Heitkamp, MD 

W. Robert Hudgins, MD 

Matthew K. Hummell, MD 

Richard Henry Jackson, MD 

Thomas A. Kingman, MD 

Mark J. Kubala, MD 

Martin L. Lazar, MD 

James J. Leech, MD 

Erwin Lo, MD 

Thomas S. Loftus, MD, PA 

Christopher B. Michael, MD 

Luis A. Mignucci, MD 

James A. Moody, MD 

Mahmood Moradi, MD 

Richard C. Naftalis, MD 

Warren Neely, MD 

Ibrahim Muftah El Nihum, MD 

Stig E. Peitersen, MD 

James Michael Randle, MD 

Raymond Sawaya, MD 

Abdolreza Siadati, MD 

Alex B. Valadka, MD 

Utah 

Ronald I. Apfelbaum, MD 

William T. Couldwell, MD, PhD 

Joel D. MacDonald, MD 

Virginia 

Charles Azzam, MD 

Nasrollah Fatehi, MD 

Robert M. Gorsen, MD 

Donald G. Hope, MD 

Peter M. Klara, MD, PhD 

Bothwell Graves Lee, MD 

Charles L. Levy, MD 

Jonathan P. Partington, MD 

Nicholas Poulos, MD 

Eric B. Schubert, MD 

Crystl D. Willison, MD 

Washington 

W. Ben Blackett, MD, JD 

Richard G. Ellenbogen, MD 

Steven Lewis Klein, MD 

Barry J. Landau, MD 

Jae Y. Lim, MD 

Benjamin C. Ling, MD 

Daniel G. Nehls, MD 

Norman C. Rokosz, MD 

Richard N. Wohns, MD 

Jacob N. Young, MD 

West Virginia 

Frederick H. Armbrust, MD 

Julian Bailes, MD 

Warren W. Boling, MD 

Larry Carson, MD 

Robert J. Crow, MD 

Jeffrey Allen Greenberg, MD 

Charles L. Rosen, MD, PhD 

John H. Schmidt III, MD 

Wisconsin 

Robert Dempsey, MD 

Walter J. Faillace, MD 

Richard L. Harrison, MD 

Dennis Jay Maiman, MD, PhD 

Jeffrey E. Masciopinto, MD 

John H. Neal, MD 

Phillip J. Porter, MD 

Sanjay C. Rao, MD 

Mark K. Stevens, MD, PhD 

Wyoming 

Steven Joseph Beer, MD 

Joseph Sramek, MD 

National Organizations 

American Association of 

Neurological Surgeons 

Congress of Neurological Surgeons 

Canada 

James T. Rutka, MD, PhD, FRC 

Puerto Rico 

Ricardo H. Brau, MD 

Juan M. Padilla, MD 


MOC Takes Shape 

ABNS Begins Maintenance of Certification Rollout in 2006 

RALPH G. DACEY JR., MD, M. SEAN GRADY,MD,HUNT BATJER,MD, AND WILLIAM CHANDLER,MD 

In 2006 the American Board of Neurological Surgery 

begins rollout of its Maintenance of Certification, or 

MOC®, program. The ABNS was founded in 1940 to provide 

initial certification to practitioners of neurosurgery 

who meet specific training and practice requirements. In 

recent years the public, payers, other healthcare organizations 

and governmental agencies have called for periodic 

recertification of specialists. 

In March 2000 all member boards of the American Board of 

Medical Specialties, including the ABNS, adopted a commitment 

to modify their current or planned programs for recertification 

into programs for MOC. After analyzing the arguments for the 

establishment of an MOC program, ABNS directors concluded 

that regulatory bodies will very soon require neurosurgeons to 

participate in the process. ABNS directors are committed to making 

available to all diplomates a meaningful and practical MOC 

program, one that takes into account the concerns of diplomates 

and meets the standards of the ABNS, as well as those established 

by the ABMS. 

Through its MOC program, the ABNS supports its diplomates’ 

dedication to lifelong learning. The guiding principle in this 

endeavor is to foster excellence in patient care. 

The ABNS MOC program is designed to reflect the realities of 

today’s neurosurgical practice. Emphasis is placed on core neurosurgical 

knowledge and practice common to all neurosurgeons. 

The process is designed to permit diplomates to include the areas 

of their individual expertise when devoting time to continuing 

medical education activities, selecting a module for the cognitive 

examination and submitting key cases from their practice. 

Diplomates are enrolled in the program upon issuance of timelimited 

ABNS certificates and submission of a completed MOC 

application. Time-limited certificates, current for 10 years, were first 

issued to new ABNS diplomates in 1999. In order to maintain their 

certification, diplomates certified during or after 1999 must participate 

in the MOC program. Each individual’s progress through the 

MOC program requirements will be tracked online. 

Non-time-limited certificate holders may participate in the 

program at any time. Current for the life of the individual, nontime-limited 

certificates were issued to all ABNS diplomates certified 

before 1999. A non-time-limited, original certificate will not 

expire regardless of the individual’s participation in the MOC program. 

Individuals in this group, however, are strongly encouraged 

to participate in the MOC program. 

Program Requirements 

There are four basic components of all specialty MOC programs: 

evidence of professional standing; evidence of lifelong learning and 

self-assessment; evidence of cognitive knowledge; and evidence of 

performance in practice. 

Into this framework, the ABNS MOC program has integrated 

seven requirements: chief of staff questionnaire; CME hours, both 

category 1 and category 2; cognitive examination; communication 

assessment tool (the CAHPS); key case analysis; Self-Assessment in 

Neurological Surgery Examination (the SANS); and unrestricted 

license to practice medicine. 

The four basic components and the individual ABNS requirements, 

plus the frequency with which they must be updated, have 

been integrated as follows. 

1. Evidence of Professional Standing 

A. Full unrestricted license to practice medicine in all jurisdictions in which 

the diplomate practices will be verified every three years. 

B. Unencumbered hospital admitting privileges to practice neurosurgery 

will be verified every three years. 

C. Questionnaires will be completed by the chief of the medical staff of 

the diplomate’s primary hospital every three years. 

2. Evidence of Lifelong Learning 

and Self-Assessment 

A. Lifelong Learning: At least 150 CME hours must be accumulated 

every three years and must include a minimum of 60 category 1 neurosurgical 

hours with the remainder in either category 1 or category 2. 

At least 80 percent of the 150 hours must be specific to neurosurgery. 

The ABNS reserves the right to establish the activities that qualify for 

CME categories 1 and 2; a list of accepted activities will be available 

on the ABNS Web site. Self-assessment exercises and examinations 

can be used to satisfy portions of the requirement. Accrual of CME 

hours will be tracked in conjunction with the American Association of 

Neurological Surgeons, and the information may be verified online. 

B. Self-Assessment: The diplomate must participate in a Web-based educational 

program. For this the ABNS has selected the SANS examination. 

Its development and administration is done by the Congress of Neurological 

Surgeons. Participation in the examination will be verified electronically 

and forwarded to the ABNS data repository every three years. 


3. Evidence of Performance in Practice 

A. Key Cases: Every three years diplomates must submit the details of 

10 consecutive cases of one procedure selected from a list of procedures 

that cover the subspecialties. If the diplomate practices general neurosurgery 

or a subspecialty not represented, he or she may send in 10 consecutive 

cases of the most frequent procedure. Questionnaires must be 

filled out by the diplomate regarding each reported consecutive case. The 

list of cases so far consists of the following: (1) Anterior Cervical Discectomy; 

(2) Chiari Decompression; (3) Clipping of Anterior Circulation 

Aneurysm; (4) Craniotomy for Cerebral Glioma; (5) Craniotomy for Temporal 

Lobectomy; (6) Endovascular Embolization of an Anterior Circulation 

Aneurysm; (7) Lumbar Discectomy; (8) Radiosurgery of a Metastatic Brain 

Tumor; (9) Release of Tethered Cord; (10) Removal of Intracranial 

Hematoma; (11) Surgical Treatment of Pituitary Tumor; (12) Surgical Treatment 

of Trigeminal Neuralgia; (13) Ulnar Nerve Transposition; (14) Nonsurgical 

Treatment of Back Pain. Key case participation will be validated 

and feedback given to diplomates for analysis. 

B. Communication Assessment Tool: Practice assessment of physicianpatient 

communication must be submitted every three years. Patient perception 

of physician performance in the areas of interpersonal and 

communication skills will be measured using a survey given to 20 patients 

who respond via telephone or the Internet. Participation in the communication 

assessment survey is validated and feedback given to the participant 

for analysis. 

C. Chief of Staff Questionnaire: Every three years a chief of staff questionnaire 

must be submitted by the diplomate. The questionnaire will allow 

the ABNS to verify the diplomate’s standing at his or her primary hospital 

and will cover the MOC areas of professionalism, communication skills 

and participation in systems-based practice. 

D. SANS: Content is developed by the SANS CNS editorial board to assess 

the competencies of interpersonal skills, professionalism, practice-based 

learning and improvement, and systems-based practice. Items are then 

refined to meet the standards of the ABNS and the National Board of Medical 

Examiners for cognitive knowledge examinations. 

E. Additional Modules: Other modules, including one on patient safety, will 

be added as developed. Participation is expected to be every three years. 

4. Evidence of Cognitive Knowledge 

A cognitive examination must be taken and passed in the eighth, ninth or 

10th year of each 10-year MOC cycle. Prior to taking the examination, the 

applicant must have met these criteria: 

3 Active continuous participation in the MOC program (all three-year 

cycles—i.e., CME hours, key cases, SANS, communications assessment 

tool, unrestricted license and chief of staff questionnaires) or 

successful reinstatement in the process if there was a period of nonparticipation. 

3 No fees outstanding to the ABNS. 

This secure computer-based examination will be given at regional testing 

centers. It will consist of 200 questions and will be entirely clinically 

based. The pass rate is anticipated to be very high. A significant portion 

of the content of the MOC cognitive examination will be similar in style 

and content to the material presented in previous SANS examinations. 

Three different modules will be offered: 

(1) General Examination: Consists of 200 basic clinical neurosurgery 

questions. 

(2) Spine Examination: Consists of 150 of the basic clinical neurosurgery 

questions, plus 50 complex spine questions. 

(3) Pediatric Examination: Consists of 150 of the basic clinical neurosurgery 

questions, plus 50 pediatric questions. 

As soon as the results become available, participants will receive their 

examination score reports and notification of their passage or failure. Participants 

who do not receive their results within 16 weeks should call the 

ABNS office and request a report. Examination results will be communicated 

to the diplomate via a written report mailed to the diplomate’s postal 

address; no results will be communicated via telephone, fax or e-mail. 

Most diplomates who participate in the MOC cognitive examination will 

be successful. Those who do not pass will be encouraged to continue the 

MOC process and retake it at the earliest possible time, as long as they 

are within their 10-year cycle. An examination fee must be paid each time 

the examination is taken. Diplomates may retake the examination as long 

as they continue to meet the program requirements expected of active 

participants. 

3 For Time-Limited Certificates: Diplomates with time-limited certificates 

are required to pass the MOC cognitive examination. The examination may 

be taken during the eighth, ninth or 10th year of the MOC process. Individuals 

who have not passed it by the end of the 10-year period may reinstate 

their diplomate status only by repeating all the requirements for 

initial ABNS certification, including passing the primary and oral examinations 

and thereby earning a new, valid, time-limited certificate. Consequently, 

diplomates are encouraged to take the MOC examination in the 

eighth or ninth year of their 10-year cycle so that, in the event they do not 

pass, they can retake it prior to the expiration of the 10-year period. 

3 For Non-Time-Limited Certificates: Diplomates with non-time-limited certificates 

who wish to satisfy the requirements of the MOC process but do 

not pass the cognitive examination by the end of their 10-year period will 

not lose their certification; however, they will no longer be considered 

active in the MOC process unless granted an exemption by the ABNS. 

Ralph G. Dacey Jr., MD, M. Sean Grady, MD, Hunt Batjer, MD, and William Chandler, 

MD, are directors of the American Board of Neurological Surgeons, www.ABNS.org. 


N EWS. ORG 

AANS/CNS SectionsCommitteesAssociationsSocieties 

“Lost” AANS Members 

Year Joined, 

Last Known Location 

Hugh W. Barr, MD 

1969, Ontario 

Wesley A. Cook Jr., MD 

1974, North Carolina 

Giuseppe Dalle Ore, MD 

1970, Italy 

Jeremy W. Denning, MD 

2000, Texas 

Stefanie Ann DiCea, PA-C 

2005, Michigan 

Robert A. Evans, MD 

1970, California 

William S. Fields, MD 

1960, Georgia 

Adolphe Y. Gerol, MD 

1963, Wisconsin 

H. Stephen Goldberg, MD 

1977, Texas 

Daniel Charles Good, MD 

1978, Pennsylvania 

John Hankinson, MD 

1973, England 

Thomas J. Holbrook, MD 

1950, West Virginia 

Henry L. Hood, MD 

1961, Pennsylvania 

William S. Huestis, MD 

1965, Nova Scotia 

Kenneth I. Kiluk, MD 


Stephen Francis 

Kornyey, MD 

1958, Hungary 

Joyce A. Kunkel, RN, 

CNRN 


Warren H. Leimbach II, MD 

1992, Ohio 

Nills G. Lundberg, MD 

1969, Sweden 

Ignacio A. Magana, MD 

1993, Florida 

Richard Malmros, MD 

1969, Denmark 

Help Find “Lost” AANS Members The AANS seeks 

readers’ help in locating the members listed at left. In 

an effort to locate them, the AANS has contacted 

their medical schools, residency programs, institutions 

where they practiced medicine and state neurosurgical 

societies, and has conducted Web 

searches. Those with contact or other information 

that may help to locate an individual are asked to 

contact AANS Member Services at (888) 566-2267, 

ext. 538, or kal@aans.org. 

AANS Endorses NextGen EMR System AANS members 

now can receive a discount on NextGen electronic 

medical record systems, available through a new 

alliance agreement. EMR systems can help physician 

practices improve quality, reduce risk, cut costs and 

increase revenues. NextGen’s EMR system is appropriate 

for any size of medical practice—solo or small 

practice or large, multiprovider, multilocation 

group. Providers that want to share and manage 

clinical and administrative patient information 

through a comprehensive, single-source application 

can visit www.nextgen.com or call (215) 657-7010 to 

learn more. Neurosurgical templates are available. 

For information on other AANS partner programs, 

visit the AANS Web site at www.aans.org/membership/mem_services.asp 

AANS Achieves ACCME Accreditation Through 2009 

Following a routine review of AANS continuing 

medical education activities, the Accreditation 

Council for Continuing Medical Education accredited 

the AANS until the next review in November 

2009. The ACCME notified the AANS in 

November of accreditation, finding compliance in 

all areas and exemplary compliance in two areas. 

As an ACCME-accredited provider, the AANS 

takes full responsibility for its certified activities 

including planning, implementing and evaluating 

them. Accreditation by the ACCME allows the 

AANS to directly sponsor CME programs such as 

AANS coding courses, practice management 

courses, clinical courses and oral boards courses. It 

also allows the AANS to jointly sponsor CME programs 

with unaccredited providers and to cosponsor 

CME programs with accredited providers. 

Additional information on joint sponsorship, 

cosponsorship and all AANS CME activities is 

available at www.AANS.org/education. 

ACS/AANS Health Policy Scholarship The 2006 Health 

Policy Scholarship, offered by the American College 

of Surgeons and the AANS, supports attendance at 

the Leadership Program in Health Policy and 

Management at Brandeis University from May 29 

to June 3, 2006. The goal of the leadership program 

is to provide clinical leaders with the policy and 

management skills essential for creating innovative 

and sustainable solutions that improve the quality, 

cost-effectiveness, and efficiency of healthcare service 

delivery. The awardee must be between the 

ages of 30 and 55 and a member of both the ACS 

and the AANS. The application deadline is Feb. 1. 

Additional information is available at www.aans 

.org/ACS_AANS_Scholarship.pdf. 

“Contemporary Neurosurgery” Now Counts Toward 

AANS CME Requirements Each issue of Contemporary 

Neurosurgery, a biweekly newsletter, has been recognized 

as a cosponsored activity for which 1.5 category 

1 credits are awarded toward the AANS Continuing 

Education Award in Neurosurgery. A description of 

the newsletter is available at www.lww.com/product/ 

0163-2108. Subscribers to Contemporary Neurosurgery 

may submit CME certificates to the AANS 

retroactive to January 2005. AANS members are eligible 

to receive a one-time 10 percent discount on 

their subscriptions by calling (800) 638-3030 and referencing 

the AANS promotional code YNLAANS. 

AANS Endorses TotalChart Medical Software System 

TotalChart, a complete and portable electronic chart 

and medical record, allows access to up-to-date 

coding information, patient information, schedules 

and clinical notes. “One of the critical elements to 

the success of a surgical practice is the efficient 

management of the coding and billing process,” 

said Ronald Warnick, MD, chair of the AANS 

Member Development Committee. “TotalChart is 

one of a new breed of practice solutions that put 

control of this process in the hands of the surgeon.” 

AANS members a receive 10 percent discount of 

the current list price for the TotalChart software 

license. Additional information is available at 


I N M EMORIAM 

Remembering 

Lyal G. Leibrock, MD 

JAMES R. BEAN,MD 

At the passing of Lyal G. Leibrock, MD, we all lost 

a dear friend, a wise and humorous companion, 

and an intrepid and dearly loved fellow-traveler 

on the highway of neurosurgery. 

We will miss him, with his unfeigned modesty, 

his too little acknowledged distinction, and his 

understated leadership. He devoted his life to his 

profession, even to this bitter and untimely end. 

He was instrumental in bringing the Council 

of State Neurosurgical Societies to the position of 

influence and respectability in neurosurgery that 

it now enjoys. His guidance and enthusiasm are 

unmatchable and irreplaceable. 

He worked until his will no longer trumped 

his illness, enduring his trial without complaint. 

This expected news brings unaccustomed sorrow. 

We see death often, but rarely does it touch our 

lives so deeply. We mourn his passing. 

Dr. Leibrock died Sunday, Nov. 13, of metastatic 

colon cancer. He is survived by his wife, Judi, 

children Michele, Elizabeth and Christopher, and 

a granddaughter, Olivia. 

Biography 

For 27 years, Lyal G. Leibrock, MD, was an active 

participant in the Department of Surgery at the 

University of Nebraska Medical Center, most 

www.aans.org/membership/totalchart.asp and at 

www.TotalChart.com, (888) 220-1050. 

AMA Says P4P Programs Must Be Fair and Ethical At its 

semiannual policymaking meeting in November, the 

American Medical Association voted to oppose 

Medicare pay-for-performance initiatives (such as 

“value-based purchasing programs”) that do not 

meet the AMA’s Principles and Guidelines for Payfor-Performance.“The 

AMA today sends a clear message 

that pay-for-performance must be focused on 

quality and be patient-centered, fair and ethical,” said 

AMA Trustee John Armstrong, MD. The five AMA 

principles for fair and ethical pay-for-performance 

programs are: ensure quality of care; foster the 

recently as professor and 

department chair. When a 

neurosurgery training program 

was approved at UNMC 

in July 1993, Dr. Leibrock 

served as its program director. 

Dr. Leibrock had an interest 

in pain, skull base, and 

spinal surgery. He was a visiting 

professor at many universities in the United States 

as well as Shiraz University in Shiraz, Iran, and the 

China/Japan Friendship Hospital in Beijing, China. He 

was a fellow of the American College of Surgeons, a 

member of the Society for Neurological Surgeons as 

well as the American Association of Neurological Surgeons 

and the Congress of Neurological Surgeons for 

which he served on numerous committees, and a 

founding member of the North American Skull Base 

Society. He participated in the Council of State Neurosurgical 

Societies for more than a decade, serving as 

chair from 1999 to 2001. The CSNS recently honored 

him with the Distinguished Service Award. 

Dr. Leibrock was born in Alma, Kan., Nov. 20, 

1940, and raised in California, where he graduated 

from the University of Southern California School of 

Medicine. Dr. Leibrock performed a surgical internship 

at Los Angeles County USC Medical Center 

from 1969 to 1970. He completed his neurosurgical 

training at Johns Hopkins Hospital in the summer of 

1976 under the direction of A.E. Walker, MD, and 

Donlin Long, MD, and he then served two years on 

active duty at the Naval Regional Medical Center, 

Oakland, Calif. 3 

patient-physician relationship; offer voluntary physician 

participation; use accurate data and fair reporting; 

and provide fair and equitable program incentives. 

Additional information is available at 

www.ama-assn.org. 

2006 NASS Research Grant and Fellowship Applications 

Due May 5 The North American Spine Society is 

offering research grants for investigative research on 

the spine, as well as a clinical traveling fellowship and 

a research traveling fellowship. The application deadline 

is May 5. Additional information and an application 

are available at www.spine.org/Research/ 

ResearchProgram.cfm. 

S. Napoleon Martinez, MD 

1962, Canada 

Luciano M. Modesti, MD 

1972, New York 

Juan Negrin Jr., MD 

1952, New York 

Helge Nornes, MD 

1976, Norway 

Jorge Rene Ordonez, MD 

1979, Maryland 

Richard G. Perrin, MD 

1998, Ontario 

Richard Henry Retter, MD 

1958, Ohio 

Charles W. Rossel, MD 

1967, Ohio 

William A. Rouady, MD 

1978, Virginia 

John Albert Savoy, MD 

1976, Maine 

James F. Sheridan, MD 

1973, Ohio 

Richard B. Small, MD 


Donald Leon Stainsby, MD 

1960, Washington 

Gordon J. Strewler, MD 


Fred N. Sugar, MD 

1976, Colorado 

Jean Talairach, MD 

1970, France 

John L. K. Tsang, MD 

1955, Nevada 

Andrew F. Venditti, PA-C 

2001, Indiana 

Jody M. Wellwood, MSN, 

ACNP 

2002, Michigan 

Walter R. Whitehurst, MD 

1967, Florida 

Stuart R. Winston, MD 

1977, Arizona 

Luis Yarzagaray, MD 

1975, Columbia 

John C. Zahniser, MD 


David S. Zealear, MD 


Leonard L. Zinker, MD 

1962, Florida 


C ODING C ORNER 

G REGORY J . 

P RZYBYLSKI, MD 

Coding Changes for CPT 2006 

Payers May Lag Behind Jan. 1 Implementation 

In the past 18 months, several codes have 

moved through the Current Procedural 

Terminology process, valuation by the 

Relative-value Update Committee and 

publication in the 2006 Medicare fee schedule. 

These codes include spinal incision and 

drainage, vertebral augmentation after cavity 

creation (kyphoplasty) and intracranial 

stenting. This Coding Corner will examine 

the new category I codes for 2006 as well as 

their valuation in relative value units, or 

RVUs, since Medicare payment is determined 

by a code's RVUs multiplied by the 

conversion factor. The deletion of several 

evaluation and management codes also 

will be addressed. 

The American Academy of Orthopaedic 

Surgeons requested the development 

of spinal incision and drainage codes 

to parallel similar codes that exist for 

extremity joints. After collaboration with 

the AANS, CNS and North American Spine 

Society, a pair of codes was developed to 

describe posterior incision and drainage of 

a subfascial infection. Code 22010 (21.69 

facility RVUs) reflects posterior drainage of 

a subfascial cervicothoracic abscess, whereas 

code 22015 (21.50 facility RVUs) 

described the same procedure in the lumbosacral 

region. Neither code should be 

reported with instrumentation removal 

(codes 22850 and 22852) or drainage of a 

complex postoperative wound (code 

10180, 4.59 facility RVUs), which was the 

only code available for this procedure 

before 2006. 

AANS and CNS Call for New 

Kyphoplasty Codes 

The AANS and CNS requested the development 

of codes to reflect vertebral augmentation 

after cavity creation and/or 

fracture reduction (kyphoplasty). 

Although similar codes for vertebroplasty 

were developed years earlier, the AANS 

and CNS requested a new set of codes to 

reflect the additional work of balloon 

kyphoplasty. Code 22523 (16.29 facility 

RVUs) reflects percutaneous vertebral 

augmentation, including cavity creation 

and biopsy, using a mechanical device in 

the thoracic spine. The code will be used 

once in an operative session, even if bilateral 

access is obtained. Additional levels of 

kyphoplasty performed in either the thoracic 

or lumbar spine would be coded 

22525 (7.47 facility RVUs). If only lumbar 

vertebrae are treated, then the primary 

code used would be 22524 (15.61 facility 

RVUs). Although previously reimbursed 

at 50 percent more than vertebroplasty by 

some payers under the unlisted code 

22899, the survey process revealed only an 

incremental difference in physician work 

when comparing intraoperative work for 

vertebroplasty and kyphoplasty. 

If the surgeon uses image guidance, the 

supervision and interpretation of the 

imaging is to be separately reported. The 

imaging codes for vertebroplasty were 

revised to include kyphoplasty as well. 

Code 76012–26 (1.88 facility RVUs) would 

be used for guidance by fluoroscopy, 

whereas code 76013–26 (1.93 facility RVU) 

would be used for computed tomographic 

guidance. The modifier –26 is appended 

when the surgeon does not own the equipment, 

but rather is only providing the professional 

component of the service. A 

radiology report must be dictated to reflect 

the supervision and interpretation of the 

radiological procedure, but it may be 

included in the operative note as a separate 

and distinct paragraph. Alternatively, a 

completely separate radiology report may 

be dictated. 

A series of five endovascular treatment 

codes also was developed to reflect recent 

innovations in intracranial endovascular 

procedures. Code 61630 describes 

intracranial balloon angioplasty, whereas 

61635 describes placement of an intracranial 

stent including balloon angioplasty, if 

necessary. Both codes include all selective 

vessel catheterization and diagnostic imaging 

including supervision and interpretation 

of the images obtained. For treatment 

of vasospasm, code 61640 describes balloon 

dilatation on the initial vessel in vasospasm, 

whereas 61641 reflects each additional vessel 

treated in the same vascular family and 

61642 each additional vessel in a different 

vascular family. Likewise, the selective vessel 

catheterization and diagnostic imaging 

including supervision and interpretation of 

the images is included. Unfortunately, the 

Centers for Medicare and Medicaid Services 

have identified these as non-covered 

services and did not publish RVU values. 

Redundant E&M Codes Eliminated 

In addition, several evaluation and management 

codes have been eliminated for 

2006. Three follow-up inpatient consultation 

codes (99261–99263) will now be 

reported as subsequent hospital care 

(99231–99233). The former codes were 

felt to be redundant with the subsequent 

hospital care codes, which will now be 

used for any subsequent E&M service provided 

after an inpatient consultation 

(99251– 99255). Similarly, the confirmatory 

consultation codes (99271–99275) will 

now be reported as an outpatient consultation 

(99241–99245). The confirmatory 

consultation codes were also deemed 

redundant. If a third-party payer requests 

the consultation, the –32 mandated services 

modifier should be appended to the 

outpatient consultation code. 

Note that although the codes become 

valid on Jan. 1, it can take payers as long as 

six months to recognize the new changes. 3 

Gregory J. Przybylski, MD, is professor and director 

of neurosurgery at JFK Medical Center in Edison, N.J. 

He is co-chair of the AANS/CNS Coding and 

Reimbursement Committee and a member of the 

CMS Practicing Physicians Advisory Council, and he 

plans and instructs coding courses for the AANS and 

the North American Spine Society. 


E 

E VENTS 

S 

Calendar of Neurosurgical Events 

ACI’s 7th National Conference on 

Adding, Updating & Expanding 

Neuroscience Centers of Excellence 

Jan. 26–27, 2006 

Phoenix, Ariz. 

(312) 780-0700 

www.acius.net 

Update in EEG, EMG and Clinical 

Neurophysiology 2006 

Jan. 29–Feb. 4, 2006 

Scottsdale, Ariz. 

(480) 301-4580 

www.mayo.edu/cme 

Richard Lende Winter Neurosurgery 

Conference + 

Feb. 3–8, 2006 

Snowbird, Utah 

(801) 581-6554 

www.lendemeeting.com 

Neurology Neurosurgery 

Interface 2006 

Feb. 17–19, 2006 

San Juan, Puerto Rico 

(215) 898-6400 

www.med.upenn.edu/cme 

Joint Annual Meeting of the AANS/CNS 

Cerebrovascular Section and the 

American Society of Interventional & 

Therapeutic Neuroradiology + 

Feb. 17–20, 2006 

Orlando, Fla. 

(888) 566-2267 

www.neurosurgery.org/cv 

44th Annual Dr. Kenneth M. Earle 

Memorial Neuropathology 

Review Course 

Feb. 20–24, 2006 

Bethesda, Md. 

(202) 782-2637 

www.afip.org/Departments/ 

edu/coursehtm/06neuro 

path.htm 

22nd Annual Meeting American 

Academy of Pain Medicine 

Feb. 22–25, 2006 

San Diego, Calif. 

(847) 375-4731 

www.painmed.org/ 

annualmeeting 

Carotid Interventional: 

Interactive Seminar and Live 

Demonstration + 

Feb. 27–28, 2006 

Buffalo, N.Y. 

(716) 887-5200 x2135 

Current Topics in Neurosurgery: 

Meet the Experts 

Feb. 27–March 5, 2006 

San Juan, Puerto Rico 

(732) 235-7430 

www.umdnj.edu 

Southern Neurosurgical Society 

Annual Meeting + 

March 2–5, 2006 

Southampton, Bermuda 

www.southernneurosurgery.org 

International Spine & Spinal 

Injuries Conference 

March 3–5, 2006 

New Delhi, India 

www.scs-isic.com 

Interurban Neurosurgical Society 

Annual Scientific Meeting + 

March 3, 2006 

Chicago, Ill. 

(715) 542-3201 

mrakow@frontiernet.net 

2nd Annual Update Symposium 

Series on Clinical Neurology 

and Neurophysiology 

March 6–8, 2006 

Jerusalem, Israel 

www.isas.co.il/ 

neurophysiology2006.com 

21st Annual Meeting of the 

AANS/CNS Section on Disorders of 

the Spine and Peripheral Nerves + 

March 15–18, 2006 

Lake Buena Vista, Fla. 

www.spinesection.org/ 

MeetingsEd.htm 

Carotid Intervention: 

Interactive Seminar With Live 

Demonstration Simulation + 

March 27–28, 2006 

Buffalo, N.Y. 

(716) 887-5200 x2135 

58th Annual Meeting American 

Academy of Neurology 

April 1–8, 2006 


www.aan.com 

3rd State of the Art in 

Chronic Low Back Pain 

Symposium 

April 9–12, 2006 

Bodrum, Turkey 

www.vitalmedbodrum.com 

2006 AANS/CNS Section on 

Pain Surgery Annual Meeting + 

April 21, 2006 

San Francisco, Calif. 

(888) 566-2267 

www.neurosurgery.org/pain 

2006 AANS Annual Meeting 

April 22–27, 2006 

San Francisco, Calif. 

(888) 566-2267 

www.AANS.org 

American Society of Neuroradiology 

44th Annual Meeting 

April 29–May 5, 2006 


(630) 574-0220 

www.asnr.org 

Carotid Intervention: Interactive 

Seminar with Live Demonstration 

and Simulation + 

May 1–2, 2006 

Buffalo, N.Y. 

(716) 887-5200 x2135 

The Society of Neurological Surgeons 

Annual Meeting 

May 21–23, 2006 

Durham, N.C. 

www.societyns.org 

18th Annual International Bethesda 

Spine & Peripheral Nerve Workshop 

May 31–June 6, 2006 

www.bethesdaspine.com 

American Society for Stereotactic and 

Functional Neurosurgery 

June 1–4, 2006 

Boston, Mass. 

www.assfn.org 

9th International Conference on 

Cerebral Vasospasm 

June 27–30, 2006 

Istanbul, Turkey 

www.cerebralvasospasm9.org 

Computer Assisted Radiology and 

Surgery (CARS 2006) 

June 28–July 1, 2006 

Osaka, Japan 

www.cars-int.org 

12th Computed Maxillofacial 

Imaging Congress 

June 28–July 1, 2006 

Osaka, Japan 

www.cars-int.org 

+ These meetings are jointly sponsored or cosponsored by the American Association of Neurological Surgeons. The frequently 

updated online meetings calendar and continuing medical education information are available at www.aans.org/education. 

AANS Courses 

For information or to register call (888) 566-AANS 

or visit www.aans.org/education. 

3 Managing Coding & Reimbursement Challenges 

in Neurosurgery 

*“Coding for Pros” prerequisite: AANS coding course taken 

within two years. 

Jan. 27–28, 2006 . . . . . . . . .Las Vegas, Nev. 

Feb. 17–18, 2006* . . . . .San Antonio, Texas 

March 3–4, 2006 .St. Pete Beach/Tampa, Fla. 

May 5–6, 2006* . . . . . . . . .Philadelphia, Pa. 

Sept. 8–9, 2006 . . . . . . . . . . . . .Chicago, Ill. 

Nov. 3–4, 2006* . . . . . . . .Los Angeles, Calif. 

3 Neurosurgery Review by Case Management: 

Oral Board Preparation 

May 7–9, 2006 . . . . . . . . . . .Houston, Texas 

Nov. 5–7, 2006 . . . . . . . . . . .Houston, Texas 

3 Current Advances in Spinal Fixation: 

Advanced Course 

Feb. 11–12, 2006 Memphis, Tenn. 

3 Minimally Invasive Spinal Techniques 

June 10–11, 2006 . . . . . . . . . .St. Louis, Mo. 

3 Neurosurgical Practice Management: 

Improving the Financial Health of Your Practice 

May 7, 2006 . . . . . . . . . . . .Philadelphia, Pa. 

Sept. 10, 2006 . . . . . . . . . . . . . .Chicago, Ill. 

Volume 14, Number 4 • AANS Bulletin 

51

AANSA NSWERS 

T HOMAS A. MARSHALL 

AANS LEADERSHIP 2005–2006 

OFFICERS 

Fremont P. Wirth, MD, president 

Donald O. Quest, MD, president-elect 

Robert L. Grubb Jr., MD, vice-president 

Jon H. Robertson, MD, secretary 

James R. Bean, MD, treasurer 

Robert A. Ratcheson, MD, past president 

DIRECTORS AT LARGE 

Robert E. Harbaugh, MD 

Christopher M. Loftus, MD 

James T. Rutka, MD 

Warren R. Selman, MD 

Troy M. Tippett, MD 

REGIONAL DIRECTORS 

Jeffrey W. Cozzens, MD 

Paul E. Spurgas, MD 

Clarence B. Watridge, MD 

Edie E. Zusman, MD 

HISTORIAN 

Eugene S. Flamm, MD 

EX-OFFICIO 

Rick Abbott, MD 

Lawrence S. Chin, MD 

Fernando G. Diaz, MD 

Robert F. Heary, MD 

Andres M. Lozano, MD 

Dennis E. McDonnell, MD 

Richard K. Osenbach, MD 

Robert H. Rosenwasser, MD 

Alex B. Valadka, MD 

Ronald E. Warnick, MD 

LIAISONS 

Isabelle M. Germano, MD 

Mark G. Hamilton, MD 

Nelson M. Oyesiku, MD 

AANS EXECUTIVE OFFICE 

5550 Meadowbrook Drive 

Rolling Meadows, IL 60008 

Phone: (847) 378-0500 

(888) 566-AANS 

Fax: (847) 378-0600 

E-mail: info@AANS.org 

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 

DEPARTMENTS 

Communications, 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 OFFICE 

725 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 

AANS Serves Up Success 

Table’s Already Set for Increased Innovation 

The fiscal 2004–2005 year-end report was 

presented to the AANS Board of Directors 

at its November 2005 meeting. The 

report affirmed that for the fourth consecutive 

year, the AANS enjoyed an extremely 

favorable cycle of financial stability and growth of 

services to its members. In fact, this marks the 

first time in the organization’s records that the 

AANS has enjoyed four consecutive years “in the 

black” since its founding 75 years ago. 

What is evident is that the AANS successfully 

weathered a series of internal and external 

upheavals that most organizations rarely must 

confront separately, let alone simultaneously, in 

the final years of the 1990s and the initial years of 

this decade. 

In the late 1990s, the budget was losing 

between $3 million and $5 million annually, there 

was a management revolving door of three AANS 

executive directors hired successively in 1998, 

1999 and 2000, and the Executive Office staff, 

while somewhat inflated in number, was turning 

over at a rate of 117 percent in 2000 and 2001. 

Though daunting, these management challenges 

were not the real cause for concern. Far 

more ominous clouds threatened, not on the horizon, 

but directly overhead. 

The AANS had become dangerously reliant on 

only two very undependable sources of income for 

its operations: the annual meeting and membership 

dues. Not only could earthquake, terrorist 

attack, or, as we just saw in New Orleans, devastating 

flood wipe out the former, the AANS was not 

even systematically and consistently collecting the 

latter. The only thing that was consistent about the 

dues was that they were raised every year as a budgetary 

matter of course to reflect a cost-of-living 

increase. (Dues have not been raised in the last four 

consecutive successful fiscal years). 

Given what the organization faced at the time, 

how the AANS has reached the levels of stability 

and service that you enjoy today as a member is 

worth truly understanding. 

While it is true that dramatic restructuring, 

downsizing and spending cuts at the front end 

Thomas A. Marshall 

is AANS 

executive director. 

paved the road to recovery, those key decisions are 

already enjoying too much of the focus and credit. 

Critical as those strategies were, they were only 

the “table setting” for the success that followed. 

The reasons behind today’s success can be 

attributed to far more than the belt-tightening 

tactics of five years ago. Crucial to this success is 

that simultaneously the AANS augmented a 

thoughtfully chosen menu of new, and at least for 

the AANS, unproven revenue streams: the expansion 

of educational programming; the development 

of products and services based upon 

accurate assessment of what you, the member, 

told us you wanted; the revision of organizational 

policies covering dues, investment revenue, and a 

cash reserve; and the measured outreach to a variety 

of allied publics who had an interest in the 

health of neurosurgery and its most diversified 

membership association. 

Five years’ worth of AANS leadership and staff 

can take pride in the success of those basic strategies. 

But it was always the AANS members who 

were the intended ultimate beneficiaries of those 

early decisions. 

At a time when most organizations would seek 

shelter to ride out the fiscal, structural and philosophical 

storm, the decisions to propel the AANS 

into a proactive production mode were critical to 

providing better and expanded services to AANS 

members. This proactive mode is the core of 

AANS’ strategic planning for the latter half of this 

decade and well beyond. The new and improved 

AANS is an organization ready to move forward 

in the 21st century with innovative programming 

for its members, and positioned to launch the specialty 

to new heights. 3

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