The Horizon’s Aglow With Promise, but Clouds Loom
| The specialty of neurosurgery emerged as late as 1919 with the realization that special training was required in addition to that of the general surgeon. Expanding on the same general principal and driven in large part by advances in research and technology, several neurosurgical subspecialties have emerged since that time: cerebrovascular surgery, neurotrauma and critical care, pain management, pediatric neurosurgery, surgery of the spine and peripheral nerves, and stereotactic and functional neurosurgery.
The Bulletin invited representatives of neurosurgery’s subspecialties to provide their personal perspectives on the outlook of the neurosurgical workforce over the next 10-20 years with regard to their respective areas. Each was asked to consider these questions:
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Cerebrovascular Surgery
Warren R. Selman, MD
The dynamic nature of the field of cerebrovascular surgery is evidenced by the sustained growth experienced by the AANS/CNS Cerebrovascular Section over the past 15 years. The section currently has 591 active members, and the AANS census indicates that about 25 percent of AANS neurosurgeons list cerebrovascular surgery as their primary, secondary or tertiary subspecialty.
One of the driving forces behind the growth of cerebrovascular surgery is that stroke continues to be a major healthcare concern. It is estimated that more than 700,000 individuals will suffer a stroke each year, and stroke remains a leading cause of loss of independence in adults. As the population ages, it is estimated that the impact of stroke will be even greater in the future. Balanced against this is the development of new therapies designed to treat and prevent strokes.
These new technologies initially engendered concern that the role of neurosurgeons in the treatment of cerebrovascular disease would be eliminated. In the article “Endovascular Treatment for Cerebral Aneurysms Will Replace Clipping,” DeWitte T. Cross III, MD, stated, “It is only a matter of time before traditional vascular neurosurgeons performing craniotomies and clippings of cerebral aneurysms will be as quaint and endearing as the Amish driving their horses and buggies on the interstate highways of Pennsylvania.” I am reminded of Mark Twain’s famous observation, “The report of my death was an exaggeration.” The distinction that must be appreciated here lies in the definition of the “traditional vascular neurosurgeon.” The “traditional vascular neurosurgeon” of the future will be skilled in all the techniques needed to treat the entire gamut of cerebrovascular disorders and will be viewed as anything but “quaint.”
It is clear that the need for neurosurgeons with microsurgical cerebrovascular expertise will remain strong. Nonetheless, it would require an ostrich-like view to believe that new technology will not affect the scope and practice of neurosurgeons in the treatment of cerebrovascular disorders. Neurosurgeons must possess all the tools needed to treat patients with cerebrovascular disorders, or find their role marginalized in ways that few would find acceptable.
Fortunately, the trend already is clear and more neurosurgeons are acquiring endovascular skills. According to the AANS Census, the number of neurosurgeons with endovascular skills continues to grow. In several training programs, vascular access and basic endovascular skills are already part of residency training. As proficiency in both microsurgical and endovascular technique becomes second nature, the dichotomy between practitioners of each treatment will disappear. In the future, the neurosurgical cerebrovascular specialist will be identified by the disease and the patient treated, not by the technique employed.
There is no question that the allure, availability, and in some cases, the advantages of “minimally invasive” techniques affect patient flow and decision-making. The cerebrovascular specialist of the future will be required to have all the tools available to treat all forms of cerebrovascular disease, or may be left waiting for others to decide when and if to refer a patient. With this understanding, the need for neurosurgeons who specialize in the treatment of cerebrovascular disease will remain strong, and neurosurgeons will continue to find fulfillment in treating patients with cerebrovascular disease.
Warren R. Selman, MD, is chair of the AANS/CNS Cerebrovascular Section, and director of the Cerebrovascular Center/Center for Stroke at University Hospitals of Cleveland.
Neurotrauma and Critical Care
Donald W. Marion, MD
According to data published by the Centers for Disease Control and Prevention, 1.5 million people sustain traumatic brain injuries each year, 50,000 die from their injuries, and 80,000-90,000 experience prolonged or lifelong disability. In 2001 traumatic brain injury caused 3,000 deaths and 29,000 hospitalizations for children age 14 and younger. Brain injuries remain the leading cause of death and disability for people in the United States between the ages of 1 and 45.
But the availability of neurosurgical care for these people may be deteriorating. Today far fewer neurosurgeons are taking emergency call. Increasingly, hospitals are complaining that they have a difficult time obtaining neurosurgical coverage. The underlying problems are insufficient numbers of neurosurgeons and their frequent on-call schedules combined with little or no reimbursement in return either for time on call or for the resulting lost income from their own practices. Neurosurgical practice opportunities are frequently advertised with the enticement that there will be little or no trauma call. While the AANS/CNS Section on Neurotrauma and Critical Care worked hard to develop and publish a position statement endorsing reasonable stipends for providing on-call service, it seems increasingly apparent that reimbursement for trauma care is not as important to many neurosurgeons as spending more time with family and other quality of life issues.
This is particularly a concern for the next generation of neurosurgeons. Neurosurgeons just finishing their residencies increasingly are choosing spine or other neurosurgical subspecialties that they think will reduce their on-call obligations. Further, the new 80-hour workweek restriction for residents threatens to persuade neurosurgical trainees that their careers will not involve more than this amount of time each week.
These are all very difficult workforce issues which must be resolved to the satisfaction of the trauma centers, trauma surgeons, and neurosurgeons.
Some in the neurotrauma community are promoting the concept of “regional neurotrauma centers.” Concentration of patients with severe traumatic brain injury at one hospital can make sense in larger communities where the covering neurosurgeons could be fellowship-trained trauma neurosurgeons who would be most equipped to provide consistent, high quality, cutting-edge care. The volume of patients cared for at such centers would allow for large clinical trials. Such centers could develop fellowship programs in neurotrauma and truly promote this subspecialty. However, there also are concerns that such regionalization would risk the potential for prolonged transport of patients with time-sensitive intracranial hematomas. Also, general trauma surgeons would likely view regional neurotrauma centers as encroaching on their livelihood.
In rural communities neurosurgeons may find it appropriate to expose select general surgeons to the basics of performing a trauma craniotomy and develop close relationships with those surgeons who live in rural communities where a neurosurgeon is unavailable. A teleradiology linkage could allow a neurosurgeon to direct the rural trauma surgeon during a lifesaving cranial procedure.
The responsibility of caring for emergent neurosurgical patients must be instilled early during neurosurgical training. The Society of Neurological Surgeons should review its curriculum requirements for training programs and attempt to ensure that residents are taught the ethical responsibilities of their profession. Neurosurgeons must also play a greater role in the planning of regional trauma systems. They must make themselves available to sit on committees planning the development of new trauma centers and the recertification of existing trauma centers.
It is not reasonable for a neurosurgeon to be required to take call every other night, but taking some call is a part of being a good physician and good surgeon. The Trauma Section supports stipends for trauma call that are reasonable, but they should not be excessive. Finally, neurosurgeons must recognize that theirs is the specialty that is most equipped and most capable of providing high quality care to the patient with traumatic brain injury. We must not abdicate our role in treating the most important cause of trauma-related death and disability.
Donald W. Marion, MD, is chair of the AANS/CNS Section on Neurotrauma and Critical Care, professor and chair of Neurosurgery at the Boston University School of Medicine, and chief of Neurosurgery at the Boston Medical Center.
Pediatric Neurosurgery
Andrew D. Parent, MD
Pediatric neurosurgery is a small subspecialty that focuses on the evaluation and surgical management of congenital and pediatric problems. The recent AANS demographic census of neurosurgical subspecialties suggests that more than 30 percent of all U.S. neurosurgeons consider pediatric neurosurgery to be one of the subspecialties that they practice. On the other hand, only 264 neurosurgeons belong to the AANS/CNS Section on Pediatric Neurosurgery, while the more formally focused American Society of Pediatric Neurosurgeons records only 175 members, of whom 114 currently practice in the United States.
Despite these small numbers, an informal survey of the employment advertisements in medical journals seeking pediatric neurosurgeons during the past year reveals that approximately 40 positions were available and that many of those positions were in academic practices. Most of these advertisements solicited fellowship-trained pediatric neurosurgeons, but only 23 fellowship training positions currently exist in North America, and less than half of these positions were filled last year.
These estimates suggest that not enough pediatric neurosurgeons are being trained. Furthermore, during the next five years the first generation of pediatric neurosurgeons will begin to retire, causing roughly a 20 percent decrease in the pediatric neurosurgical workforce.
During the last decade, pediatric neurosurgery adopted new therapies that include endoscopic third ventriculostomies, baclofen pump insertions for spasticity, and recent advances in pediatric epilepsy surgery. Obviously, the demand for specialists trained in these techniques exceeds the number that is being trained. In the future, new therapies (such as deep brain stimulation, neuroaugmentation surgery, and, conceivably, genetically engineered procedures) might further strain our present workforce.
Other factors strain the subspecialty as well. It is unclear precisely how many pediatric neurosurgeons have altered their career paths for professional satisfaction, family or lifestyle considerations, a more financially lucrative practice in neurosurgery, or a more compatible locale. Medical liability pressures also negatively impact pediatric neurosurgeons. Depending on the state, medical liability exposure may extend from the current age of the child to 21 years plus two years to allow for discovery, and in some cases, general neurosurgeons are dropping pediatric privileges.
Despite these strains, which have contributed to a steady attrition in the workforce, pediatric neurosurgeons continue to practice productively because they are dedicated to children’s neurosurgical care. The everyday spectrum of procedures includes recurrent shunt malfunctions, spinal dysraphic defects, and pediatric neoplasms, as well as pediatric trauma that too often is the result of child abuse.
Pediatric neurosurgeons uniquely interact not only with parents but also with school systems, social workers, and pediatricians, following patients over many years. This characteristic commitment of caring for patients in the long term is especially time-intensive and almost always requires a group practice.
Andrew D. Parent, MD, is chair of the AANS/CNS Pediatric Section and professor and chairman of Neurosurgery at the University of Mississippi Medical Center.
Stereotactic and Functional Neurosurgery
Jaimie M. Henderson, MD
As a subspecialty, stereotactic and functional neurosurgery has experienced steady growth in recent years. The advent of image-guided surgical techniques, the resurgence of interest in surgical treatment of movement disorders, and the burgeoning applications for neuroaugmentation have led to an increase in the number of surgeons with an interest in this area. The recent meeting of the American Society for Stereotactic and Functional Neurosurgery attracted the most attendance in its history, and abstract submissions likewise increased by 50 percent. Further, a glance through the classified ads in Neurosurgery and the Journal of Neurosurgery shows that a growing number of practices are looking specifically for neurosurgeons with expertise in stereotactic and functional neurosurgery. Is neurosurgery prepared to meet the growing demand in this subspecialty area?
Although no firm figures are available, there are an estimated 10-12 programs in North America with formal, structured fellowships in stereotactic and functional neurosurgery. It appears at the present time that the supply of graduates from these programs is equal to or greater than the demand.
In most private practice settings, functional neurosurgical procedures make up a relatively small percentage of cases compared to spine or general cranial operations. In some communities, neurosurgical practices have met requests to provide services such as deep brain stimulation for Parkinson’s disease by designating one of the general neurosurgeons in the practice to perform these procedures. By and large, these neurosurgeons approach the task of learning functional techniques conscientiously, and under most circumstances can probably achieve reasonable, if not optimal, outcomes. However, specific fellowship training in stereotactic and functional neurosurgery can expose surgeons to a range of difficulties and problems, allowing them to develop troubleshooting skills in a controlled, monitored environment. Although it has not been rigorously studied, one would expect that this additional training would lead to better outcomes, especially given how dependent these outcomes are on the complexities of proper anatomical and physiological localization.
One of the key issues now being faced by stereotactic and functional neurosurgeons is reimbursement, both for professional fees and for the equipment that is increasingly becoming an integral part of our practice. Within 10 years, sophisticated chronic electrode systems will allow unprecedented access to many different parts of the cortex and a whole host of subcortical structures. Working on the assumption that today’s science fiction is tomorrow’s science fact, there is no technical reason that augmentative brain implants could not become as widespread as many other types of implants are today. Great scientific strides have already been made in neural interfacing and in new targets for neurostimulation, but so far there has been little planning for the economic impact of a growing number of implantable devices. As deep brain stimulation for Parkinson’s disease has become a standard treatment, hospitals and neurosurgeons are finding that reimbursement, both from the federal government and private insurers, in many cases cannot keep pace with the high cost of providing these services. Neurosurgeons need to take a proactive stance to be certain that the incredible technology now being developed in the laboratory and in initial clinical trials becomes available to the intended recipients, our patients.
In the end, workforce issues in stereotactic and functional neurosurgery will revolve around the willingness of government, insurance companies, and patients to pay for new technology, and the willingness of manufacturers to stimulate the growth of this field by keeping their devices affordable. If current trends continue, neurosurgeons and hospitals will be unable to financially support the applications of new technology, and stereotactic and functional neurosurgery will be relegated to “hobby” status for most neurosurgeons. If, on the other hand, the success of the spine surgery community can be emulated in making certain that the devices are covered by patients’ insurance and the surgery is adequately reimbursed, then the growth of stereotactic and functional neurosurgery specialty could be dramatic, forcing a reevaluation of the workforce available to deliver these services to our patients.
Jaimie M. Henderson, MD, is associate staff in the Department of Neurosurgery and Functional and Restorative Neurosciences Center at the Cleveland Clinic Foundation.
Tumors and Neurosurgical Oncology
Raymond Sawaya, MD
A vast array of oncological disorders affects the nervous system of hundreds of thousands of individuals each year in the United States. Historically, neurosurgeons were called upon to evaluate or treat most patients with a primary brain tumor, and a limited and select number of patients with a single metastatic tumor to the brain. Through improvements in training, surgical techniques, and technologies, neurosurgeons have had a greater impact on the survival and quality of life of a much wider spectrum of patients, including those with multiple brain metastasis, skull base tumors, primary and metastatic spinal and sacral tumors, peripheral nerve tumors, and cancer-related medically refractory pain disorders. To this list one must add the equally challenging number of patients whose tumor recurs or whose nervous and/or skeletal system suffers from the side effects of therapy and requires neurosurgical intervention or care.
Traditionally, the basic training of neurosurgical residents was sufficient to meet the needs of the population relative to the level of expectations of the time. The dramatic explosion in our understanding of cancer biology, coupled with the technological advances in imaging and in intraoperative instrumentation, has led to a shift in expectations: The neurosurgeon is now expected to provide greater good with lesser morbidity. Such heightened levels of performance require specialized training and focused experience in neurosurgical oncology. It is not surprising, therefore, that most neurosurgical training programs have recruited or are seeking to recruit at least one faculty member whose specialty area is oncology. In recognition of the need for trained neurosurgical oncologists, the Society of Neurological Surgeons is imminently expected to approve a document on the accreditation of neurosurgical oncology fellowship training programs.
The practice of neurosurgical oncology is one that demands technical, biological, and interpersonal skills. The disorders that require a neurosurgical oncologist’s intervention consume substantial amounts of time at all levels of the physician-patient interactions and in particular in the operating room. My own estimation over one year of the average duration per case of all neurosurgical procedures in one comprehensive cancer center is 5 hours 15 minutes. To this figure one must factor in the added time required to inform and guide the patient and the family members in selecting the most suitable form of intervention or therapy, and if a clinical trial is under consideration, the time requirement is possibly doubled.
In the final analysis, a neurosurgical oncologist is a central figure among the group of individuals that comprises the modern multidisciplinary team. Without the leadership provided by such an expert, accurate diagnoses, gross total resections, adequate reconstructions, and functional recoveries would not be maximized, and the progress experienced in molecular oncology would not be matched by progress in the delivery and the outcome of the therapies. These are exciting times, and neurosurgery as a specialty is up to the task.
Raymond Sawaya, MD, is chair of the AANS/CNS Section on Tumors, and professor and chair of Neurosurgery at MD Anderson Cancer Center in Houston, Texas.