The Future of Neurosurgery: Shaping a Workforce to Meet the Needs of Our Patients
Neurosurgery is at an inflection point in its evolution as we move from a specialty that was previously bent on preservation of life and neurological function, to one that is increasingly focused on reclamation and enhancement of lost functions occurring as a result of injury, insult or degenerative diseases. A 1973 article written by Richard M. Bergland, MD, and published in the New England Journal of Medicine, Neurosurgery May Die, began with the declaration, “Neurosurgery has stopped evolving.” Some 45 years later, nothing could be further from the truth. While Dr. Bergland’s exhortation to reorganize neurosurgical training is based on the historical evolution of training, cultural relationships between practices and academic institutions at the time as well as assumptions about population decline and the scope of neurosurgery, many of the points made remain in the public discourse about our profession today – particularly with respect to our work force.
Early neurosurgery focused on removal and resection of abnormal tissues, treating pressure and compression of neural tissue from tumors, infections, hematomas, hydrocephalus, herniated discs and the like. Many of our early procedures were even destructive, aimed at the compassionate goals of relief from pain, tremor, psychiatric distress or the abatement of malignancy. Over the past few decades, however, as a variety of other disciplines, such as field care and transport, anesthesiology and critical care, have also evolved, mortality rates from trauma and elective neurosurgical procedures have dramatically declined in comparison. As a result, we have been able to push other boundaries, moving from performing life-saving operations and surgeries aimed at preservation of brain, spinal cord and nerve tissue, to extending life, preventing future catastrophe, prolonging and improving functionality and quality of life, and even restoration of function.
Amongst other issues, including funding, regulation, quality assurance, population needs, global economic concerns and cultural expectations, we must take into account the expansile nature of our profession when making decisions about the future neurosurgical workforce. Dr. Bergland quoted a 1972 New York Times editorial entitled Physician Planning, in which it was stated:
“There is wide agreement that in many areas of this country there are more surgeons than are needed, with the result that a large proportion of these highly trained specialists are employed far below their capacity . . . If the medical profession cannot make the necessary adjustments, then the government may have to step in, with all the risks of bureaucratic error and arbitrariness such a course would raise.”
Interestingly, this is just the situation we are facing today with increasing pressure from many sides (at times even from our own surgical colleagues) for more government regulation of our training processes and oversight of the ways in which medical and surgical care is delivered. We are also facing a global surgical shortage in which patients in many countries cannot get access to basic life-saving neurosurgical care.
In the face of evolving sub-specialization, a knowledge explosion and the rapid technological advances achieved in recent decades, it is challenging for even those with expertise in neurosurgery to predict the future of our specialty 10 to 15 years on. It is incomprehensible that those outside the profession of neurosurgery specifically (and medicine more broadly) would have sufficient insight to make workforce projections that will meet the needs of our patient population in the future. One must consider that it takes more than a decade to train an individual who already has a bachelor’s degree to become a neurosurgeon, and even longer if neuroscience study begins during the undergraduate years or if graduate scientific and other educational pursuits are involved. For future thought leaders to develop on specific subjects within neurosurgery, it takes longer still. It becomes evident that we ourselves must consider the future of our specialty in an ongoing fashion and resist outside bureaucratic interference with our training programs. It is, however, incumbent upon us to grow, change with the times and evolve our expectations of training, as has been so thoughtfully done in recent years by those groups involved in neurosurgical graduate medical education.
We must also resist pressure to limit the scope of what we can provide to our patients via increasing administrative burdens, financial constraints and bureaucratic impediments. We must foster innovation and growth not only in our quest to develop better operations and therapeutic options for neurosurgical problems, but also in improving efficiency of neurosurgical care delivery. We can improve access to high-quality neurosurgical care and achieve better functional outcomes not by limiting the number of neurosurgeons as was suggested so many years ago and continues to be proposed by those outside our profession, but via collaboration and appropriate forecasting. We will continue to work with other disciplines to advance science and practice as well as with our government and private payor partners to highlight the improvements in outcomes that can be achieved by expenditures on research and clinical care in neurosurgery. By doing so, we can ensure the legacy of neurosurgical expertise for those patients suffering from neurological disease and injury long after we are gone.
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