The question is often asked “Are there too many neurosurgeons?” The answer is not a simple yes or no. It lies deep within the complex environment of the discipline of neurosurgery, and hinges on its definition. Perhaps one should first ask the question, “what is a neurosurgeon?” Although neurosurgeons are commonly thought of as “brain surgeons,” this aspect of neurosurgery only encompasses 25-30 percent of the whole. Occlusive vascular surgery, critical care, spine and peripheral nerve surgery etc., comprise the remaining 70 percent.
Neurosurgery Manpower – The Statistics
The job market for neurosurgeons is, as with all other specialties, somewhat uncertain. The medical and surgical specialties have been challenged regarding their position in the marketplace by the recent article by Seifer et al in the Journal of the American Medical Association3. Seifer et al’s work, however, has itself been challenged regarding neurosurgery by Alberstone et al1 ( in this issue of the AANS Bulletin).
Non-neurosurgery specialists, such as internal medicine, gastroenterology, anesthesiology and orthopedic surgery fared poorly in the marketplace in recent years, as assessed by help wanted index parameters used by Seifer et al.3 Neurosurgery (utilizing similar assessment techniques), however, is faring relatively well and, in fact, is stable in this regard1.
Can Neurosurgeons Compete?
In order for neurosurgeons to effectively compete, they must solidify their foundation. They must develop strategies that include the augmentation of post-graduate neurosurgeon education. This can be accomplished through pre-meeting courses, as well as via the Professional Development Program of The American Association of Neurological Surgeons. Great strides, in fact, have been made in this domain in recent years.
Neurosurgery fellowships in spine surgery, peripheral nerve surgery, occlusive vascular surgery, etc., increase the ‘presence’ of neurosurgeons in the academic arena, as well as in the marketplace. This provides training for neurosurgeons so that competent specialist physicians may be appropriately placed in academic centers; thus ensuring that all training programs are capable of training qualified neurosurgeons in all spheres of neurosurgery. This, however, requires that training programs utilize this increased level of expertise to train residents effectively in all aspects of neurosurgery.
Scholarly pursuits must follow. Neurosurgeons must be recognized as being academically progressive and astute in spine care, pain management, tumor, peripheral nerve surgery, occlusive vascular surgery and critical care. For spine care, this includes the domains of spinal cord injury, biomechanics, back pain, outcome assessment, bone physiology, peripheral nerve surgery, occlusive vascular surgery and critical care research.
Unity
Unity is mandatory. This is graphically evident in the domain of spine surgery. The de-emphasis on certificates of special or added qualifications regarding spine surgery (and other components of neurosurgery), and an emphasis on the fact that neurosurgeons are qualified spine surgeons, has played an integral role in the maintenance of neurosurgery’s unity. Neurosurgeons are trained as spine surgeons and have been recognized as such by the Counsel on Spine Societies (COSS). In this vein, board certified or eligible neurosurgeons are equivalent to fellowship trained orthopedic spine surgeons.2
If neurosurgeons had not ‘stood together’ their ranks may have been decimated. The elimination of spine surgeons from the ranks of neurosurgery would have decreased the number of neurosurgeons by greater than one-half. The fact that neurosurgeons stood together helped separate neurosurgery from it competitors, and helped establish neurosurgeons as spine surgeons.
The Paranoia
In mmany respects, neurosurgeons are their own worst enemies. They persist in asking “are there too many neurosurgeons? Are there too many training programs? Should we restrict training?” If a neurosurgeon performs only brain surgery , the answer to these questions is “yes.” If neurosurgery broadens its scope to include the aforementioned components of neurosugery, the answer is “no.” An assessment of the ‘capitated’ marketplace may help to clarify this issue.
In a capitated environment, the average reimbursement for a cranial neurosurgeon is approximately 7-10 ¢ per member per month (pmpm). If one considers the traditional spine neurosurgeon as the appropriate ‘definition’ of neurosurgeon (performing both cranial and traditional spine surgery, as well as peripheral nerve surgery, etc.), the neurosurgeon is ‘worth’ approximately 20-25 ¢ pmpm. However, if the neurosurgeon provides all of the aforementioned , plus a comprehensive non-operative back pain management program he/she may be worth as much as 40-50 ¢ pmpm. These are sobering figures. They portray the neurosurgeon, in his/her broadest sense (a comprehensive cranial, spinal, and peripheral nerve surgical and non-surgical care provider); and to be worth much more than if considered in his/her narrowest sense (i.e. solely as a brain surgeon).,p>
What Neurosurgeons Must Do
Neurosurgeons as a group must demonstrate competence. They must establish and confirm the comprehensive nature of their training and demonstrate a strong academic and a research presence. The demonstration of competence can be achieved by utilizing standard outcome assessment tools. If clinical results are suboptimal (resulting in suboptimal outcomes), patient management strategies must be altered. If clinical results are good, these results should be used as a marketing tool.
Quality research must be based on the soundest of clinical and scientific foundations. Regarding spine surgery alone, it must be based in multiple arenas, including spinal cord injury, biomechanics, back pain, outcome assessment and bone physiology. Neurosurgeons must firmly and convincingly define (redefine) themselves. They must define themselves as cranial neurosurgeons, occlusive vascular surgeons, peripheral nerve neurosurgeons, pain management physicians, traditional spine surgeons, complex spine surgeons and non-operative spinal specialists. They cannot be uni-dimensional, but must indeed be multi-dimensional as a group (and for the most part as individuals). They must develop and nurture new and previously inadequately established attributes.
The days are rapidly vanishing when a spine surgeon can refuse to care for a patient without a surgical problem. Those were the days of the silver platter. Instead, neurosurgeons must answer the questions posed by the referring physician and the patient, regardless of the presence or absence of an indication for surgery. The neurosurgeon must deliver the complete package.
Are there too many neurosurgeons and training programs? The answer appears to be no! What neurosurgeons must establish is a high standard of neurosurgical care, and they must maintain this standard. They must remember their roots. Neurosurgeons are complex spine surgeons. They are peripheral nerve surgeons. They can effectively manage pain. They can care for critically ill patients. Neurosurgeons must define themselves. However, they cannot abuse their privileges. They must participate in directing their future.
THE FUTURE
In order to determine how neurosurgeons might survive in the years and decades to come, let us examine how neurosugery may more effectively position itself in the marketplace. Back pain and the treatment of spinal disorders is perhaps, the perfect paradigm to examine in this regard.
Back Pain: The Paradigm
There are many ways to deal with patients with back pain. One can employ both operative and non-operative management strategies. Internnal structural support, by way of spinal fusion, may be employed for most patients. Alternatively, an exercise program that strengthens the supporting structures of the spine is very effective in the majority of cases.
In order to effectively deal with the problem of back pain, back pain must first be defined. It is, indeed, not a homogeneous entity, but rather a very heterogeneous disorder consisting of a broad spectrum of poorly defined maladies. These include: 1) overt structural failure, 2) muscle spasm, 3) neurogenic disorders, 4) mechanical back pain and related disorders, and 5) a variety of other less common pathologies. The treatment of overt structural failure and neurogenic disorders are relatively straightforward. Overt structural failure, (e.g., secondary to trauma), is effectively treated by surgical stabilization, external splinting and rehabilitation. Neurogenic complaints and radiculopathy are treated by decompression in many cases and non-operative strategies in others. Muscle spasm and mechanical low back pain are effectively treated non-operatively in the great majority of cases.
The Scope of the Problem
It is with the aforementioned in mind that one must consider the significance of the ‘back pain problem’, as well as its overall significance, in a global manner. Eight of ten people will see a physician for back pain in their lifetime. 93,000,000 work days are lost annually due to back pain. Chiropractors are reimbursed three fold more than neurosurgeons and orthopedic surgeons combined for the management of back pain. Therefore, one might logically conclude that back pain is “big business” and that it behooves neurosurgeons to take a more aggressive posture in this marketplace than they have in the past.
The Charge
Neurosurgeons must educate patients, referring physicians and peers. They must employ active management programs and de-emphasize passive programs. A program that encompasses all aspects of patient care, including cessation of smoking, weight loss, aerobic exercise, and stretching and strengthening exercises (active programs with respect to patient participation) may be implemented. They provide an opportunity for the neurosurgeon to monitor specific aspects of the program. They provide an opportunity for the physician to “contract” with the patient so that the patient and physician are effectively working together to “fight” the enemy – the patient’s back pain. Passive therapy regarding patient participation, such as surgery or narcotic analgesic use, diminishes this opportunity and disengages the patient from ‘therapeutic responsibility’.
The employment of active patient participation treatment strategies provides the neurosurgeon with an opportunity to study the effect of these treatment programs on patient outcome. It provides an opportunity for the neurosurgeon to document the cost of care, the savings provided, and the patient’s satisfaction, as well as the outcome achieved.
A Strategy
One might ask how a neurosurgeon can possibly achieve such goals in a busy practice. A neurosurgeon should consider him or herself as the “captain of the ship” (because he/she knows more about back pain than do other health care providers) and, therefore, the director or employer of mid-level health care providers, primary care physicians and others who help “deliver” the product (a comprehensive back pain management program). In order to accomplish this, alliances must be made between the neurosurgeons and primary care physicians and mid-level health care providers. The neurosurgeon can then function as the overseer of such a management scheme (team). The non-surgeon members of the team can then determine, to a significant degree, the management schemes to be used on a patient specific basis. Only rarely is surgery required, but the neurosurgeon is always in “proximal control” by being positioned as the “overseer” or the “captain of the ship.” This “”proximal control” creates an environment in which all patients are managed similarly. Furthermore, it creates a fixed referral source for surgical pathology, while providing the “complete package” for the customer. It is no longer acceptable to say to the patient “I am sorry I cannot help you (because you do not need surgery).” Rather, the neurosurgeon perhaps should say, “You do not need surgery, but I can provide an alternative management strategy for you.” This appeals to most patients, as well as referring physicians.
Is a neurosurgeon worth 7 ¢ pmpm or 50 ¢ pmpm? Can neurosurgeons demonstrate cost savings, patient satisfaction and optimal outcomes in a comprehensive back pain management program? If the answers to these questions are yes, the neurosurgeon should be able to market him/herself effectively, and be able to effectively compete in capitated and managed care environments.
A neurosurgeon must be able to practice efficiently. He/she must ‘visualize’ and meet the needs of the community by achieving a high and efficient standard of care, as well as by identifying his/her competitors. It is emphasized that these competitors are not just other neurosurgeons and orthopedic surgeons. They include chiropractors, physical therapists, primary care physicians, occupational medicine physicians, and physiatrists.
The Marketplace
Neurosurgeons, have the potential for increasing their market share. However, the neurosurgeon’s status in the marketplace is not clearly defined. Nevertheless, it is evident that the marketplace decline of other specialists, both surgical and non-surgical, is contrasted by the relatively stable nature of neurosurgery’s marketplace status. Neurosurgeons appear to be in a good position to take advantage of the current environment. This may be accomplished by assuming a more aggressive posture regarding patient care. It most certainly cannot be accomplished by retreating.
A Philosophy
As is true for much of surgery, spine surgery, in the majority of cases, is only appropriate if the patient has failed an aggressive non-operative management program. An aggressive and effective non-operative management program leads to appropriately selected surgical candidates. It helps the neurosurgeon adjust to the new and evolving healthcare environment. It provides satisfaction to the surgeon, as well as the patient, and improves surgical outcomes by providing more precisely selected patients for surgery. This, in turn, makes the surgeon more marketable. In addition, it increases surgical volume because the surgeon has an increased market share. Finally, it augments the interest level and enthusiasm of the surgeon. The surgical cases become more rewarding because the pathology is often more striking and more amenable to surgical management. More importantly, the patients’ outcomes are optimized.
Edward C. Benzel, MD Chairman, AANS Professional Development Program Past Chairman, AANS / CNS Joint Section on Disorders of the Spine and Peripheral Nerves