Liability Crisis Dominates Discussion

Plenary Session Tackles Neurosurgical Workforce, Education, and More

The Council of State Neurosurgical Societies (CSNS) held its semiannual plenary session in Denver in conjunction with the annual meeting of the Congress of Neurological Surgeons (CNS). The well-attended sessions were dominated by concerns about the escalating medical liability crisis. States that were not perceived to have a problem two years ago now have seen doubling of professional liability insurance rates, liability insurance carriers leaving their states, and neurosurgeons receiving notification that they will no longer be able to receive liability coverage. The general impression is that there now is no such thing as a state which is not at risk.

In response, neurosurgeons are relocating to areas where liability insurance is affordable and the litigation climate is tolerable. Missouri, for example, reported that last year 15 percent of its neurosurgeons either chose not to practice any longer or moved to another state. With a steep rise in premiums again this year, it is anticipated that another 20 percent may leave the state. The high rates of relocation in Missouri are related to the fact that many of the neurosurgeons on the Missouri side of Kansas City are moving their practices to the Kansas side of the city where the liability insurance rates are considerably lower.

Another response to the medical liability crisis is that, in increasing numbers, neurosurgeons are limiting their practices to non-pediatric spine procedures. During the quadrant sessions a number of delegates offered anecdotal instances of a patient either becoming comatose or dying because of an intracranial emergency in a hospital where neurosurgeons were on call, but had given up their intracranial privileges. By the time air transport had been arranged, the patients had deteriorated beyond saving. In contrast, neurosurgeons reported instances in which they were able to save as much as $100,000 per year in liability premiums by relinquishing their intracranial privileges. In one instance, a neurosurgeon was told by his carrier that he could continue his liability coverage only if he revoked his intracranial privileges and limited his practice to spinal procedures.

Plenary Session Sparks Lively Discussion
During the plenary session, seven resolutions were presented. The deliberations are summarized below, and additional information is available at .

Resolutions I and II called for the formation of an ad hoc committee to develop guidelines as to which neurosurgical procedures might be appropriate for Allied Health Professionals to perform. Andrea Strayer, CNRN, representing the American Academy of Neuroscience Nurses, testified that currently no guidelines exist and that hospital medical staff often struggles with what procedures a physician’s assistants or neurosurgical nurse specialists should be allowed to perform. She felt that guidelines developed by neurosurgery’s national organizations would provide the medical staff with the necessary direction.

The resolutions further suggested that the committee examine the workforce of neurosurgical physician assistants and nurse practitioners and consider creating guidelines for the development of new training programs in academic centers for PAs and NPs who might be interested in specializing in the neurosciences. These two resolutions were referred to an ad hoc committee chaired by Mick Perez-Cruet, MD, who will report back to the CSNS at the spring plenary session.

Resolution III, submitted by the California Association of Neurological Surgeons, addressed the planned requirements by the American Board of Neurological Surgery (ABNS) for continuing medical education: every two years, 100 hours of category 1 CME credit approved by the Accreditation Council of Continuing Medical Education, with 40 hours being “neurosurgical CME.” The resolution pointed out that attending meetings of the North American Spine Society, the American Epilepsy Society, the American College of Surgeons, and others, should count toward continuing education in neurosurgery. The resolution implored the ABNS to do away with the requirement for 40 hours of “neurosurgical CME” and requested that all category 1 CME be recognized as part of the requirement for 100 hours every two years.

The decision was made to refer to this matter to committee. David Jimenez, MD, was asked to bring this resolution to the attention of the ABNS and to report back to the CSNS at the spring plenary session.

Resolution IV also was offered by the California Association of Neurological Surgeons. It pointed out that the recently adopted CNS bylaws change in Article V, Meetings and Elections, requires eligible candidates for office to have served for at least three years on the CNS Executive Committee. The resolution also addressed the issue that under the current structure, the CNS Nominating Committee is appointed by the Executive Committee rather than elected by the members, thus bypassing input by the membership. Further, the resolution asserted that this bylaws change was adopted by an e-mail vote, with the e-mail ballot failing to reach a large percentage of the membership.

More time was spent in debating this resolution than any of the others. The CNS leadership testified that their in-house attorney had counseled that, under CNS bylaws, an e-mail ballot was acceptable. Furthermore, when bylaws changes are voted upon at the annual CNS business meeting, typically only 40 to 50 members are present, compared with the more than 500 votes received by e-mail on the recent bylaws change. The CNS leadership stated that they were committed to pursuing change to an electronic format for the benefit of their membership, but would take steps to be more inclusive of the membership in the future.

The CSNS felt that an electronic ballot needed to provide an opportunity for debate, as well as adequate time for the membership to evaluate the issues before the close of the voting. The CSNS also requested that regional members-at-large be elected to the CNS Executive Committee and that the CNS Nominating Committee be elected by the CNS membership rather than appointed by the Executive Committee.

Resolution V called for the AANS and CNS to publish a list of neurosurgeons who had been sanctioned for breaching the rules of the organizations. Testimony was given that in New York State, plaintiff’s attorneys are not required to name expert witnesses in advance of the trial and that often times, sanctioned neurosurgeons may give testimony in court without the court being apprised of the relevant history of that “expert.” The decision was made to defer the resolution to the Medicolegal Committee to see if it might be permissible for the AANS and CNS to publish such a list on a password-protected Web site that is accessible by the membership.

Resolution VI, submitted by the CSNS Workforce Committee, proposed the development of a peer-reviewed journal dedicated to socioeconomic issues affecting neurosurgeons. It was noted that the Journal of Neurosurgery and Neurosurgery are scientific journals and have not been interested in publishing articles on economic issues in the past. This resolution was referred to the Workforce Committee with a report on the cost and feasibility of such a journal to be given at the spring plenary session.

Resolution VII called for the CSNS to ask the ABNS to conduct a study to evaluate the impact of the proposed Maintenance of Competence program on practicing neurosurgeons. David Jimenez, MD, who would be representing the CSNS at the ABNS meeting, stated that he would bring the issue to the attention of the ABNS and report on the outcome at the spring plenary session.

2004 NLDC Planned in Washington, D.C.
Fernando Diaz, MD, reported that plans for the next Neurosurgical Leadership Development Conference, which will be held in Washington, D.C., July 18-20, are well underway. The purpose of the NLDC is to train individual neurosurgeons on how to be effective grassroots leaders so they can develop relationships with their members of Congress and become effective lobbyists for neurosurgery.

Each state society has been asked to send a minimum of three delegates. Lobbying for medical liability reform will likely be at the forefront, given that the conference is planned to take place two weeks before the Democratic National Convention. It is hoped that all of you will make plans to attend and to use the conference as an opportunity to visit with your legislators to express your concerns.

Frederick Boop, MD, is chair of the Council of State Neurosurgical Societies.