I have been a neurosurgeon in private practice for over 25 years, and when I became President of the AANS a little over two months ago, I was well aware that this is a crucial time for the field of neurosurgery. Changes in reimbursement and technology have led to a challenge in traditional referral patterns and treatment protocols for neurosurgical disorders. The referral patterns and case loads we establish now will affect the field of neurosurgery for years to come. We must decide if we want to be “complete” neurosurgeons practicing all breadths of the profession, or just operating on malignant brain tumors and competing for the occasional disc. The current chaos in the medical system will eventually settle and if we as neurosurgeons don’t take action to try and establish where neurosurgery will sit, someone will decide for us.
One of the areas being challenged most right now is the cerebrovascular field. I am not willing to give up the entire cerebrovascular field to neurologists, interventional radiologists, vascular surgeons and cardiologists. Stroke is a neurosurgical problem and we are the central nervous system specialists. Neurosurgeons clearly have the greatest understanding of the brain and these disorders and need to stay involved in the care of these patients. Treatment is not about a particular technical skill. There is a place for these talents, but the overall care of the patient must be managed by the person with the most comprehensive understanding of the disease process, the complications and the outcomes — the neurosurgeon.
Many neurosurgeons may not consider themselves exclusive “cerebrovascular specialists,” but we need to ask “can you survive without doing any cerebrovascular cases, and will the next generation of neurosurgeons be able to?” I know my practice would take some hard hits if we eliminated all the cerebrovascular work.
The AANS and CNS have joined forces to create cerebrovascular fellowships and action recommendations through the Neuroendovascular Task Force; carotid endarterectomy and aneurysm outcomes programs through the Outcomes Committee; and marketing tools for stroke through the SMART Committee. As national organizations, the AANS and CNS can create policy statements, lobby appropriate groups, and develop marketing tools, but task forces, programs and committees aren’t going to win this battle, only provide resources for our members to work with. This battle is going to be won in the emergency rooms, operating rooms and hospital board rooms across the country.
It is essential that every neurosurgeon be aware of these issues and get involved at the local level. If there is a medical center stroke team, you need to be on it. If protocols for cerebrovascular patients are being written, you need to be an author. When referring physicians and the community think of cerebrovascular disease, their initial response should be “neurosurgeon.”
This is not going to be easy and it is going to take a commitment of time — something most neurosurgeons do not have in excess. But it is a battle worth winning, and to win we must all work together for the profession. If it is a matter of learning new techniques, then neurosurgeons need to educate themselves, if it’s matter of cost, then we need to evaluate our spending patterns and create new, efficient treatment processes.
Currently, there are two projects that need the support of our members, and I ask that each of you at least consider implementing these programs into your practices. The Cerebrovascular SMART program will be released early next year and will include teaching slides, brochures and guidelines to help you raise awareness of neurosurgical cerebrovascular care in your own home-town. The research, the graphics and the quality of the materials promise to be top of the line, but it is the individual neurosurgery “ambassadors” who must go out and lecture to primary care physicians, emergency medicine workers and community members with a potential high-risk for stroke.. As part of the program, the AANS and CNS will be sponsoring cerebrovascular exhibits at the Annual Meetings of The American Academy of Family Physicians, The American College of Physicians and The American College of Emergency Medicine and we will attempt to spread the word to thousands of doctors at once, but we are relying on you to finish the job once these doctors return home.
The Outcomes Committee has also developed several tools for evaluating patient outcomes and treatment that are easy to use and available on NEUROSURGERY://ON-CALL®. We have the opportunity to create a large database of cerebrovascular patient information, but we need data from individual neurosurgeons to make this project work.
The fact that neurosurgeons are comprehensive cerebrovascular care providers may seem obvious to us, but we need to make this known to primary care physicians, managed care organizations, emergency medicine physicians, neurologists and the patients themselves. We must be willing to take referrals and consultations, volunteer for hospital committees, bring our costs down to comparable levels, stay on the forefront of cerebrovascular research and new technology and most importantly, stand up and make ourselves know as they cerebrovascular experts.
Most of all this is going to require the time and effort of each of us the local level. If you want to be a cerebrovascular neurosurgeon, or treat aneurysms and perform carotids, it begins with stroke. In my experience, a neurosurgical practice starts from the ground up. We need to emphasize that stroke is a brain attack, a neurosurgical emergency and most importantly, be there to care for these patients when internists, family physicians, and emergency physicians call for help no matter the time of day.
This is not the only battle like this we will face over the next few years. There is still work to be done in spine, skull base, pain and mild head injury. We are working to address these areas as well. Medicine has become a competitive market place and as other medical specialties lose niches and patients, they will continue to look at neurosurgery for new areas upon which to encroach unless we become active and stand our ground.
Russell L. Travis, MD
AANS President