Counterpoint: Regionalization of Neurosurgical Care, Not Subspecialization of Providers
“The value of experience is not in seeing much, but in seeing wisely.”
-Sir William Osler
Who would you rather have repair your car’s transmission – a mechanic with 20 years of experience who has worked on every imaginable model or a guy who has a certification working on transmissions specifically for Hondas? Who would you rather repair your kitchen faucet – a handyman who has 30 years of experience and is comfortable working in any room of the house or someone from a plumbing company who is certified to specifically repair Moen brand faucets? Your hypothetical answer to these semi-rhetorical questions reflects a great deal on your view of our increasingly fragmented world. In the information age, where no one has the ability to keep up with the myriad streams of continuously updated data, people increasingly value expertise over experience. Gone are the days of your local mechanic, replaced by a bevy of certified technicians for every system in your car. Gone are the days of calling your handyman; instead, you call your local HVAC, plumbing or electrical company to have a certified technician come out to service your house. It may be, in the not so distant future, that your local neurosurgeon is replaced by a certified neuroradiologist, epileptologist or surgical oncologist. How our generation of neurosurgeons chooses to handle the issue of subspecialization will greatly determine the future of neurosurgery as a viable, and vibrant, specialty.
The Definition of Neurosurgery
Currently, no less than the American Board of Neurological Surgery (ABNS), the certifying body for all practicing neurosurgeons, defines neurosurgery in the following fashion:
“NEUROLOGICAL SURGERY constitutes a medical discipline and surgical specialty that provides care for adult and pediatric patients in the treatment of pain or pathological processes that may modify the function or activity of the central nervous system (e.g. brain, hypophysis and spinal cord), the peripheral nervous system (e.g. cranial, spinal and peripheral nerves), the autonomic nervous system, the supporting structures of these systems (e.g. meninges, skull & skull base and vertebral column) and their vascular supply (e.g. intracranial, extracranial and spinal vasculature).
Treatment encompasses both non-operative management (e.g. prevention, diagnosis – including image interpretation – and treatments such as, but not limited to, neurocritical intensive care and rehabilitation) and operative management with its associated image use and interpretation (e.g. endovascular surgery, functional and restorative surgery, stereotactic radiosurgery and spinal fusion – including its instrumentation.” (http://www.abns.org/en/About%20ABNS/Definition%20of%20Neurological%20Surgery.aspx/)
This represents a very broad and inclusive definition of our specialty. When a neurosurgeon matriculates and successfully completes his or her oral board exam, he or she is certified in all these aspects of neurosurgery. From the inception of our specialty a little over a century ago, neurological surgery has been a unique surgical specialty that covers the entire anatomy of a patient and manages all aspects of care, surgical and non-surgical, for patients with neurologic conditions.
In recent years, however, there has been a move toward narrowing the focus of practice and developing fellowship training and subspecialties within neurosurgery. The first, and only, subspecialty to develop its own separate board certification was pediatric neurosurgery.
In recent years, a panoply of fellowship programs have arisen to provide additional training (one to two years) after residency for neurosurgical trainees to further hone their skills in a specific area of practice, such as spine, endovascular, neuro-oncology, skull base surgery, functional (including epilepsy, movement disorders and pain), to name a few. More and more, such fellowship experiences are being pursued prior to graduation and are enfolded into residency training. The Society of Neurological Surgery (SNS), which oversees neurosurgical residency training, has even taken the step of developing a certification program for these fellowships. The Committee on Advanced Subspecialty Training (CAST) is developing accreditation and certification standards for subspecialty fellowships.
Why This Growing Trend Toward Subspecialization?
There are a number of forces that contribute to this movement. An important one is hospitals and health systems. In an increasing competitive and consolidated market, and one in which every aspect of patient care is under the scrutiny of a growing body of accreditation organizations, hospitals wish to develop a marketing edge by being able to advertise a number of “Centers of Excellence.” Few disease processes or clinical service lines contribute to a health system’s bottom line like a Spine or Neurosciences Center. If the hospital can demonstrate that they possess “fellowship trained experts,” it can mean a significant bump in market share through advertising. It can also lead to their own certifications and designations, such as a Primary or Comprehensive Stroke Center, or as a ‘Certified Center of Excellence’ from the organization from which they can wrangle a certificate. Many certification bodies and patient safety advocacy groups, such as the Leapfrog Group, often push for staffing in hospitals by subspecialty trained physicians. In this type of health care climate, it is no wonder that residents seek additional training during or after residency. Countless job postings seek “fellowship trained” surgeons.
Another factor that contributes to the trend toward subspecialization is that the nature of neurosurgical training has changed dramatically in the past 15 years. Beginning in 2003 with the initial reduction in resident work hours, the process of training neurosurgeons has become increasingly challenging. Resident time in the operating room is curtailed by duty hours restrictions with the result that many residents, by the end of training, do not feel comfortable performing the full spectrum of neurosurgical cases. The consolidation of health care services and systems also contributes to this. Many highly specialized services are concentrated in high-profile, high-volume centers. Technological and surgical technical advancements have also transformed neurosurgical practice. The open clipping of cerebral aneurysms is being replaced by endovascular coiling. Traditional open spine procedures are being supplanted by minimally invasive techniques.
As health services, in particular specialty services such as surgical procedures, become increasingly consolidated, much has been made of the correlation between clinical volumes of surgeons, hospitals, complication rates and mortality. Several major medical centers made headlines a year ago when they pledged to eliminate low-volume, high-risk surgeries. A number of research studies in general surgery, as well as neurosurgery, appear to support the claim that high-volume surgeons and medical centers deliver higher quality care for complex patients and procedures.
To Specialize or Not to Specialize, That is the Question
With all this evidence at our disposal, is it time for us to take the plunge as a specialty, the way general surgery has, and shed our generalist tendencies? I would argue, not yet. As a chief resident at the threshold between training and practice, I have thought long and hard about what my next step will be and what I want my career to look like. I entertained the idea of pursuing a subspecialty focus. Ultimately, there was no aspect of neurosurgery I wanted to embrace to the exclusion of all others. I enjoy spine procedures. I enjoy tumors, especially pituitary tumors. I enjoy vascular procedures. I enjoy trauma. And I saw, based on many of my attendings’ experiences, that you can have a fulfilling career doing all of these things and taking excellent care of patients in the process. What I realized is that the important question to ask is not what do you want to do in neurosurgery, but where do you want to do it?
One important wrinkle in the volume-outcome research is that it lumps high-volume centers together with high-volume surgeons. The actual relationship between surgeon volume, quality and outcomes is less understood. It is difficult to divorce these concepts because for every successful high-volume surgeon there is a terrific OR team, floor nurses and ancillary staff that support his or her work. One other flaw in the volume-outcome argument for surgery is that it does not apply to all kinds of surgeries. In fact, recent evidence suggests that smaller hospitals can provide care equal in quality to large medical centers, and in many cases, at lower costs. For complex surgeries and patients, however, high-volume centers do provide better care.
It is intuitive that the more you do the better you will be as a surgeon. Anyone who has been involved in a competitive sport or played a musical instrument can attest to this. Birkmeyer et al confirmed this with their study of laparoscopic surgeons. One important item to point out in the Birkmeyer study is that the surgeons who were in the high skill category performed more of all types of surgeries and only 20 percent completed laparoscopic fellowships. They were good at laparoscopic bypass because they were good at all kinds of surgeries because they had done a lot of surgeries. They had a lot of experience.
In neurosurgery, many of the surgical skills we acquire during residency are translatable across subspecialty foci. Doing more spine surgery makes you a better cranial surgeon and vice versa. There are specific skills that require dedicated, time-intensive practice, such as catheter work in endovascular surgery and microsurgical skills in general. However, for the most part, as a surgeon develops experience and facility with all aspects of neurosurgical technique, he or she will be in a position to easily acquire a new surgical skill set.
As a specialty, many of our patients and procedures require a high-level medical facility for their care, at least a tertiary care center. Classically, the expected ratio of neurosurgeon to the general population has been cited as one in 100,000. This ratio has been recently called into question as a result of subspecialization trends. In actual practice, a new neurosurgeon would benefit from moving to a population center larger than 100,000 in order to benefit from the volume and breadth of neurosurgical disease processes.
Finally, the answer to the original question, should neurosurgeons embrace subspecialization: No. However, neurosurgeons should strategically place themselves in population centers that can function as hubs with outlying spokes to less densely populated regions. The regionalization of neurosurgical services will lead to developing clinical pathways and institutional expertise across the spectrum of neurosurgical care. Does it make more sense for a health system, which has a catchment of one million, to hire seven or eight neurosurgeons with subspecialty training in different aspects of neurosurgery, or to hire four or five neurosurgeons who are comfortable practicing all aspects of neurosurgery but who each have a niche interest? If each subspecialty-trained surgeon performs 150-200 cases in his or her field of training, while each general trained surgeon performs 300-350 cases that run the gamut of neurosurgical care, the amount of work done will be the same. The cost to the health system will be almost half.
Furthermore, one thing I have learned in my residency, with experience comes discretion. While I enjoy working with my younger faculty, many of whom have subspecialty expertise, they oftentimes lack the judgment that comes with doing the thousands of cases that teach a surgeon what works and what does not. In a health care climate increasingly focused on outcomes, as surgeons, we will be called upon to justify the work we do along a number of domains. We will no longer be able to justify our surgical approach based on clinical indications, and we will also be judged based on costs and patient-reported outcomes. The only way to become fluent in these domains of care is to be very skilled in all aspects of neurosurgery.
As a specialty, we should not throw the baby of our neurosurgical training out with the bathwater of health care consolidation. No doubt the neurosurgical care of the future will happen in high-volume centers. But the answer to this trend is to develop regional centers of care, where high-volume, high-quality surgeons can ply their trade and develop data registries, clinical care pathways and service lines, and even clinical trials, based on their volume and experience. If neurosurgery chooses the path of subspecialization, health care stakeholders will divide us over reimbursement and manpower issues, leading to the cannibalization of our specialty. United in strong regional care centers we stand; divided into subspecialty fiefdoms, we will fall.
1st International and 5th Annual Meeting of Nepalese Society of Neurosurgeons
March 8-11, 2017; Kathmandu, Nepal
7th Annual Seattle Otology & Advanced Rhinology Course
March 9-11, 2017; Seattle
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