Portal de Periódicos da CAPES

A Question of Balance

2015; Lippincott Williams & Wilkins; Volume: 62; Issue: Supplement 1 Linguagem: Inglês

10.1227/neu.0000000000000786

1524-4040

Daniel K. Resnick,

Advances in Oncology and Radiotherapy

Thank all of you for allowing me to serve Congress as president this past year. I am grateful for the opportunity for personal and professional growth and treasure the experiences I have had over the past 15 years on the Congress of Neurosurgical Surgeons (CNS) Executive Committee. Interestingly, I never had any ambitions toward political activity in neurosurgery. My plan coming out of residency was to have a well-funded laboratory in spinal cord injury research and an active spine practice where I could translate laboratory findings into clinical trials. I was very suspicious of the "career politicians" lecturing me from podiums about socioeconomic and ethical issues. I assumed they could not operate, did not have research interests, and found neurosurgical politics a way to keep busy and feel relevant. I was dumbfounded by the sheer number of neurosurgical organizations that seemed to exist simply to exist. I could not even keep track of all the initials, probably because they all had an N and S in their names somewhere, along with 1 or 2 As, and perhaps a C or a U for variety. I fell into neurosurgical politics somewhat by accident and slowly began to realize the value and importance of organized neurosurgery in terms of affecting the training and education of neurosurgeons, the day-to-day practice of neurosurgery, and the ability of neurosurgeons to reach patients who would benefit from our talents. Without the advocacy efforts performed by neurosurgeon volunteers—efforts funded by 50% of your CNS dues—we would be a much different, much smaller, and much less relevant group. Volunteers such as those on our executive committee devote hundreds of hours of their time to bettering the environment for neurosurgeons and, more important, for our patients. At this point, I know what most of the initials of our major societies stand for and am somewhat offended by attacks on those organizations by self-proclaimed "visionaries" with little to no knowledge of how things work in the real world of neurosurgical education and advocacy. While that needed to be said, that is not what I am going to talk about today. The theme of this meeting is A Question of Balance. I chose this theme for several reasons. First of all, the Moody Blues was among my favorite bands growing up, and their A Question of Balance album in particular still reverberates in my subconscious. The frustration in "Question," the confusion of "How Is It (We Are Here)," and the nihilism of "And the Tide Rushes In" are emotions I still struggle with today when dealing with political, professional, and personal dilemmas. "The Balance" may sound somewhat hokey to our mature sensibilities, but to an angst-filled child and teen, acceptance and serenity were rare and valued sensations. I have no financial or other relationship with any record company, unfortunately, but you should all go out and buy the album if you do not already have it. Years ago, Joe Maroon used this platform to talk about the importance of balance in the individual neurosurgeon's life. His talk, "From Icarus to Aequanimitas" reviewed the importance of balancing professional, physical, and spiritual stresses and activity.1 Joe reprised some of these lessons for us in an eloquent presentation yesterday in which he updated us on his continued journey of accomplishment and humility. A few years ago, Rusty Rodts used this same platform to discuss industry relationships and the need for balance between surgeon innovation with industry and protection of the educational product of our medical society. He also discussed the evolution of our relationship with orthopedic spine surgeons and the fact that there are now many more similarities than differences between the 2 camps.2 Although both of these topics remain relevant, today I am going to talk about something different. The main reason I chose this theme, however, is that I feel that our profession, neurosurgery, is out of balance. I am going to start with some case examples to illustrate my point. This first image (Figure 1) is a sagittal computed tomography (CT) obtained in a 90-year-old man with a 60-year history of chronic back pain. According to the medical record, he was sent to see a neurosurgeon because of more recent complaints of neurogenic claudication. The CT reveals some stenosis at L3-4, and I think most of us in this room would have considered the option of a focal decompression if the patient's symptoms were severe enough and his overall health was good enough to warrant surgical intervention. That is not what he was offered. He, in fact, was treated with an L1-S1 laminectomy and instrumented fusion with multiple interbody devices. Months after surgery, he was in a nursing facility recovering from a lengthy intensive care unit stay and psychological collapse.FIGURE 1: Sagittal computed tomography obtained in a 90-year-old man with a 60-year history of chronic back pain and recent history of neurogenic claudication immediately before an L1-S1 decompression and fusion with multiple interbody devices and pedicle screw fixation.The next image (Figure 2) is a T2-weighted sagittal magnetic resonance image obtained in a 60-year-old woman with chronic low back pain. Her concomitant medical history is notable for diabetes mellitus, morbid obesity, sleep apnea, fibromyalgia, and polymyalgia rheumatica requiring methotrexate. Clearly, this woman is a very high-risk operative candidate who is vulnerable to myriad complications and at high risk for surgical failure. Fortunately, there does not appear to be much surgically relevant pathology on the imaging study. She has a few end-plate fractures of indeterminant age resulting from her osteoporosis. There is certainly no evidence of neurological compression or structural instability. If her examination correlated well, perhaps consideration of a vertebral augmentation procedure might be in order, but given her history, even this minimally invasive treatment should be considered carefully. The next image (Figure 3) shows an intraoperative image of her operation, another L1-S1 decompression and instrumented fusion with multiple interbody devices. Needless to say, she did not enjoy a smooth recovery from this operation.FIGURE 2: T2-weighted sagittal magnetic resonance image from a 60-year-old woman with multiple medical and psychological comorbidities who presented with low back pain.FIGURE 3: Intraoperative image of L1-S1 decompression and fusion with multiple interbody devices and pedicle screw instrumentation performed on the same patient as illustrated in Figure 2.As these cases illustrate, neurosurgeons are behaving badly. Most of you in this room are neurosurgeons. As far as the public sees it, we all are behaving badly. These are but a few examples of what I see in our community of instances of clearly inappropriate patient care. I get sent a lot of cases to review for professionalism issues because of my position in organized neurosurgery and spine surgery. I understand that each of us has a few cases that, in retrospect, we probably should not have done, and I would hate to have my career judged on the basis of my worst day. I am not talking about a few questionable cases, however. Many of us have noted repeated and systematic misbehavior by members of our community. This past April (2014), Ben Eisler3 of CBS News presented an analysis of the recently released Medicare database with regard to spinal fusion. When looking at high-volume surgeons (>10 lumbar fusions per year for degenerative disease in the Medicare population), the authors found that, in a 2-year period, the average "high-volume" surgeon saw 651 Medicare patients with degenerative disease of the lumbar spine and offered surgery to 43 (approximately 7%) of these patients. Fewer than 7 patients, or about 1%, on average, were treated with complex fusion, defined here as >4 levels fused (patients with prior surgery, deformity, trauma, tumor, and infection were excluded from the analysis). To put this in perspective, in the entire state of Wisconsin, 5 such surgeries were done during the collection period. Against this baseline, a few surgeons stood out. A small percentage of surgeons were doing a disproportionate number of fusions and complex fusions. This small group of surgeons was doing >430 fusions each during the same time period, 10 times the average rate. They were performing fusions on 35% of new patients seen, 5 times the average rate, and they were performing significantly more "complex" fusions as well. Now, we must remember that one of the stated purposes of releasing the Medicare database was to allow patients to seek out high-volume providers to improve quality of care. Perhaps these high-volume practitioners were the regional experts and had very selective referral patterns as a result of their reputation and practice pattern. Perhaps these surgeons were doing exactly what they should be doing with a carefully selected and prescreened patient population. When I was interviewed by the author of the study, I raised this exact point. He then sent me series of cases to review. I do not know how the cases were selected, and I do not know if the selected cases were truly representative of the practices in question. However, in the cases I reviewed, I saw systematic overreporting of pathology on magnetic resonance images, systematic expansion of surgical complexity based on highly questionable diagnostic criteria, and systematic overapplication of theoretical principles to justify larger, longer, riskier, and more expensive procedures. When I Googled the surgeons on my own, I was not surprised to see extensive malpractice and disciplinary histories. These were not regional experts performing valuable procedures on well-selected patients. In addition to clinical care, we are also guilty of malfeasance in the business aspects of medicine. The next figure is the title page of a lawsuit brought by the federal government against a neurosurgeon who is accused of Medicare fraud and receiving kickbacks from a medical device supplier (Figure 4). The next figure is reproduced from a New York Times article, describing a bill from one of our members to a patient for $117 000.00 for assisting on a routine anterior cervical procedure.4 Now, I am not saying that neurosurgeons should not be paid well for their services. We were all at the top of our classes from high school through medical school; we have all missed countless nights at home, holidays, birthdays, and graduations because of call responsibilities and the rigorous training required for neurosurgical practice. I think that we are largely underpaid compared with other professions demanding such an investment of time, energy, and resources. That said, can we forgive or expect our patients to forgive the Oregon neurosurgeon who was convicted of Medicare fraud for performing multiple reoperations on vulnerable patients (Figure 5)? As I mentioned, we are a very small specialty, but we are disproportionately represented in these types of publicized activities. As far as the public, as far as policy makers, and as far as our patients know, we are doing unnecessary surgery, we are hurting people, and we are guilty of fraud.FIGURE 4: Title page from federal lawsuit against a neurosurgeon accused of accepting kickbacks from an instrumentation distributor (http://www.justice.gov/opa/pr/government-files-suit-against-missouri-neurosurgeon-and-medical-device-supplier-violations, accessed September 21, 2014).FIGURE 5: Screenshot from the Wall Street Journal article describing an Oregon neurosurgeon accused of Medicare fraud. Available at: http://www.wsj.com/articles/SB10001424052748703858404576214642193925996. Accessed September 29, 2014.How can this be happening? Were we not all the good kids in school? We are the ones who made good grades, volunteered at retirement homes, and stayed up late working on science projects. I look at our residency applicants and note that almost all of them are actively participating in overseas missions, local charities, and medical outreach projects. Although not all of these students are driven purely by charitable aims, many are, and we have numerous examples of neurosurgeons giving back to the less fortunate locally, nationally, and internationally. I do not believe that neurosurgeons start out as poor actors. What is happening to us to cause this terrible behavior? More important, what can we do to improve the situation? H.L. Mencken5 once said something to the effect that for every complicated problem there is a solution that is simple, easily understood, and wrong. In this particular case, I think the problem is reasonably straightforward, but I still struggle to suggest a surefire solution. According to multiple sources, physicians are the professional group most susceptible to burnout.6,7 Burnout is stress reaction that occurs in certain situations and is more common in individuals with certain characteristics. Characteristics that predispose an individual to burnout are a strong motivation for success, dedication to the field in which the individual works, adoption of their field of work as part of their identity, and a tendency for perfectionism. Situations that lead to burnout are those in which tasks appear to be without end or appear to be impossible, those in which rewards are felt to be inadequate, those in which multiple demands are made that are incompatible, and those that are associated with significant bureaucracy.6-8 When I read the description of those susceptible to burnout, I am reading a description of the perfect neurosurgical candidate. We are bred for burnout from early in our career in terms of our dedication, ambition, and willingness to adopt our role as a neurosurgeon in society. When I read the list of situational factors contributing to burnout, I reflect on the many frustrations of a neurosurgical practice and particularly reflect on the role that the Affordable Care Act has had on exacerbating these frustrations. In the past decade, we have seen an incredible increase in the burden of reporting measures that have nothing to do with how we actually care for our patients, we have been incentivized to achieve "quality metrics" that have nothing to do with patient outcomes, our autonomy has been stripped professionally, and we have faced a decade of significant cuts in reimbursement. As the practical rewards of practice have diminished, we have faced an exponentially increasing bureaucratic burden that has changed the makeup of our profession from one composed largely of individual and small group practitioners free to focus on the wants and needs of their local population to one composed almost entirely of employees of hospital systems or large group practices chained to corporate goals and benchmarks. Added to this is a pervading sense of doom, the anticipation that everything is going to get worse as opposed to better over the next decade or so of practice. Burdens and frustrations are up; autonomy and rewards are down. When these are coupled with our traditional psychology, we have a perfect storm. What happens when neurosurgeons are burned out? The same thing that happens to anyone else who is burned out. Neurosurgeons suffer apathy, cynicism, and social withdrawal. I have personally heard colleagues speak of "making hay while the sun shines," referring to making as much money as possible now before the system dries up; "This isn't nearly as bad as what those guys up the street/across town/next town over are doing"; and "If I don't do, it someone else will." What can we do as individuals, as educators, and as a society to remedy the situation? There are basically 4 areas in which we can influence the behavior of a neurosurgeon. First, we select those whom we allow to train for a career in neurosurgery. Whom do we select? As a program director, I can tell you that we look for candidates who are highly motivated and those who are dedicated to the field of neurosurgery and willing to adopt the role of neurosurgeon as part of their identity. We want to have residents and surgeons who tend toward perfectionism, and we want residents who are willing to make the sacrifices necessary to achieve excellence in an extremely complex and demanding field. We are essentially choosing candidates like ourselves who are the most vulnerable to career burnout. Do I think we should change? There are now a number of consulting firms that will do psychometric training and hold focus groups to try to match personalities with career options. I do not think any process, no matter how expensive and politically correct, will improve on the present. I want perfectionists in my program, and if my child needs brain surgery, I want a perfectionist doing that operation. Education is the second area in which we can influence behavior. During residency, the focus is on the acquisition of the medical knowledge and skills necessary to practice neurosurgery. Efficiency and thoroughness are rewarded: The faster you get your work done, the more opportunities there are for you to do more. This aspect of our training is not in itself a bad thing; however, when combined with the finite amount of time of a residency, exacerbated by the work hour restrictions, it creates a perceived sense of urgency in our trainees. This is most commonly manifest in the difficulty we have in getting residents to attend clinic. Unless we absolutely require the resident to be in clinic, the resident will be in the operating room because the operating room is seen as a higher-density learning environment. Further exacerbating the situation is the fact the neurosurgery is an expanding field. Every year, there are new treatments and new diseases treated by neurosurgeons. When I was in training, spinal surgery was in the midst of a revolution. At the beginning of my residency, neurosurgeons did not perform fusion procedures, but by the fourth year of my experience, we were doing them regularly, using instrumentation and incorporating new principles of biomechanics into our thought processes for patient selection. Endovascular neurosurgery and functional neurosurgery were in their infancy. There really was not a whole lot to know about these fields because there was not a whole lot known. At present, there is a broad range of indications for both endovascular and functional interventions that did not exist just a few years ago, and residents need to know about the relative risks and benefits of these interventions and acquire the technical ability to apply these technologies. We are requiring our residents to learn a lot more in a lot less time. Although this expansion in the scope and impact of our field is a great thing and should, if anything, be encouraged, it does have a potentially negative impact on the residents and needs to be managed. One aspect of our education process that could be modified to help alleviate this negative impact is our current primary board examination. On the basis of the principle that all neurosurgeons need to have a basic competency across all aspects of neurosurgery, our residents spend a substantial amount of time learning about aspects of neurosurgery that are only obliquely related to clinical practice. Does mastery of the histological examination of central nervous system tissue really improve a surgeon's performance in patient management? Perhaps that time and energy could be better spent in the laboratory, in the clinic, or even in the operating room. One area where we do a terrible job during residency training is the business aspects of a neurosurgical practice. I can tell you that this is not for a lack of trying. At our place, we regularly bring in private practice neurosurgeons to talk with our residents, we have our coders and billers do 2 grand rounds per year and meet in small groups with the residents to discuss billing practices, and we have had our hospital chief executive officer and the chief executive officer of our local competition come in to talk about payment models, practice evaluation, and administrative aspects of practice. The checking of cell phones and laptops is markedly increased during these sessions. Despite our efforts, our residents still feel ill prepared for life in the real world. The reason in part is that these topics are generally regarded by the residents as neither urgent nor sexy and therefore may not be taken to heart as much as the vivid description of an avoidable intraoperative complication. Another reason is that the landscape is changing so rapidly that anything learned today will likely be irrelevant by the time the resident needs it. An easy example is the introduction of the International Classification of Diseases, 10th Revision system that requires an entirely new set of codes and a much different level of complexity than the International Classification of Diseases, Ninth Revision system now in use. From a resident perspective, these lessons are really useful only for basic principles (dictate exactly what you did, bill for what you dictate), and any further information is largely ignored. Trying to develop a comprehensive understanding of these processes during residency truly is a task without end. Education continues after residency. This education is provided largely by membership societies such as the CNS or AANS (American Academy of Neurological Surgeons), the joint sections, or specialty-specific organizations. By attending this meeting, you are demonstrating a commitment to continued education regarding the nuances of neurosurgical practice and are benefiting from a forum of your peers where we have the ability to learn from each other. While as the president of a continuing medical education–providing organization and a faculty member, in many courses, I would love to wax eloquently on the quality and diversity of the didactic sessions, and I am very proud of the innovation, dedication, and skill brought to these processes by the volunteers and staff of the CNS. Here at the CNS, you can learn about evidence-based guidelines, hear clinical controversies discussed by world experts, learn about benchmarks for clinical care, and see the coolest new gizmos for sale. However, what I would like to emphasize at this point is the value of peer-to-peer interactions that can occur only at meetings such as this. It is through speaking with each other in the lecture halls, in the hallways, in the exhibit halls, and in the restaurants and bars that surround the convention center that we maintain a sense of community. Academic presentations are great, but hearing from folks just like us about challenges they face on a daily basis, sharing some of our own challenges, and getting individualized practical advice are what being a member of a neurosurgical society is all about. This type of education is probably best thought of as support; there is no continuing medical education attached to it, no easy way to quantify or measure it, and no way to overestimate its importance. Thank you for being here and for contributing to this support system. Another function of membership societies is to discipline members who operate outside the fold. Realistically, however, this mechanism is seldom used to regulate behavior outside the realm of inappropriate medicolegal testimony. The codes of ethics of both the CNS and the AANS allow a broad range of behaviors, with the assumption that the surgeon is acting in the best interest of the patient.9,10 In general, sanctions or other disciplinary measures are used only if another member brings charges and evidence of inappropriate testimony to the professional conduct committee of one or the other organization. Neither the CNS nor the AANS has the resources to investigate any except for the most straightforward instances of misbehavior. Furthermore, because our membership organizations are voluntary, do not credential, do not license, and do not certify any physician, the effectiveness of any disciplinary action on curbing behavior may be questioned. In reality, then, opportunities to prevent burnout and the subsequent bad behavior are limited. Candidate selection processes cannot be realistically changed, and I for one do not believe that they should be. Resident education may be improved, and the matrix and milestones process may encourage more effective inclusion of socioeconomic principles and a better emphasis on lifelong learning. We will see. The enfolded fellowship process may ameliorate or exacerbate the problem, depending on how the clinical responsibilities of the fellow affect other residents. The work hour restriction is not going away, however, and the breadth of neurosurgery is not going to decrease. Disciplinary actions from our member societies are questionably effective for anything except for discouraging inappropriate testimony in malpractice cases, and the true mouthpieces usually do not belong to our societies, specifically to avoid censure. Where does that leave us? In short, it leaves the responsibility to monitor our behavior to each of us and all of us. By participating in this meeting and by acting as a peer, learning about what each other is going through and applying peer pressure, we as a society can support each other and, I hope, prevent the social isolation and cynicism responsible for poor behavior. As I reach the end of my presentation, I would like to emphasize the privileged position that we all are in. We are blessed to practice neurosurgery in an era when we have unprecedented diagnostic capabilities. We have a rapidly expanding understanding of the basic pathophysiology of diseases that we were powerless to treat in decades past. We are just now developing and measuring some of the true impact that our work has on individuals and society as a whole. Finally, we have really, really, really cool tools to play with. Although it is critical that we pay attention to and prepare for social, economic, and legislative threats to our profession, we need to periodically step back and appreciate how lucky we are to be able to do this job—in my opinion, the best job a human being could possibly have. In terms of an individual mandate, I would like to finish with the Oath of Maimonides, published in his Guide to the Perplexed, a book he may well have specifically meant for me: The eternal providence has appointed me to watch over the life and health of thy creatures. May the love for my art actuate me at all times. May neither avarice, miserliness, nor thirst for glory or for a great reputation engage my mind: for the enemies of truth and philanthropy could easily deceive me of my lofty aim of doing good to thy children. May I never see in the patient anything but a fellow creature in pain. Grant me the strength, time, and opportunity to always correct what I have acquired, always extend its domain; for knowledge is immense and the spirit of man can extend itself indefinitely to enrich itself daily with new requirements. Today he can discover the errors of yesterday and tomorrow he can discover a new light on what he thinks himself sure of today. Oh God, thou hast appointed me to watch over the life and death of thy creatures; here I am ready for my vocation and now I turn to my calling. Thank you very much for your attention, and thank you for allowing me to lead this wonderful organization. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.