At various times in the history of neurosurgery, the value of research and research training has been challenged. Perhaps at no time in history, however, is this challenge more important. The Balanced Budget Act of 1997 (BBA) has made significant changes to the Medicare program, including Medicare payments by billions of dollars. As a result, the average teaching hospital is projected to lose $45.8 million in Medicare payments between 1998 and 2002. Included in the BBA’s changes to Medicare provider payments are reductions in Graduate Medical Education, which reimburses teaching hospitals for training physicians.
Only two years into its five-year implementation, the BBA’s damaging impact is causing an immediate financial crisis at teaching hospitals-access that threatens the educational mission of neurosurgical programs. Left unchecked, the BBA’s Medicare cuts will force the nation’s teaching hospitals to reduce the scope and promotion of their research efforts. Several bills granting BBA relief to teaching hospitals have been introduced in Congress. In particular, the “Graduate Medical Education Payment Restoration Act of 1999,” recently passed in Congress, slows the BBA’s implementation of cuts associated with the residency training and research period.
Research in Neurosurgery Training Programs
In late 1998, the Research Committee of the Society of Neurological Surgeons conducted a Program Directors Survey, focusing on research in training programs. All 95 neurosurgical Program Directors responded. According to the survey results, the average program has seven neurosurgeons providing patient care, with 2.7 of those faculty members doing laboratory research and 2.6 conducting clinical research supported by outside funds. The survey also revealed that the average program has 1.5 residents per year, is 66 months in length and dedicates 14 months to research. Nearly 75 percent of the Program Directors surveyed indicated that all training programs should require research in their curriculum. Funding and mentoring were regarded as the principal barrier to a productive research experience.
Presently, less than half of the programs receive research support from the National Institutes of Health (NIH), 25 percent receive support from non-NIH governmental sources, and most receive some financial support for research from industry sponsors. Direct financial support from all extramural sources for research in U.S. neurosurgery training programs was $78 million in 1998.
Value of Research
Neurosurgery is a fiercely independent discipline, where neurosurgeons are required to think objectively, diagnose accurately, choose treatments appropriately, evaluate outcomes honestly and, most important, stay abreast of current treatments. As we train neurosurgeons of the future, the value of research with exposure to the scientific method becomes clear. Well-designed and well-executed clinical and experimental investigations are crucial to the advancement of our specialty.
As our lively field continues to be fueled by an explosion of technological advancements, scientific principles rather than expert opinion and authority derived from tradition, will direct clinical practice. These principles will ensure that our field remains vital and meaningful while our students are instilled with a sense of curiosity and thoughtfulness.
Value of Neurosurgeons
Clinical neurosurgeons are, in many ways, best aligned to enhance and direct the future of research. Without the expertise of clinicians, vexing problems such as brain tumors, spinal cord trauma, cerebral vasospasm and dystrophic abnormalities lack a clinical context. Certainly after caring for patients, neurosurgeons are best qualified to perform the colossal task of defining and honing the current uncertainties in neurosurgery. Neurosurgeons are, and must continue to be, invaluable members of researrch teams as they formulate questions, help find answers and employ these answers to the task of caring for patients.
Looking Ahead
As the field of neurosurgery moves into the new millennium, it is important to respect our past and contemplate our future. After all, neurosurgery was founded on a commitment to research and training in the scientific method. These covenants must be cherished and secured. As our educational system evolves, it must not only foster the growth of neurosurgeons in adequate numbers and exceptional competence, but also support men and women capable of creating and shaping the future of neurosurgery. Dedicated time for research will ensure this continuous growth and progress.
Julian T. Hoff, MD, Professor and Head of the Department of Neurosurgery at the University of Michigan (Ann Arbor) and Chair of the AANS Neurosurgery Research and Education Foundation, and Sanjay Gupta, MD, Chief Resident in the Department of Neurosurgery at the University of Michigan, contributed to this article.