The development of neurological surgery from its roots at the turn of this century to the present can be defined in catastrophic theory. Most hold now that the rapid changes which have influenced neurological surgery were initiated by the Medicare legislation in the mid-1960’s and the faulty implementations of the Great Society program later in that decade. Those actions led to an unbridled increase in medical training, technological advancements and access to medical care as will never again occur in our lifetimes. The cumulative effects might be analogous to the building of pressure in Mount St. Helens and its sudden explosion.
When one views this invaluable evolution, marveling at the billions of dollars that have been spent for MRI scanners, Gamma and Linac radiosurgical equipment, virtual reality real-time neurosurgical operating theaters, spinal instrumentation and basal skull surgery, and is able to put into perspective the pressures these have evoked on the economy, it is not difficult to understand the origin of the catastrophe of managed care.
Such discontinuous events have so frequently led to despair that the real opportunities presented by change go unrecognized by the uninformed. The wanton profits gleaned by aware executives of Corporate America in the very rapid transition of medicine from fee-for-service to its ultimate capitation basis can be but one small example of these opportunities.
Socioeconomic Education
If today’s neurological surgeon continues to look at current events as a breach of contract on the part of society in the lack of realization of the material rewards of delayed gratification, then disillusionment and dejection will be the likely result. If one can go beyond the tangible rewards, however, opportunities might more easily be recognized.
Business and entrepreneurial activities could not have been the driving force behind decisions to enter neurological training years ago, even for those just entering practice. Such motivation is anathema to most practicing neurosurgeons. Therein lies one of the opportunities: expanded education to include needed business acumen and management of resources.
Your association has maintained its mission of providing quality neurosurgical care by addressing the education of its members, promoting aggressive interaction with outside agencies, encouraging research in neurosurgery and enlightening the populace in prevention of trauma. The initiation of hand-on courses in spine, basal skull surgery, stereotaxis and endarterectomy was met by serious concern on the part of well-meaning individuals who believed this was not the function of your association. The success of these educational opportunities, albeit with the recognition of some abusive practices, attests to the foresight of the leaders who were forced to “take the heat” for that decision at that time.
Similar imputation has been leveled by those who believe the association should not be involved in education about managed care, such acknowledgment being tantamount to endorsement. Coding and managed care teaching programs have allowed neurosurgeons the ability to work within the system, unpleasant at best, so as to maintain economic practice stability. Caution must always be present, however, so that this association, dedicated to education in neurological surgery, the principles of caring and the identification of opportunities to encourage fertile minds to seek new methods and avenues of technology, not become a guild or trade union. The enrollment of the Canadian and Mexican neurological surgeons into the fabric of your association, and your strong participation in the World Federation of Neurological Surgeons, gives full recognition to the immense resources available in neurological surgery outside North America. There should be little concern, then, that educational efforts in matters of such parochial interest would eclipse neurological education in favor of formation of such a guild, since these have little interest in socioeconomics.
Your association should not be looking at survivability, but rather enhanced viability, in maintaining operations on the brain, spinal cord, their support structures and distal elements as the single most exciting specialty in medicine today and in the future. Careful balance must be achieved in guarding against neurological surgery becoming only a business, while being practical in recognizing the effects of competition invoked by Corporate America, other segments of medicine and ourselves. Our initial training and continued education in neurological surgery must be done not only well, but better than our competition.
Opportunities for new sources of funding for basic and clinical research must be identified if we expect to add weapons to our armamentarium of competition and excellence.
We must continue to educate each other in the avoidance of liability by increased use of new forms of communication, documentation and the rapid recognition and acceptance of alternative methods of care.
Personal Opportunities
Other opportunities afforded by this change must include assessment of personal worth. Evaluation of individual education, financial expenditures and sacrifice to attain the title of neurological surgeon must be an integral part of the equation. Decisions that have a tendency to denigrate worth include those based on the tenuous merit of specific numbers of surgical procedures to maintain expertise, the fear that not offering services for less than value would encourage others to impact upon those numbers, and the fragile delineation of expectations for personal life style.
Insecurity about the future might be countermanded by accepting opportunities to participate in personal outcomes measurement, establishment of efficient patterns of practice and identification of medical necessity through guidelines. The realities of preservation of the extremes of life and the impact on families and society need not have elitist connotations. The opportunities to further clarify the benefits of prevention, especially in trauma, and the expense to society in ignoring these must be a very substantial part of this new medicine.
Perhaps an unintended opportunity would be increased awareness of personal time, family life and evaluation of priorities. For a time, retirement and relocation will be opportunities offered to some by managed care. For those few whose expectations and fantasies about neurological surgery have not been realized, the opportunity to change course, to retrain in another area of medicine or to enter a new field, even business, might be a welcome one.
Your association will continue its unceasing efforts in damage control and shaping of change. It will not lose sight though, of its fundamental reason for being: the education of neurosurgeons in every aspect of their profession, and continued recognition of opportunities leading to successful and fulfilling practices, even in these precarious times.