The Council of State Neurosurgical Societies (CSNS) continues to provide an important platform for the AANS and CNS to identify, deliberate and formulate policies on the ever-evolving socioeconomic issues affecting neurosurgical practice in the United States. The CSNS tackles diverse socioeconomic issues through the collective efforts of several committees, namely: Communications and Education; Medical Practices; Medico-Legal; Neurotrauma and Emergency Neurosurgery; Patient Safety; Coding and Reimbursement; Workforce; Washington; and Young Neurosurgeons Committees. The Young Neurosurgeons Committee affords neurosurgical residents an opportunity for leadership development through active participation in CSNS activities. CSNS resident fellows, who are members of the Young Neurosurgeons Committee, take part in the activities of the various committees of the CSNS. There is also state representation at the CSNS through the quadrants; Northeast, Northwest, Southeast and Southwest.
The fall 2019 CSNS meeting agenda included committee meetings, special reports, resolutions and plenary sessions as well as lectures by several distinguished speakers. The Young Neurosurgeons Committee participated in all committee discussions as well as in drafting and voting on resolutions. Resolutions are position statements on specific socioeconomic issues, which are actively debated at the CSNS meeting and finally adopted or rejected. The adopted resolutions may influence policy-making through various mechanisms, such as AANS and CNS position statements and further research on a given issue.
There were many issues discussed at the various committee meetings that are of interest to Young Neurosurgeons.
- The Leadership Development and Mentoring Committee discussed resident fellow recruitment, orientation and retention. Measures to be taken to increase resident fellow recruitment should include continued broadcasting of the existence of the CSNS fellowship on social media and involvement of medical students. On resident retention, several measures were proposed, including rapid fire oral presentations (4-6 minutes, previous fellows only) during AANS/CNS caucus meetings vs. plenary sessions, pairing of the new fellow with the outgoing CSNS fellow at the AANS Annual Scientific Meeting or with a mentor, making past fellows automatic state delegates after graduation, encouraging involvement through State Councils and encouraging fellows to volunteer as alternative delegates.
- The Young Neurosurgeons Committee discussed opportunities for fellows to stay involved in the CSNS and organized neurosurgery after the fellowship ends. Opportunities discussed included CNS and AANS caucuses, reference committee, Washington Committee-AMA fellowship, volunteer committee participation and the AANS Young Neurosurgeons Committee.
There were a number of resolutions that were debated and adopted, which are of relevance to Young Neurosurgeons.
- CSNS Resolution I – Augmenting the Allocation of Resources for Socioeconomic Education. This resolution calls on the CSNS to work with the AANS and CNS to expand the availability of educational opportunities focusing on pertinent socioeconomic topics for trainees. It was further resolved that that the CSNS requests its parent bodies to allocate additional resources for these educational opportunities, which may include scholarships and funded fellowships, along with expanding the number of socioeconomic courses.
- CSNS Resolution III – Expanding subspecialty-focused traveling fellowship during neurological surgery residency. This resolution, which received broad support, calls on the CSNS to advocate for the development of traveling fellowships to the parent bodies and the joint sections.
- CSNS Resolution VIII – Further study of preparedness of neurosurgical graduates for practice. It was resolved that the CSNS work through the parent organizations with the ABNS to analyze select de-identified data to objectively assess trends in resident preparedness for practice. It was further resolved that the CSNS produce a white paper based on the data and trends identified in the analysis above outlining how these trends may affect preparedness to practice.
Neurosurgical residents took the opportunity to present several interesting research findings. Megan Jack, MD, PhD, neurosurgical resident at University of Kansas Medical Center, made a presentation entitled “Historical and Future Perspectives on Gainsharing”. Gainsharing was described as a fiscal tool that seeks to align physicians and hospitals, to improve quality and reduce direct cost of supplies, devices, implants and drugs, with profit savings shared with physicians. It was noted that gainsharing in medicine goes back to 1988-1996 with Medicare Participating Heart Bypass Center Demonstration (MPHBCD), which assessed the feasibility and cost effectiveness of inclusive bundled payment arrangement for CABG surgery. In 1996, the Health Care Financing Administration also investigated gainsharing in orthopedics. As a result of these investigations, the Office of the Inspector General (OIG) Advisory Bulletin issued a statement in 1999 that suggested that gainsharing agreements are illegal based on the Civic Monetary Penalty (CMP) and federal Anti-Kickback Laws. However, in 2001, the OIG issued an opinion that gainsharing with safeguards may not be subject to the CMP penalty. It was noted that gainsharing was not widely practiced in neurosurgery. This background led to a CSNS Resolution XI – 2018F: Gainsharing in Neurosurgery. The resolution called on the CSNS to develop a survey to learn about the use of gainsharing initiatives by practicing neurosurgeons and other administrators identified through NERVES. It further resolved that the CSNS will generate a white paper from the data gathered from the survey regarding the current use of gainsharing in neurosurgery. Dr. Jack and her collaborators subsequently developed the survey and the study is currently being completed.
Devon LeFever, MD, neurosurgical resident at LSU Health Sciences Center – Shreveport, made a presentation on his study entitled “Medical Review Panels and Neurosurgery: The Louisiana Experience.” The goals of the study were to provide an overview and history of the medical legal environment in Louisiana; to recognize the responsibilities and limitations of the medical review panel (MRP); and to identify objective figures to evaluate the impact of medical review panels. MRPs usually consist of a combination of physicians (often the same specialty as the defendant) and attorneys. MRPs review cases prior to a trial with the goal to protect the interests of the plaintiff, while decreasing the burden of lawsuits without merit. The study found a total of 670 cases against neurosurgeons. In the past 10 years, a settlement was reached in 15.2% (102/670) MRP decisions, despite only 6.1% (41/670) of cases finding the neurosurgeon outside the standard of care. The total pay over 10 years was $31,928,937 (Range: $10,000 – $1,250,000). The Louisiana average settlement was $313,029, compared to a national average of $344,811. The study concluded that plaintiffs and defendants both benefit from MRPs from the standpoint of time saved, financial savings and access to third-party expert opinions.
Jakub Godzik, MD, neurosurgical resident from the Barrow Neurological Institute, also made an inspiring presentation on “Incorporating Augmented and Virtual Reality Platforms for Training in Neurosurgical Residency”. This presentation was followed by a demonstration of the virtual reality platform. The presentation gave the audience a view into the future of neurosurgery in the age of virtual reality and artificial intelligence.
The CSNS Luncheon speaker was Vanila Singh, MD, MACM, an American physician, educator, policy maker and patient advocate dedicated to public health who is currently tackling one of the nation’s most widespread, expensive and devastating epidemics of our time – the opioid and greater drug epidemic. Dr. Singh’s talk was entitled “National Perspective on the Opioid and Pain Public Health Epidemic-findings of the Inter-agency Pain Task Force”. The Pain Management Best Practices Inter-Agency Task Force (Task Force), of which Dr. Vanila Singh was chair, was convened by the U.S. Department of Health and Human Services in conjunction with the U.S. Department of Defense and the U.S. Department of Veterans Affairs with the Office of National Drug Control Policy to address acute and chronic pain in light of the ongoing opioid crisis. The Task Force mandate was to identify gaps, inconsistencies and updates and to make recommendations for best practices for managing acute and chronic pain. Dr. Singh emphasized in her presentation the need for a multidisciplinary approach to management of the complex aspects of acute and chronic pain. This multidisciplinary approach would include the use of various classes of pain medication; restorative therapies (implemented by physical therapists and occupational therapists); interventional approaches (trigger point injections, radio-frequency ablation; cryo-neuroablation and neuromodulation); behavioral approaches to address the psychological, cognitive, emotional, behavioral and social aspects of pain; and complementary and integrative health approaches (acupuncture, massage, movement therapies such as yoga and tai chi, and spirituality).
The CSNS aims to empower residents and increase awareness of socioeconomic issues. For those interested in getting further involved on projects, presenting resolutions to improve neurosurgery on a national level or for other comments/inquiries, visit the CSNS website or email Anand Veeravagu, MD at anandv2@stanford.edu.
Cletus Cheyuo, MD, PhD
West Virginia University
Anand Veeravagu, MD
Stanford University