what are neurosurgeons doing outside of neurosurgery?

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a neurosurgery career in Boxing and Head Injuries: Lifelong Interest Can Develop from Unimaginable .... cate me as to the best way to educate, coerce or otherwise influence our ...... of computer-based and non-computer-based simulations for ...
IS THE OFFICIAL NEWSMAGAZINE OF THE CONGRESS OF NEUROLOGICAL SURGEONS

SUMMER 2014




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THE EVOLUTION OF LIFE AND CAREER
IN BOSTON AT THE 2014 CNS ANNUAL MEETING THIS OCTOBER 18-22, I HOPE THAT A SIGNIFICANT MAJORITY OF NEUROSURGEONS WILL JOIN US IN A DISCUSSION ABOUT HOW TO BALANCE ACCESS TO CARE WITH RESPONSIBLE STEWARDSHIP. < explained “misunderstandings.” Surgeons were clearly doing many more operations, and many more aggressive operations, than their peers on a much greater proportion of patients seen in clinic. I was asked to review de-identified records from one such practice, and I found consistent discrepancies between radiologists’ and surgeon’s interpretations of imaging studies, with much more pathology identified by the surgeon in every case. I found consistent reliance on discography in the face of normal or near normal MRI to include, as opposed to exclude, patients as surgical candidates and to justify extra levels. I found gross oversimplification of biomechanical principles used to justify long segment fixation for minimal pathology. I do not know who the practitioner is or who the patients are. I do not know how the charts were selected, or whether the designated charts are a truly representative sample of the practice. We all have cases that we wish we had done differently. I do not know when the operations were done, and acknowledge that

there has been an evolution of thought regarding the use of discography and understanding of biomechanical principles over time. I also did not have access to the actual imaging studies in question, just the reports, so I cannot say whether or not the discrepancies between the surgeon and the (multiple) radiologists were reasonable. The patterns of surgeon-reported and radiologist-unreported pathology, reliance on overly sensitive diagnostic methods and seemingly over-aggressive surgery were consistent. I also know that this practitioner is not alone, and that this practitioner is a neurosurgeon. The theme of the upcoming meeting is A Question of Balance. Through the development and promulgation of clinical practice guidelines, the CNS has provided the bulk of the information used by our Washington Committee to comment upon and modify payment and policy decisions which could potentially limit patient access to effective and timely care. Intrinsic to our arguments is the intimation that neurosurgeons are generally following these clinical practice guidelines, and that

payment for these procedures is reasonable within the general spirit of the guidelines. In many cases, practices and procedures are not commented upon by the guidelines, either because there is not a sufficient literature base or simply because no one has gotten around to writing on that topic. The example above demonstrates practice far outside of the lumbar fusion guidelines which were published in 2005, and are directly relevant to the cases reviewed (these have been updated for publication this summer). These guidelines specifically address the limitations of discography and limit recommendations for fusion to specific procedures for specific patients. In Boston at the 2014 CNS Annual Meeting this October 18-22, I hope that a significant majority of neurosurgeons will join us in a discussion about how to balance access to care with responsible stewardship. I am hoping that you will educate me as to the best way to educate, coerce or otherwise influence our peers to adhere to guidelines when they exist.