is the 2005-2006 AANS president. He is in private practice at the Neurological Institute of Savannah in Georgia.
This idea is at the heart of one of the older story forms, the fable, a pithy and palatable means for communicating a message that an audience might not particularly want to hear. Consider this recounting of Aesop’s The Eagle and the Arrow:
The archer saw the eagle perched high atop a rock. Taking careful aim, he shot his arrow true. The eagle, mortally wounded, saw in a single glance that he himself had furnished the arrow’s feathers. “It is a double grief to me,” he exclaimed, “that I should perish from an arrow feathered by my own wings.”
The moral of the story? We often supply others with the means of our own destruction.
This simple tale springs to mind when considering the complex issues that contribute to what many describe as a crisis in neurosurgical emergency care. While only a very small number of neurosurgeons report that they no longer take emergency call, the fact that any neurosurgeon might feel compelled to forsake neurosurgical emergencies is a matter of great concern.
To borrow a phrase from Aesop, it is a double grief to me that some patients may not receive neurosurgical emergency services from neurosurgeons, who surely are best equipped to provide such care, and that by not providing such services, neurosurgeons themselves set in motion a chain of events which eventually may prevent their own participation in neurosurgical emergency care.
AANS Explores Neurosurgical ER Coverage
The AANS Board of Directors has been aware of the developing crisis in delivery of neurosurgical emergency care and recognizes that in selected areas of the United States, neurosurgical emergency coverage is less than optimal. As it unfolds, the tale explaining why this is so is far from entertaining.
An in-depth view of the issues involved and results of the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey were reported in the Winter 2004 issue of the AANS Bulletin. The 2004 ER survey demonstrated that the great majority of neurosurgeons or their practices were providing at least one hospital with neurosurgical emergency coverage at all times. The survey also revealed serious concerns with the delivery of care, with strain most evident among neurosurgeons in solo or small-group practice. Survey results added detail to the continuing story of a strained workforce in which there remain more open positions than neurosurgeons to fill them. Subsequently, evidence has mounted that an increase in patient transfers to academic centers causes delay in patient care and stresses the resources of these facilities.
To study the problem of neurosurgical emergency care further, last fall the board organized the AANS Task Force on Neurosurgical Care and Physician Workforce Issues. This task force, introduced in my last column, is charged with developing and proposing a solution to this problem. It now has met twice and will meet again during the AANS Annual Meeting in April, the theme of which appropriately is Meeting the Challenges of Neurosurgery: Expanding Resources for a Growing Population.
AANS Workforce Survey Builds Case for Action
One of the task force’s first acts was to commission a comprehensive study of workforce issues, including neurosurgical emergency coverage: the 2006 AANS Workforce Survey. Results include the finding that 9993 percent of neurosurgeons currently take emergency call, but 76 percent perceive call coverage to be a problem in their region.
It is clear to us in neurosurgery that neurosurgical emergency care encompasses much more than nervous system trauma. It encompasses acute spinal cord compression from tumor or hematoma, intracerebral hemorrhage, subarachnoid hemorrhage, acute increased intracranial pressure from shunt malfunction as well as from expansion of intracranial mass lesions, among others. These complex problems are challenging even for neurosurgeons, who are trained specifically to manage these conditions.
Many other forces impact the provision of emergency care, limiting the availability or willingness of neurosurgeons to perform these services. These include liability costs, absent or inadequate reimbursement, and lack of hospital resources that includes neurosurgical intensive care unit beds, appropriate imaging capabilities, neurosurgical endovascular capabilities and adequately trained personnel to assist in the complex care of neurosurgical patients.
While the task force’s proposals will be released at a later date, there already is agreement that neurosurgical care is best delivered by trained neurosurgical providers. Further, we know that hospitals want to provide neurosurgical services at least in part because neurological illness is a profitable service line. We also know that there are more hospitals providing “neurology services” than there are neurosurgeons in this country. Given these facts, it is likely that the task force will recommend some reorganization of the system for providing neurosurgical care. Such an approach has the potential for improving the quality of life for neurosurgical providers as well as enhancing the availability of high quality neurosurgical care for our patients.
Acute Surgical Care Specialty?
Of course, a number of other physicians also are concerned about this problem, among them emergency physicians, hand surgeons, orthopedic surgeons, and trauma surgeons. Various solutions have been proposed. One of these is the development of an acute care surgical specialty, which would expand the current trauma and critical care specialty to include emergency neurosurgery and orthopedic surgery.
The AANS has opposed this expansion for a number of compelling reasons, chief among them training and current evidence. It is unlikely that trauma surgeons can learn to manage neurosurgical trauma with the addition of one or two years of training. The pathophysiology and anatomy of the nervous system are complex, quite distinct and unique compared to the pathophysiology of the chest and abdomen. Furthermore, a study by Knut Wester, MD, recently found that emergency neurosurgical care provided by general surgeons in Norway’s community hospitals resulted in increased morbidity and mortality when compared with care of patients who were transferred to a neurosurgeon, even when this required moving patients distances of 100 miles or more. This and other evidence suggests that an expansion of critical care trauma surgery into the field of neurosurgical trauma could be expected to negatively impact patient safety and quality of patient care.
The crisis in emergency care with respect to neurosurgery has as much to do with distribution of neurosurgical trauma care as with a shortage of it. The American College of Surgeons has developed an excellent program of trauma center designation, and there now is evidence in peer-reviewed journals, specifically a study by Demetriades and colleagues which found that level 1 trauma centers provide higher quality care than other facilities. Since most trauma surgeons work in level 1 trauma centers, additional training in neurosurgery — even if effective — is unlikely to benefit neurosurgical trauma patients because by definition neurosurgeons already are available at level 1 trauma centers.
The story of how neurosurgical emergency care delivery will be resolved remains a work in progress. The acute care surgical specialty concept is unlikely to be totally abandoned, though it may evolve into a surgical hospitalist concept. Having recently had the opportunity to meet with the leaders of other surgical specialties at an ACS-organized meeting to address the issue of emergency care, I am optimistic that surgery may be able to move forward with one voice on many aspects of this issue. Our collective goal is to develop an effective, unified message to leadership in the U.S. Congress that will facilitate a solution to the delivery of appropriate emergency care to our patients.
The Moral of the Story
Neurosurgery, a profession known to celebrate tradition, is replete with stories of its pioneers. As the AANS begins celebration of its 75th anniversary year, it seems appropriate to remember Cushing — neurosurgery’s founder — and his homage to Hippocrates, the father of medicine. In a 1926 address to graduating medical students, Cushing said this of the Hippocratic oath: “There is nothing that expresses so well…the ideals which from the first have actuated the doctor and have led to the solidarity of the profession you are entering.”
Many readers will be familiar with the oath’s modern version, which reads in part, “May I always act so as to preserve the finest traditions of my calling, and may I long experience the joy of healing those who seek my help.”
I hope this ideal reaches beyond a fable’s moral or a greeting card’s sentimentality. Physicians have struggled before and since Hippocrates, before and since Cushing, with finding the difficult balance of business and profession. To abandon provision of neurosurgical emergency services now, even for compelling marketplace reasons, would be sending an arrow which we ourselves have feathered through the heart of our profession.
The AANS believes that the best neurosurgical emergency care is provided by neurosurgery professionals. AANS members have demonstrated their commitment to providing emergency neurosurgical care. Be assured that the energies of the AANS are bent upon improving the environment for doing so.
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