Within the AANS, the organizational activity perhaps least familiar to the average member is the political and socioeconomic arm of the body of neurosurgery. For most members, the important benefits of a national professional society are educational meetings and publications, contact with technical and equipment vendors, casual and professional social contacts, and exposure to new and changing ideas and techniques-and the people who have them. Less obvious, but no less influential in everyday practice, are the laws and regulations governing medical practice; federal program and budget policies; and the economic, professional, and business environment in which practice is embedded. These issues are the focus of neurosurgery’s socioeconomic arm, the Council of State Neurosurgical Societies (CSNS).
The CSNS is the socioeconomic and political interface between the AANS and CNS and their individual members, through representatives chosen at the state level. The CSNS is a delegate assembly jointly sponsored and funded by the AANS and CNS, which meets twice a year as a formal assembly and conducts business on socioeconomic issues.
History of the CSNS
In 1986, the CSNS grew out of the Joint Socioeconomic Committee (JSEC) of the AANS and CNS, expanding a single committee to a delegate assembly with seven subsidiary committees and over 100 elected or appointed delegates. The delegate assembly structure allowed expanded input from neurosurgeons from all geographic regions and types of practice, as well as a means for reaching a democratic consensus on policies or initiatives that impact members’ practices. The CSNS has become a two-way thoroughfare. It gives members with ideas access to fellow members and national organizations to implement their ideas, and it gives organized neurosurgery a forum for communicating their current policies and socioeconomic initiatives with grassroots members.
The CSNS draws membership from each state neurosurgical organization, based on a representation ratio of one delegate per 50 neurosurgeons registered in the state society. Delegates are elected by the state society for three-year terms. The membership basis allows wide and proportional geographic representation, bringing an array of interests and experiences to bear on the debate and decisions made by the assembly. Additionally, representatives appointed by the AANS and CNS, constituting no more than one-third of the total assembly, bring the perspective of each parent organization to the debate, balancing the regional state influence and adding special expertise as the need arises.
Organizational Structure
The CSNS is divided into four quadrants for purposes of regional representation and geographic caucuses. Each quadrant meets as a group at each CSNS meeting to discuss and compare regional, political and practice events over the prior six months, and again at a separate session to caucus over resolutions before the CSNS and discuss how the quadrant wants to support, oppose, or amend the resolutions.
Regional representation on the AANS Board of Directors as the voice of everyday neurosurgical practice was a volatile issue in the mid-1980s, when the CSNS was developed. In response, four Regional Director AANS Board positions were created, mirroring the four regional CSNS quadrants. The Director from each quadrant is elected every third year by the quadrant members, creating between the CSNS and the AANS Board a bond that transcends mere committee-governing body relationships. Furthermore, close ties are maintained between the CSNS and both the AANS Board and the CNS Executive Committee by appointment of the CSNS Chairman as a liaison or ex-officio member of both bodies.
The CSNS underwent a fundamental restructuring of its resolution process five years ago, bringing it out of a labyrinth of often confused debate and a morass of frequently ineffective decisions. The change was a stage in the growtth of the Council, as it learned from past errors. Three key elements made the transformation profoundly effective: 1) required submission of resolutions prior to the assembly meeting (no spontaneous, impulsive motions), 2) a tripartite resolution process, using first a reference committee hearing, second a caucus meeting to review reference committee recommendations, and finally a formally structured parliamentary debate and vote, and 3) involvement of the parent organizations in the deliberation process. The result in eliminating ill-considered or unworkable resolutions and in improving the quality, effectiveness and consensus of adopted resolutions was nothing short of astonishing.
Organizational Actions
By its resolutions and reports, the CSNS has had a substantial and growing impact on both sponsoring organizations and their political policy arm, the Washington Committee. A number of initiatives over the past five years began in the CSNS and found their way into organizational action.
The fellowship accreditation concept grew out of a resolution passed in 1996. It was followed by several surveys documenting resident demand for fellowships, and wound its way through the AANS, CNS, American Board of Neurological Surgery, Residency Review Committee, and currently to the Senior Society, where implementation of fellowship accreditation seems most likely to occur.
Marketing initiatives have surfaced repeatedly in the CSNS over the past decade, resulting in the Getting SMART programs on Lumbar Spinal Stenosis and Stroke. The programs were created in an effort to raise the tide of public awareness of the problems neurosurgeons deal with, whether in spinal disease, stroke, or other conditions, and increase referrals for all neurosurgeons, either by improving recognition of the problem or encouraging appropriate referral of the patient.
The CSNS Workforce Committee has labored for years over studies on the number of neurosurgeons, how many are needed, and how many are being trained. Several publications analyzing neurosurgical workforce supply and estimating future demand have grown out of committee studies in the past five years. Its most recent report, reviewing a series of surveys over a five-year span, exposes a relative undersupply of neurosurgeons caused by a virtual explosion of technical neurosurgical capabilities and patient demand for specialized services.
A new CSNS Neurotrauma Committee was formally created this year, after several years of ad hoc activity researching the socioeconomic aspects of trauma care. The committee has created liaison relationships with the AANS/CNS Section on Neurotrauma and Critical Care, bringing consideration of legal and reimbursement issues alongside more typical scientific and practice experience information.
Expanding Role of the CSNS
The CSNS has taken on an increased role in socioeconomic educational responsibilities. Four years ago, a series of seven videotapes were created as basic educational sources on a variety of socioeconomic topics, including medicolegal, managed care, and practice management. Subsequently, the CSNS has taken on several new educational responsibilities. It now arranges a one-and-a-half-hour socioeconomic symposium at the Plenary Session of the AANS Annual Meeting that features a nationally recognized speaker, coordinates an afternoon Socioeconomic Section Session for submitted abstracts at the CNS, and organizes an AANS Breakfast Seminar on practical practice management strategies.
It also serves as a resource for articles for the AANS Bulletin, with its new socioeconomic format, and fulfills an Associate Editor’s responsibility for the new publication CNS Neurosurgery News. A new CSNS standing committee, the Communications and Education Committee, was created last year to meet these responsibilities.
Several years ago, the CSNS found itself wwith committee projects to research, but lacking funds to do so. The CSNS voted to create a voluntary state assessment of $250 per delegate per year to establish a fund for the Council’s discretionary use outside of normal operating expenses. The response from states has been encouraging, but not universal. Out of those funds, the CSNS now finances committee research projects, shares the costs of the AANS Socioeconomic Symposium speaker, and supports two new awards for the best resident and best young neurosurgeon socioeconomic topic presentations at the CNS Socioeconomic Session.
Commitment to Young Neurosurgeons
The CSNS has reached out beyond its traditional members in the past several years to try to encourage participation by young neurosurgeons. The CSNS Young Neurosurgeons Committee (created nine years ago) has been hugely successful in involving new participants in the CSNS processes and propelling several young neurosurgeons into positions of leadership in the organization.
This past year, the CSNS created a resident delegate position for each quadrant and obtained funding for meeting attendance from outside sponsorship. The involvement of residents early in their career is important to bring a balanced perspective to the CSNS, to better educate youthful neurosurgeons about political and practice issues never encountered in training, and to develop a cadre of future leaders knowledgeable, conversant and active in socioeconomic affairs. n
For more information on the CSNS, contact Lyal G. Leibrock, MD, Chair of CSNS, at (402) 559-4301 or via e-mail at [email protected].
This is the first in a series of articles that highlight an AANS Committee or Task Force and the important work these volunteer groups perform on your behalf.
James R. Bean, MD, a private practice neurosurgeon in Kentucky, is Past-Chair of the CSNS and Associate Editor of the AANS Bulletin.