Capitation? Fee-for-service? Third party payors? Current procedural terminology codes? These typically seem like very foreign topics to neurosurgical residents who spend the seven or more years of their training attempting to assimilate advanced surgical techniques and neuroanatomy. When rapid advances in the specialty are coupled with learning traditional time-honored standards, there seems to be little time to introduce the field of medical socioeconomics. To preoccupied neurosurgeons-in-training, finances and structure of modern day health care are rarely acknowledged as anything other than a looming specter to be encountered only upon entering practice.
As a result, most residents and fellows complete their neurosurgical training, and upon commencing their search for employment, find themselves woefully unprepared to comprehend the socioeconomics of medical practice. Our current residency training model emphasizes, appropriately, the nuances of medical knowledge and patient care. In contrast, the principles of negotiating skills, medical reimbursement and regulation are underrepresented, leaving neurosurgeons at a tremendous disadvantage early in, and perhaps throughout, their careers.
A study surveying chief neurosurgery residents and program directors revealed the following disturbing trends (3):
- 95 percent of residents did not believe their residency program provided adequate training in socioeconomic issues, while only 58 percent of program directors felt this was lacking.
- 95 percent of residents did not feel adequately prepared to deal with the business aspects of a medical practice or with insurance companies and the managed care environment.
- 87 percent of residents did not think they were adequately prepared to deal with a lawsuit.
- There was an overwhelming lack of understanding of basic medical socioeconomic concepts and terms.
While this particular study was performed in 1998 and is now almost 20 years old, it does not appear that these statistics are much improved in our current neurosurgical training system (2,4,5).
This incompetence is glaring in an era of increasing health care delivery complexity. In 2014, as a share of the nation’s Gross Domestic Product (GDP), health spending in the U.S. accounted for 17.5 percent, emphasizing the role medical practice has in this country and also, the need to curtail these expenditures (1). Additionally, with the institution of 2010’s Patient Protection and Affordable Care Act, federal oversight and the overall regulation of medical care increased significantly, introducing new critical concepts that should be familiar to all medical practitioners.
Protected by the educational confines of neurosurgical residency, trainees are largely shielded from these socioeconomic factors. This is likely appropriate to allow for concentration on learning the medical and technical aspects of the field. It is, however, also the best time to introduce the issues that affect the process of health care delivery. Allowing residents and fellows to learn and closely observe the economic, business and medicolegal aspects of neurosurgical practice can create an appreciation for and enhanced comprehension of the benefits and constraints these place on the profession.
To properly educate our neurosurgical resident trainees, it is essential that socioeconomic and medicolegal concepts be integrated early in their training. Reports of the implementation of these programs, such as the one developed at Columbia University, reflect the “overwhelmingly positive” response from resident staff (6). This education gap can and should be closed during neurosurgical training. “Recognizing that socioeconomic knowledge is necessary to provide optimal care in a complex health care system,” it is clearly evident why neurosurgical residents should care about these issues and the ‘when’ is quickly becoming obvious to those running residency programs: as early as possible.
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