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| Newsletter Editor Edward Vates, MD, PhD Assistant Editors Matthew J. McGirt, MD Jay Jagannathan, MD Henry Aryan, MD Ben Newman, MD J. Bradley Bellotte, MD Shervin R. Dashti, MD, PhD Sarah Woodrow, MD, MSc, Med Eve Tsai, MD, PhD Officers Brian Subach, MD Jonathan Friedman, MD Edward Vates, MD, PhD |
Brian R. Subach, MD, FACS
Duty Hours and Neurosurgical Education
G. Edward Vates, MD
2008 Young Neurosurgeons Committee Silent Auction
Matthew J. McGirt, MD
Washington Committee Report
Jonathan Friedman, MD, YNC Vice-Chairman
Jason Huang, MD
Third Annual Neurosurgical Top Gun Competition
Michael Oh, MD
2008 AANS Annual Meeting - Welcome to Chicago!
William W. Ashley, Jr., MD, PhD, MBA
Remembering Dr. Sam Hassenbusch
Catherine Jeakle Hill, Senior Manager, Regulatory Affairs, AANS/CNS Washington Office
How We are Supporting the Best and the Brightest Medical Students in Neurosurgery
Eve Tsai, MD, PhD
Medical Student Summer Research Fellowship Program
Career Fairs
Resources for medical students
Medical Student Courses
Mentoring
Cerebrovascular Section Looking for Help with Its Website
G. Edward Vates, MD
Chairman's Message
Brian R. Subach, MD, FACS
Welcome to the Young Neurosurgeons Committee newsletter. I first became involved in the YNC more than 10 years ago and have watched the committee grow in both numbers and responsibilities. Initially, this committee was developed as a means of getting residents, and neurosurgeons newly entering practice, involved in the AANS. You may realize that our organizations (AANS, CSNS, Sections) are relatively small but extremely complicated in administration. Perhaps the greatest barrier to getting new blood into these organizations was the absence of a group solely dedicated to the concerns of the most energetic part of neurosurgery: our youth. Now one of the greatest hurdles we face is finding enough chairs for committee meetings or enough sandwiches for the Young Neurosurgeons Luncheon. All kidding aside, the AANS Board of Directors had given us tasks and charges to which we have responded with entirely new ideas, thoughts and plans. The YNC membership is an exceptional, brilliant and motivated collection of surgeons, elected initially as individuals, now functioning as a team.
Did you know that the Marshals at the national meetings are organized by our group? Who do you think does all the calling to find donors for the NREF Silent Auction and occasionally drives objects across a national border in a questionably legal maneuver? The Top Gun program was not an idea bought on eBay. It came from one young neurosurgeon with a dream. Did you realize that we publish a semi-annual newsletter, conduct Real World courses at the national meetings and educate medical students about our lives and our profession? These tasks are accomplished by the hardest working group of people that I know and furthermore accomplished in their spare time. Why you ask? Because it matters to the future of our specialty. It matters to our survival. Quite simply, it matters. If we, as the youth of neurosurgery, do not care to dedicate ourselves to worthwhile pursuits and causes, who will?
They say that a good leader appears as such by surrounding himself with people smarter than he is. In my attempt to be a good leader, I am fortunate to be surrounded by outstanding people. I would ask that you strongly consider joining this group. Whether as an elected member or volunteer, get involved. As our achievements continue, our tasks and responsibilities continue to grow exponentially. Whatever your talents or interests, I guarantee there is something rewarding available for you. Consider this question: What have you done with your past decade that has made a difference in the future of neurosurgery? Or, perhaps more importantly, what can you help us to accomplish in the next?
I am fortunate to be surrounded by outstanding people. I would ask that you strongly consider joining this group. Whether as an elected member or volunteer, get involved. As our achievements continue, our tasks and responsibilities continue to grow nearly exponentially. Whatever your talents or interests, I guarantee there is something rewarding available to you. Consider this question: What have you done with your past decade that mattered to the future of neurosurgery? Or, perhaps more importantly, what can you accomplish within your next?
Duty Hours and Neurosurgical Education
G. Edward Vates, MD
 We all know how much it hurts to be working at three in the morning…you’ve
been on call, a sick patient (or a cascade of them) has kept you up all
night, there’s still more work to be done, and you know that it
has to be “the wee hours” the morning because you feel the “creeping
chill” of sleep deprivation, that unshakable sense that you’re
cold and slowing down and you’re making a superhuman effort to keep
your eyes open and stay on task. That feeling sucks; it’s like having
the flu and you just want to stop, lie down, and go to sleep (or maybe
just die).
But you can’t because the patient you just admitted with traumatic intracerebral contusions needs an EVD and if you don’t place it, that patient will herniate and die, and the nurse isn’t going to put in the EVD. Or maybe the patient you operated on for a thoracic meningioma at 5 pm the day before has accumulated an epidural hematoma, and what was a satisfying case has transformed into an emergent thrash because that patient has developed paraplegia. Or maybe the patient you operated on for a fusiform giant middle cerebral artery aneurysm (a 10-hour case requiring a microanastamotic bypass to the distal MCA branches, trapping of the aneurysm, aneurysmorrhaphy, proximal MCA clip reconstruction to preserve the origin of lenticulostriate perforators, with neuromonitoring and intraoperative angiography) has developed swelling and needs their bone flap taken out. In other words, the work needs to be done, and you are the person to do it. Surgical pathology never heard about the 80-hour work week, these are your patients, and you are the one best qualified to fix the problem. I remember those days from my residency, and I face the same problem of sleep deprivation as a young neurosurgeon in practice. Do I have residents who buffer me sometimes from early morning interruptions? Yes, but they don’t work at every hospital I cover, they can’t do the surgeries without my guidance and physical presence, and as an academic neurosurgeon I am in the minority; most neurosurgeons practice in community settings where there is no buffer. Four years ago, I wrote an editorial for the ACGME Bulletin entitled “Teaching Professionalism in 80 Hours: Recipe for Failure” (http://www.acgme.org/acWebsite/bulletin/bulletin02_04.pdf, p. 18). At that time, all of academic medicine was wrestling with the new resident duty hour requirements. As the resident member of the Neurosurgery RRC, I was concerned that while the new system made some necessary changes to training, it also undermined what made neurosurgery a profession, not a trade. “Do whatever it takes to do the right thing for the patient” still rings in my ears. My surgical mentors drilled this dictum in my head, and it is something that I try to instill in my residents. Four years later, the consequences of the resident duty hour requirements are still rippling through neurosurgery education and practice, but now the Institute of Medicine (IOM) is questioning whether 80 hours is still too much. On December 3, 2007, and March 4, 2008, the IOM held two workshops on the topic “Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety”. Two more workshops are planned on May 8 and June 26, and a committee has been charged with synthesizing current evidence on medical resident schedules and healthcare safety, and developing strategies to enable optimization of work schedules to improve safety in the healthcare work environment. The goal is to develop recommendations that will be structured to optimize both the quality of care and the educational objectives. This is an offshoot of IOM work on medical errors that started with the much discussed report “To Err is Human”. You can check out the public information that has been offered at these meetings at the IOM Web site (http://www.iom.edu/CMS/3809/48553.aspx). If you look through the proceedings of Public Meeting #1, the direction of this process is clear enough (although the IOM Web site cautions that drawing conclusions based on the material available is “premature”). Eighty hours is too long for residents to be working, and resident duty hours should be restricted to 56-60 hours per week in accordance with what has been enacted in the European Union (where resident duty hours will be further restricted to 48 hours/week in 2009). Participants at Public Meeting #1 included sleep physiologists who have published extensively about the effects of sleep deprivation on house staff errors and driving accidents, and representatives from the American Medical Student Association (AMSA), the group Public Citizens, and the Committee of Interns and Residents (CIR), organizations that have long advocated for federal legislation regulating resident duty hours. Fortunately, the ABNS and the Society of Neurological Surgeons (aka the Senior Society, the organization of neurosurgery chairs and program directors) were given the opportunity to make a presentation at the IOM. The chair of the ABNS, Hunt Batjer, MD, FACS, presented the viewpoint of organized neurosurgery at the second public meeting. You can download his presentation from the IOM Web site (http://www.iom.edu/CMS/3809/48553/50950/51031/52255.aspx). It presents an eloquent and evocative rationale for why further work hour restrictions would be devastating to the education of the next generation of neurosurgeons. What follows is my very personal take on the issues, after having served on the RRC, and after reading Dr. Batjer’s presentation along with a lot of the sleep literature and other presentations from the IOM meeting process. I provide this to stimulate the readership of the Young Neurosurgeons Newsletter to action. Point #1: Neurosurgery is different, and so are neurosurgeons. It is the incredible combination of working in hallowed ground and helping people in dire need that resonated with me in the same way that Harvey Cushing once described: “If a doctor’s life may not be a divine vocation, then no life is a vocation, and nothing divine.” This is why I worked so hard to get into a neurosurgical residency, it’s why I worked so hard as a resident to develop the technical skills and personal stamina required to be a neurosurgeon, and it’s why I continue to work so hard for the benefit of my patients and my profession. Reflecting on my journey, I have concluded that neurosurgery is different from any other specialty of medicine, and that neurosurgeons are also different. When I was making my choice to be a neurosurgeon, I inevitably went through a process of internal reflection and questioning: am I going to be happy as a neurosurgeon? Do I have what it takes to be personally satisfied and do well for my patients? I see the same process playing out in the medical students that I advise, and I always tell them the same thing…if you can be just as happy doing something else, do that other thing, because neurosurgery is more demanding than almost any other specialty in medicine. If you can’t imagine being as happy unless you’re a neurosurgeon, then welcome to the family. Neurosurgery’s unique demands and the process of self-selection that neurosurgery residents go through before they embark on their neurosurgical training are completely overlooked in discussions about resident duty hours. These discussions assume that all doctors are endowed with the same interests, the same skill sets, the same endurance, and that all fields of medicine make the same demands. At a superficial level, the IOM process has conceded that surgeons may face special challenges, and they have invited surgeons like Dr. Batjer to participate in the public discussions being held, but most of the literature on sleep deprivation and resident duty hour limits has not reflected this distinction until recently, and there is no literature looking at the impact of resident duty hours on neurosurgical resident performance or success in practice. Dr. Batjer emphasized this point in his presentation to the IOM, but it needs to be constantly reinforced and explored systematically. Other medical specialties may not like hearing it, because it can be interpreted as an insult to their importance or skills, but nothing could be further from the truth. I am thankful that there are people who love pediatrics, OB/Gyn, and family practice, and I have limitless respect for the patience, knowledge, and dedication they bring to their specialty and patients, but it is simply illogical to assume that all specialties face the same challenges from the pathology they treat. By extension, the treating physicians need different skills and levels of physical endurance. Other specialists in medicine just don’t get it, and as neurosurgeons make up a shrinking percentage of medical practitioners, we risk being drowned out by the rising tide of voices calling for reductions in resident duty hours. Point #2: This is a problem that started in medical schools. You assumed that a wrong answer would give rise to a warm and nurturing response by the attending surgeon who asked a question. Your errors of thought and action were met with gentle kindness and the softest of educational caresses. This approach, I am sure you now agree, turned out to be a lethal educational mistake. Surgical pathology is unforgiving. It can hurt your patient (and you) in ways you cannot imagine. You should fear making errors and should steel yourself to the harsh realities of a life in surgery…Many surgical programs are trying to provide a nurturing educational atmosphere delivered in a non-threatening manner taking into account your psychosocial and ethno-cultural background. Because of this philosophy, the attending surgeon who holds you to an objectively high standard through rigorous demands is accused of eroding your self-esteem. Please remember that a shielded surgical graduate who has been protected from the vicissitudes of surgical life is a weak graduate and ultimately a weak surgeon…the product of prioritizing self-esteem over basic surgical knowledge is a graduate who feels great about knowing nothing. The culture of medical education has been corrupted, and the Socratic method is now called pimping or harassment; faculty are supposed to be friends, not taskmasters. As a consequence, medical schools routinely turn out graduates that no longer embrace the culture of sacrifice and dedication that has been the basis of American medicine since the time of Osler and Cushing. This culture shift has worked its way into residency training, and into the regulatory bodies that are charged with maintaining standards of post-graduate medical education (i.e., the ACGME), but this incessant lowering of standards needs to stop. Consider a report from 2001 that attempted to document the effect of disturbed sleep patterns on psychomotor skills in surgeons. This paper (Grantcharov, TP, et al., [2001] Laproscopic performance after one night on call in a surgical department: prospective study. BMJ 323:1222-1223) looked at how surgical trainees in Denmark performed on a laparoscopy simulator after a night on-call with a maximum of three hours sleep. The study showed that the time to complete the simulator task, the number of errors, and the number of unnecessary movements were all increased by disturbed sleep. While this is interesting, what is more interesting is their selection criteria for the house officer subjects: they had all been in post-graduate training for a median of 6 years (range 1-11), and all had limited training in laparoscopic procedures (median of ZERO). This tells me two important things: 1) training of surgeons in Denmark is woefully inadequate if post-graduate surgical trainees have done ZERO laparoscopic procedures after 6 years (resident duty hours are already limited to 48 hours in Denmark), and 2) your ability to acquire new psychomotor skills may be impaired by disturbed sleep, so you better already have those skills under your belt before you have to do them at 3 am in the morning. The ability to be a high-functioning, nimble, quick-witted neurosurgeon at all times does not develop overnight. It develops through hard work, repeated skill development, and acquisition of tolerance to work under the extreme demands made by our patients and their problems, with appropriate supervision by surgeons who already have those skills. If you want to train for the Olympic marathon, do you run only 2-3 miles daily, taking breaks for weekends and holidays, and then show up on race day thinking you’re going to finish the race? Obviously not, and in the same way you can’t learn to be a neurosurgeon, capable of completing 14-hour cases, taking call and then seeing patients in the office the next day until you have developed the psychomotor skills and stamina that make this possible. For this reason, I would propose that we stop referring to time spent by residents in hospital as “duty hours.” There has been a sufficient change in the culture of resident education that the term duty hours is no longer relevant in describing the time that residents spend in the hospital. I suggest we call them resident education hours, because the time that residents spend on task, honing patient care and technical skills, is time spent learning to be a neurosurgeon. Makes a difference in the debate, doesn’t it? If we don’t stop the lowering of standards that has worked its way up from medical school into postgraduate residency education, then our entire profession is at risk. The bar will continue to slip, and the practice of neurosurgery will become impossible because regulations will mandate that fully boarded neurosurgeons cannot work for more than 12-16 hours at a stretch. Our profession will be reduced to a trade of shift workers delivering suboptimal care to patients who no longer respect their surgeons because really, who is their surgeon? This leads to my final point, one that is completely my own thinking and in no way intimated by anything the Dr. Batjer discussed in his presentation to the IOM. This is my opinion, and no one else’s (this has, to my knowledge, never been discussed by anyone at the AANS). It is formulated from my experiences within the ACGME and my strongly held beliefs about how important an issue this is to the future of neurosurgery. Point #3: Neurosurgery must get ready to opt out of the ACGME process If organized neurosurgery takes a stand, proposes to create its own accreditation process, and every neurosurgery residency opts out of ACGME accreditation, the ACGME is confronted with a significant challenge…do you think that the ACGME or Medicare wants to be put in the position of coming up with a whole new set of training programs that will fit their idea of what neurosurgery training ought to be? What if we are joined by our compatriots in General Surgery, Thoracic Surgery, Orthopedic Surgery, Colorectal Surgery, Urology, Plastic Surgery and ENT? What if the American College of Surgeons (ACS) requests all of its member specialties to opt out of the ACGME accreditation process, and sets up its own process for accrediting surgical specialty residency education? How do you think the AHA and the AAMC (two of the member organizations of the ACGME) will try to influence ACGME regulations when they are faced with the prospect of disappearing Medicare dollars and surgical training programs? Another possibility is for organized neurosurgery to refuse to participate in the accreditation process by withdrawing our members from the Residency Review Committee (RRC). The Neurosurgery RRC voting membership is composed of neurosurgeons representing the ABNS, the ACS, and the AMA. A resident member is chosen by the RRC members from a panel of nominees put forward by the Society of Neurological Surgeons. Non-voting members include a representative from the ACS (often not a neurosurgeon), and the secretary of the ABNS. The RRC can only carry out its procedures for accreditation if the voting members are present and participate, but I can easily imagine that the voting members may have serious reservations about further attempts at reducing resident education hours and may balk at enforcing any further reductions in resident education hours. The ACGME bylaws state that its Board of Directors would then have to step in and take over the authority to accredit neurosurgery residency programs that it has up to now delegated to the Neurosurgery RRC, but until that happens, the accreditation process grinds to a halt. I don’t want neurosurgery to leave the ACGME, it will just be one big hassle from beginning to end, and the ones who will bear the brunt of the pain will be present and future residents and the neurosurgeons responsible for their education. But this process is spiraling out of control, twisting in a vortex of ding-a-ling logic that equates less training with better physicians. At some point we have to take tough actions to preserve our specialty and stand up for the care of our patients. What can young neurosurgeons do? Second, you need to work with the organizations in neurosurgery that are struggling to maintain the quality of neurosurgical education. The Council of State Neurosurgical Societies (CSNS) will be circulating a survey about resident education; please take the time to fill it out as it will provide important information that can influence discussions about how to reshape neurosurgery education to fit within constraints imposed by current ACGME regulations and the realities of neurosurgical practice. The Senior Society is trying to accumulate data about how further reductions in resident education hours would impact neurosurgical education, and if there are additional requests for information please provide it. I imagine that organized neurosurgery will also be mobilized soon, and there will be plenty of work to do and committees that need members. Young neurosurgeons should be intimately involved in this process. Third, you need to ask yourself where do you see neurosurgery in 10 years? Will neurosurgeons continue to be held in high esteem, representing the apex of modern medicine? Or will we be just another set of shift workers, showing up to “make the doughnuts” as part of a healthcare “team” - a rotating cast of characters who never take ownership of a patient, a “team” who through collective action fail to strive for excellence? Ask yourself how you see these changes in resident education playing out 5-10 years down the line, and whether you want to be a practitioner under this new regime. If you’re as disgusted as I am, please get involved. |
2008 Young Neurosurgeons Committee Silent Auction
Matthew J. McGirt, MD
We have recently concluded gift solicitation for the 10th annual Silent Auction to benefit the Neurosurgery Research Education Foundation. Given the increase in funds raised each of the last three years, the committee set $40,000 as the 2008 goal, with the intent of raising enough money to fund an entire NREF research grant. Currently, items totaling an estimated value of $43,000 have been donated. These exciting donations include vacation homes in Telluride, CO; a weekend at an historic Inn/Spa in Savannah, GA, fine wines, electronics, and art. All items will be available online through c-market, allowing for bidding 24 hours a day from any mobile site. Following in the footsteps of Chicago politics, bid early and often!
This year's committee was comprised of 10 members from the Young Neurosurgeons Committee. The committee was chaired by Matt McGirt and vice chaired by Dan Sciubba. Julie Quattrocchi is the new AANS Development Coordinator who helped coordinate the Silent Auction this year, and as always Michelle Gregory helped oversee all of our activities.
The auction will open two weeks prior to the AANS meeting and will close at the conclusion of the meeting. Thank you to all who have contributed to this year's auction and we look forward to seeing you in Chicago at the 2008 AANS meeting. Make sure you stop by the Silent Auction booth located in the AANS headquarters on the convention floor!
Washington Committee Report
Jonathan Friedman, MD, YNC Vice-Chairman
The Joint Washington Committee met on November 30. In addition to the committee's agenda, presentations were made by the Medical Executive Director of the BlueCross/BlueShield Association, and by a senior lobbyist for the American Medical Association.
Not surprisingly, the most discussed topic at the meeting related to the recent changes in the Medicare fee schedule for reimbursement of physicians. Under the Sustainable Growth Formula, compensation to physicians will decrease by greater than 10% in 2008. Combined with some unfavorable changes in work valuation, neurosurgeons face a greater than 12% decrease in Medicare payments.
As in previous years, legislators are debating options to freeze or reverse the planned cuts. While it seems unlikely that a bill will be passed before the end of the year, presumably the adjustment will be applied retroactively as it has previously. Unfortunately, Congress is likely to attach the payment adjustments to a larger bill with potentially multiple unfavorable provisions for physicians. For example, in the CHAMP bill passed by the House and currently in committee at the Senate, clauses included prohibiting physician ownership of hospitals, ASCs, and imaging centers. The Washington Committee approved a position statement supporting physician ownership of such entities.
Centers for Medicare & Medicaid Services (CMS) is continuing to review Code 61793 for stereotactic radiosurgery. Specific elements under review include the intensity of the service and whether it can be billed multiple times for multiple lesions.
Washington State held a hearing regarding state-sponsored health plans paying for spinal fusion for degenerative disc disease. A multi-specialty, multi-disciplinary group led by Dan Resnick, M.D., Jeffrey Wohns, M.D, and others made a sufficiently compelling case to continue payment for spinal fusion that and the panel voted 11-0 to continue payment for this service.
The Washington Committee approved further efforts to work with the American Academy of Orthopaedic Surgeons and the American College of Surgeons to issue a revised statement regarding emergency and on call care. The statement released by the ACS has sparked some controversy.
Last, the committee discussed the increasing government interest (led by Senators Baucus and Grassley) in the relationship between industry and physicians with respect to medical devices. Medtronic is currently under intense scrutiny in this regard as it relates to spinal devices and implants. The Committee agreed that organized neurosurgery must maintain systematic efforts to educate the membership regarding professionalism and conflicts of interest, and oversee national meetings and CME events to prevent undue industry influence and conflicts of interest.
Greetings from Iraq!
Jason Huang, MD
Editor’s Note - I have had the great good fortune to work with Jason Huang since he joined our faculty at the University of Rochester in July 2006. Jason’s life story is incredible and best told by him below, so I will embellish it only by adding that Jason, a graduate of Yan An High School in Shanghai, was a mechanical engineering student at the Shanghai University of Science and Technology when he participated in the Tiananmen Square student movement in 1989. Jason sought, and was granted, political asylum in the U.S. in 1992. He obtained a job as a busboy in California. What happened next is an American success story worth telling... Jason entered Amherst College from which he graduated magna cum laude in Neurosciences in 1994 and then graduated from Johns Hopkins Medical School in 1998. In Baltimore he reconnected with Kate Zhou, his good friend from Shanghai, who was studying Quantum Chemistry at Johns Hopkins. Jason became a U.S. citizen and he and Kate were married. He joined the U.S. Army Reserves and completed neurosurgical training at the University of Pennsylvania prior to joining our faculty. He now follows in the footsteps of a long list of Rochesterian neurosurgeons that have served our country in wartime, starting with our first chair, William Van Wagenen, who served during World War II.
As a young neurosurgeon, in training and in practice, I have seen some pretty incredible things. Clipping an aneurysm, removing a brain tumor, completing a complex instrumented spine reconstruction…what we do on a daily basis mystifies and amazes outsiders, but for us it becomes ordinary, part of a job, what we “do.” But there are still things that amaze even me, and what I want to share with you are the amazing experiences I have been having in Iraq.
Stepping back a little, you may ask “what the hell are you doing there?” My friends have asked me that: why would I interrupt my neurosurgery practice and take a big pay cut to work in a war zone? Some of my fellow soldiers do a double-take when they hear my Chinese accent and wonder how I got here. Unlike many who have served here before me, I did not use military service, either active duty or in the reserves, as a way to pay for my education. Instead, my path to Iraq was a little more circuitous, and started in China.
I was born in Shanghai in 1970, and in 1988 I started college. It was a time of political upheaval in my homeland, and in June 1989 I became involved in student protests that culminated in the student democracy demonstration in Tiananmen Square in Beijing. I will never forget the morning of June 4, 1989, when I was thrown into a battle waging thousands of armed soldiers in tanks and armored vehicles against unarmed, peaceful demonstrators hoping for a better, democratic life. It was a battle we had no chance of winning, and thousands of my fellow students died with no other weapons to defend them than their ideals. It is called the Tiananmen Square Massacre for a reason, and while I may still be getting used to wearing a uniform every day and learning military jargon, I am no stranger to brutality and death.
After Tiananmen, I was arrested and prosecuted by the Communist regime, subjected to daily brainwashing and forced to write countless confessions. Eventually I escaped mainland China, and I came to America in 1992. I was granted political asylum by this great country that I now call my home, became a permanent resident, and finally was granted citizenship. In that time, I worked my way up from being a dishwasher to enroll in a junior college, but then switched to a full college education at Amherst College. I studied hard every day, eventually earning acceptance into Johns Hopkins for medical school, and then matching at the University of Pennsylvania for my neurosurgery residency. Two years ago, I accepted a job at the University of Rochester, where I have developed a busy surgical practice (almost 300 cases in my first year!) and an active educational and research program, training residents and medical students, and running a research lab focused on traumatic brain and peripheral nerve injury. It is hard work, and I routinely clock 100-120 hours a week, but it still amazes me that I get paid well for living a life that I used to dream of in China.
It is my love for the U.S. and the opportunities that I have had that led me to join the U.S. Army reserves after our country was attacked on 9/11. For me, the need to defend our democracy is vivid and real. I never forget how fortunate I am to live in this great country, and the anger that filled me when terrorists struck our nation moved me to where I am now. I am grateful for the opportunity to serve my adopted country and pay back some of what I owe for what I have been granted. It is the only way for me to deserve the privilege to live in the best country in the world.
Of course, I didn’t just get on a plane from Rochester bound for Iraq.
After receiving my orders, I made plans to put my practice on hold. Fortunately,
I am not a “pioneer” in this regard; just a year ago, one of my
partners, Rafael Allende, MD, was deployed to Landstuhl for a three-month rotation
of service, and Paul Maurer, MD, one of my senior partners, also served during
the first Iraq conflict, so when I told my Chair, Webster Pilcher, MD, PhD,
that I was being deployed, the entire department mobilized to make the transition
as smooth as possible. I then reported for one week at Fort Benning, and subsequently
spent three days in Kuwait before arriving at the newly built Air Force Theater
Hospital at Balad Airbase, Iraq, part of the vast, 15- square mile complex
known as Logistics Support Area (LSA) Anaconda. Together
with Richard Clatterbuck, MD, PhD, I help to provide neurosurgical care to
all of our soldiers within the entire operational theater in Iraq. We also
care for American contractors, local civilians, and even insurgents.
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Not all patients are that lucky and large craniectomies, ventriculostomies and ICP monitors are all too common. The injuries we see - especially from improvised explosive devices (IEDs), are ferocious and we are extremely aggressive in their surgical treatment. One Iraqi I treated recently suffered a penetrating injury by an IED fragment to his left hemisphere with significant contusions and an open wound. I had to take him to the OR for a hemicranietomy and wound washout, with ICP monitor placement. One fortunate development with the advent of modern body armor is that, for our troops, such penetrating injuries are less common, but the brain tends to swell a lot worse after a blast injury than after the injuries we see stateside, and one aspect of blast injury that is now becoming better appreciated after our experience here in Iraq is the incidence and severity of traumatic vasospasm.
The vast majority of our neurosurgical volume is head trauma, but we do see
a limited number of complex spine procedures in the theater. In the past month,
Richard and I did two C1-C2 fusions, three lumbar fusions, and a few other
decompression procedures, all for spine trauma. Interestingly, one of my first
cases was a young American officer who presented with acute onset cauda equina
syndrome. On CT scan (we don’t have MRI here) he had a large L4-5 disc
herniation, and I got to perform an all-too-rare but extremely satisfying discectomy.
The LSA Anaconda has grown considerably and many stateside amenities are available within the base, like Burger King, Pizza Hut, Taco Bell, but we can never forget that this is a war zone. The base receives daily indirect fire attacks including mortar, rocket and small arms fire. There are many safety measures in place to protect us. The hospital is surrounded with concrete T Barriers as well as a blast roof. T Barriers and/or sand bag walls also surround our housing area and every high-traffic location. A concertina wire fence surrounds the base perimeter and there are numerous manned defensive guard towers. The single biggest risk to us is still random mortar and rocket attacks. Just last week, a rocket landed on an empty bus parked at the front gate of the hospital. Shrapnel from the rocket explosion injured one of our ICU physicians. He was taken to the OR for washout and awarded a purple heart. He was on a plane to Germany the next day.
Last month we also ran into a severe water shortage problem. The Tigress River was running low in water and the water supply pipe was also damaged. Many people here blame it on the inefficient Iraq workers who had not managed to fix the pipe (our Army engineers would have fixed the problem quickly). However, we do need to give Iraq workers a chance to take over their own reconstruction. Because of the water shortage, laundry and showers were suspended. All shops like Burger King, Pizza Hut etc were also closed. The only place that had an uninterrupted water supply was our hospital.
All officers here carry 9mm pistols and soldiers carry M16. We qualified for 9mm
at Fort Benning and practiced shooting again in Kuwait. Army personnel are
required to carry our weapons at all time. However, the chance that we actually
need to use the gun within the base is slim. At LSA Anaconda, friendly Special
Forces soldiers took me and a group of other surgeons to a weapon range to
practice with variety of weapons. I shot several hundred rounds in one morning.
The most rewarding aspect of my deployment here is the opportunity to take care
of our brave young men and women in uniform. I have a profound admiration for
the wounded and injured soldiers and Marines – they are the bravest,
most selfless people I’ve ever known. 
I have also been blessed to have
the good fortune of working with an exceptional group of talented military
surgeons of 332nd EMDG (Expeditionary Medical Group). They are Air Force general
surgeons, orthopedic surgeons, thoracic surgeons, vascular surgeons, ENT surgeons
and ophthalmologists. Their spirit, hard work, dedication, and ability to maintain
high spirits in an adverse environment are incredible. We spend a lot of time
together: assisting each other’s cases, discussing difficult surgeries,
dining together at DFAC (the dining facility), playing poker, working out in
the gym. They are the brightest and most dedicated people in medicine that
I have encountered and we have developed a strong bond.
I told my wife last week that we have an amazing group of surgeons in our military today. This has been the most humbling and enjoyable experience of my life. It is a great honor to serve my country and I am proud to serve alongside my fellow military surgeons.
Editor’s post-script: In typical fashion, Jason is multi-tasking; in spite of the difficult conditions under which he is now working, he has not stopped his scientific investigations. While at URMC, Jason started collaborating with Jeff Bazarian, MD, an associate professor in Emergency Medicine. Together, they are working to identify serum markers of TBI, hoping to create a rapid “spot test” to indicate the degree of injury. If reliable, this could be used in the battlefield to “prioritize” or prognosticate for injured soldiers; it could also be used on the home front to help identify patients that have a TBI and may or may not need a CT scan. Dr. Bazarian is a leading researcher of the unrecognized epidemic of minor TBI, and he is collaborating with Jason to collect serum and CSF samples from soldiers with TBI; these samples will be run through proteomic tests to identify potential markers that can developed into possible tests for TBI. I look forward to the results from this important research, and to Jason’s safe return.
Third Annual Neurosurgical Top Gun Competition
Michael Oh, MD
The Third Annual Neurosurgical Top Gun competition will be held in conjunction with the 2008 AANS Annual Meeting in Chicago. The competition allows residents to try their hands at three different skill stations. The resident with the highest score earns the honors of "Neurosurgical Top Gun" During the 2008 AANS Annual Meeting in Chicago, the Young Neurosurgeons Committee will present a competition for residents and fellows in the exhibit hall. This three-day event will include a new station for endovascular/carotid stent simulation, and updated stations for ventriculostomy spinal instrumentation. Contestants will receive scores for their performance and the resident or fellow with the best score will be awarded the Neurosurgical Top Gun honor and prize. Visit Booth #1730 and play to win!
Carla Sofia Reizinho, MD, a resident from Lisbon, took top honors at this year's competition.
Congratulations to all the residents and fellows that participated for making this event a success. As in the past, the turnout was great and the competition was fierce. More than just fun competition, Top Gun is also an introduction to computer-assisted neurosurgery and surgical simulators, which are gaining increasing interest as a tool for future resident training and assessment.
Planning for Top Gun 2008 is underway for the AANS 2008 Annual Meeting in Chicago. Next year’s event will have even more challenging stations to test your surgical skills. Open to all residents and fellows, this competition will offer the top performers prizes, fame, and glory. Anyone interested in assisting or sponsoring can contact Sean Armin, MD, the chair of Top Gun, at sarmin@llu.edu, or me at bradbellotte@gmail.com.
2008 AANS Annual Meeting - Welcome to Chicago!
William W. Ashley, Jr., MD, PhD, MBA
Chicago is the windy city and is known for its sights, sounds, tastes and...its
nightlife. Prepare to be blown away.
Chicago has a lot to offer. During the day make sure to check out The Art Institute and Millennium Park on Michigan Avenue. Spring is a great time to be out on the lakefront or hang out at Navy Pier. Shopping? Michigan Avenue has everything you could ever want and never need!
After a long day of meetings, you will be hungry. Chicago's diversity is reflected in its variety of food. Check out the South Loop for many trendy new spots. Eleven City Diner (1112 S. Wabash, www.elevencitydiner.com) has the best French toast in the city. Gioco (1312 S. Wabash, www.gioco-chicago.com) is our pick for Italian and boasts a great wine list. On the North Side, try Cafe Baba Reba (2024 N. Halsted, www.cafebabareeba.com) for great Spanish tapas and divine sangria. If you want to eat, drink and be merry, start the night downtown at Carnivale (702 W. Fulton Market, www.carnivalechicago.com) for a tasty Latin fusion menu, deadly mojitos and dancing on the weekends.
All work and no play makes Harvey a dull boy. Nobody parties like the Chi! If you want a smoky jazz joint, try the Green Mill (4802 N. Broadway, www.greenmilljazz.com). Get your drink on at Bin Wine Cafe (1559 N. Milwaukee Ave., 773-486-CAFÉ, http://www.binwinecafe.com/). Its a trendy little wine bar just off of North Avenue. Great wine and great area. Many, many other night spots are in walking distance. When Downtown, see and be seen at two of the hottest nightclubs - Ontourage (157 W. Ontario, http://www.ontouragechicago.com/) or Sound Bar (226 W. Ontario, www.sound-bar.com). The West Division area is among the hottest spots in town. Try Jun Bar (2050 W. Division, 773-486-6700), Inn Joy (2051 W. Division, www.innjoychicago.com) or Boundary (1932 W. Division, 773-278-1919, http://www.theboundarychicago.com/Links.aspx) to name a few. On weekends this area is teaming with beautiful people hopping from bar to bar. West Randolph is a high yield area with a variety of restaurants, bars and clubs. Bon-V (1100 W. Randolph, 312-829-4805, http://www.bonvchicago.com/) is a dance club with something for everyone. Dancing (hip hop, dance etc) on the first floor and VIP on the upper level. Get there early because this place gets packed on Saturdays. The Funky Buddha Lounge (728 W. Grand, www.funkybuddha.com) has a laid back dance atmosphere and a diverse crowd. This place is a favorite with the fashionable. Our pick for the underground spot is Lumen (839 West Fulton Market St, 312-733-2222, http://www.lumen-chicago.com/). No sign on the door - you just have to know. It’s a low key lounge with hip music, good drinks and cool people. This spot is the next level. You never know who you'll see there. It’s 2 am. Just when you thought the night was over...That’s when you head over to RedNo5 (440 N Halsted, www.rednofive.com). This is the late, late night spot. It can be packed and is always funky. Let’s just say we don't expect you home until 6 am in the morning...
Enjoy!
Remembering Dr. Sam. Hassenbusch
Catherine Jeakle Hill, Senior Manager, Regulatory Affairs, AANS/CNS Washington Office
Editor’s Note: Many young neurosurgeons may not know who Sam Hassenbusch was, but you should. Not only was he one of the first to get an NREF award, a world recognized researcher in brain tumor biology, and an inspiration given his own personal struggle with glioblastoma…he was also a tireless advocate for neurosurgery in the wild and tricky world of physician reimbursement. Many of you may not know the importance of the CPT Editorial Committee, but this is the group that determines which procedures get CPT codes. In other words, if you do a procedure and bill for it, this is the committee that makes that possible. It’s a battleground where different medical specialties vie for their procedures, competing to get the AMA and the Federal Government to recognize the work they do and the value it provides to patients. Dr. Hassenbusch worked hard to represent the interests of neurosurgeons young and old, and his contribution to our field deserves to be recognized especially by those of us who will profit most from his defense of neurosurgical procedures, and the grace with which he led his life is an inspiration. My thanks to Cathy Hill for providing this memorial.
On
February 25, 2008, Samuel Hassenbusch, MD, PhD, died at the age of 54 of glioblastoma
which was diagnosed in May 2005. Much has been and will be written about
Dr. Hassenbusch’s many clinical contributions and achievements. Less
may be known about his contributions to the AANS/CNS Washington Committee,
AANS/CNS Joint Committee on Coding and Reimbursement, and the American Medical
Association Current Procedural Terminology (CPT) Editorial Panel. Through these
activities, Dr. Hassenbusch became a mentor and friend to the AANS/CNS Washington
Office and someone who enlightened our lives professionally and personally
forever.
 |
| Robert B. King, MD awarding Dr. Hassenbusch the 1983 Research Fellowship |
Dr. Hassenbusch served as co-chairman of the AANS/CNS Committee on Coding and Reimbursement, a subcommittee of the Washington Committee, from 2002 to 2005. The Coding and Reimbursement Committee is responsible for initiating and responding to government regulatory activities of interest to neurosurgery and for bringing new and revised codes to the AMA CPT Editorial Panel and the AMA/Specialty Society Relative Value Update Committee (RUC). Dr. Hassenbusch also served as the AANS representative to the CPT Advisory Committee from 1995 to 1998 and received the 1998 AMA CPT Burgess Gordon Award in recognition of his dedication to the CPT process.
In 1999, Dr. Hassenbusch was appointed to the CPT Editorial Panel. Except for the meeting that coincided with Dr. Hassenbusch’s initial surgery for his brain tumor in June 2005, he never missed a CPT Editorial Panel meeting in the eight years he served. Dr. Hassenbusch was effective in working with advisors and staff from other medical societies to improve and explain complex coding. His thoughtful analysis of coding proposals aided in the development and clarity of many new and revised CPT codes. At his last CPT Panel meeting in October 2007, Dr. Hassenbusch received a standing ovation from the CPT Editorial Panel members, CPT Advisors, and all attending the meeting. Rhonda, his beloved wife of 36 years, accompanied Sam on all his travels after his diagnosis. Like Sam, Rhonda was gracious to all she met, most of whom felt they already knew her because Sam so often spoke of his family with great pride and love.
The irony of a brain tumor diagnosis for a neurosurgeon that had spent his life treating and working to improve care for brain tumor patients was not lost on Dr. Hassenbusch. He knew he was in a special position to serve cancer patients and did not waste anytime, accepting invitations to speak to cancer groups, appearing on the CBS Nightly News, and traveling to Washington to meet with members of the U.S. Congress to discuss the concerns of cancer patients. His unique ability to remain optimistic and dedicated in the face of a life-threatening illness was not a surprise to those who knew him. Everything about Dr. Hassenbusch was unique. His enthusiasm for life extended to all that he did. From his passion for correct medical coding to his willingness to devote his final illness to helping other cancer patients, Dr. Hassenbusch’s life was dedicated to seeing the good in every person and in every situation.
Even his requests for prayers were exceptional. They sometimes contained specific instructions to God about the region of the brain needing attention based on the most recent MRI and often ended with details of his ongoing work at the University of Texas MD Anderson Cancer Center in Houston or inquiries about the work and families of those he was asking to pray. To the very end of his life, every e-mail from Dr. Hassenbusch showed his deep care for others and always brought a smile. He typically ended his e-mail messages, which could be almost “Faulkneresque” in their stream of consciousness style, with the closing, “Thoughts?” Sometimes it was hard to know what to think or how to respond to someone as exceptional as Dr. Hassenbusch. He will be missed by many and leaves a great legacy of work and wonderful memories to all who knew him and were touched by his life.
An obituary can be found at http://www.earthmanfunerals.com/Obits/Obit.html?id=102567.
How We are Supporting the Best and the Brightest Medical Students in Neurosurgery
Eve C. Tsai, MD, PhD
The YNC continues to promote and support medical student interest in neurosurgery. Neurosurgery is one of the most fascinating and fulfilling specialties because it combines biomedical and technical developments with clinical acumen and surgical skill. Neurosurgeons operate from head to foot, and their practices can include operative, non-operative procedures, intensive-care management and research for patients with disorders affecting the brain and skull, spine and peripheral nerves. Thus, entering a neurosurgery residency gives medical students the opportunity to develop their career along many diverse paths.
Neurosurgeons are remarkable people that embrace technology and constantly strive to improve the care of their patients. They work to develop new emerging fields of expertise that include interventional neuroradiology, spinal instrumentation, radiosurgery, and minimally invasive surgery.
Although the number of medical students applying for neurosurgical residencies has remained stable, the demand for neurosurgeons and the number of training positions have continued to increase due to the resident duty hour restrictions. In response, neurosurgeons including members of the YNC are working to increase potential applicant interest in the field of neurosurgery to enable the recruitment of the best and the brightest and to allow continued delivery of optimal neurosurgical care.
Not so long ago most members of the YNC were medical students, so we are uniquely qualified to address the concerns of medical students considering a career in neurosurgery. The committee, as a whole, responded with great enthusiasm when we canvassed our members on ways to promote the attract medical students into what we know is the best specialty – neurosurgery. While many of our ideas have already been adopted, what follows below is an updated list of resources available to medical students who are considering a career in neurosurgery, and also some of the efforts our committee has pursued to improve the support of medical students interested in neurosurgery.
Medical Student Summer Research Fellowship Program
The summers during medical school are a good time for medical students to do
research and explore specialties. We all know that the body is not a democracy:
the brain reigns supreme, and there is no more interesting a field of research
as neuroscience research. In addition, much of the best research in neuroscience
originates from neurosurgical diseases (brain tumor and stem cell research,
encoding of neural circuitry for control of movement, brain and spinal cord
injury and repair, and stroke) For that reason, the AANS is sponsoring fellowships
for medical students who want to do neuroscience research. The Medical Student
Summer Research Fellowship program began in 2007 and 10 fellowships were awarded. This
year, the number of fellowships has been increased to 15. Congratulations
to the 2008 successful recipients listed below:
Claudia Berrondo
University of Utah
Lucas Harmon Bradley
University of Missouri
Derek Chew
University of Toronto
Andrew Kahlen Conner
Indiana University
Kassandra Dassoulas
University of Virginia
Dale Ding
Duke University
Brian Hanak
Massachusetts General - Harvard
Obehioya Irumudomon
Case Western Reserve
Julia Jaffe
Mount Sinai School of Medicine
Jonathan Latzman
New York University
Neal Mehan
University of Cincinnati
Whitney Parker
University of Pennsylvania
Matthew Parry
Virginia Commonwealth University
Caroline Tougas
University of Ottawa
Nina Zobenica
Barrow Neurological Institute
These fellowships provide a stipend to cover a two or three month period of research in a lab over the summer. For more information on these fellowships, please see the website at: http://www.aans.org/medical_students/summer_research_opps.asp.
Career Fairs
Most medical schools give students an early exposure to different medical and
surgical specialties through career fairs, typically a meet-and-greet opportunity
where medical students can hear a presentation about the appeal of a particular
specialty and have a chance to ask questions about what it is like to be a
practitioner in that field. This is an excellent opportunity for neurosurgeons
to encourage and inform medical students about neurosurgery, and its importance
cannot be overestimated. As a rule, neurosurgeons are confident, smart, and
engaging, and we are the ONLY people that get to do what we do. As a consequence,
these career fairs are a unique venue at which one person can generate broad
interest with minimal investment of time. The YNC has put together a package
for neurosurgeons to assist them when they speak to undergraduates. This package
includes a PowerPoint presentation describing neurosurgery and ideas for formal
and informal career counseling presentations. We are also working to make the
package applicable internationally, and are currently working on packages tailored
for the specifics of training in Canada and Mexico.
Resources for medical students
The YNC has compiled a list of Internet resources at http://www.aans.org/medical%5Fstudents/
that provides information for medical students about research and career opportunities
in neurosurgery. The information includes a list of U.S. neurosurgical residency
programs, links to a glossary of neurosurgical terms, and web links to career
counseling sites that describe neurosurgery as a career. It also includes links
to bulletin boards for medical students where they may ask questions. It is
important to note that some of these bulletin boards are unmonitored and may
provide misinformation. The YNC website also gives medical students an opportunity
to register and gain online access to neurosurgical case studies for education..
Medical Student Courses
At the AANS Annual Meeting, there is a practical course for medical students
and junior residents on becoming a neurosurgeon. This course is complimentary
for medical students and provides information on the process for applying and
getting into a residency. The course also gives tips on dealing with the challenges
of residency and how to prepare for a career when finished with residency.
There are also opportunities to enter a mentoring program that will match
an experienced neurosurgeon with a resident or medical student to help them
best achieve their career goals. The WINS (Women in Neurosurgery) has
a program available and more information on this program can be found at the
following website:
http://www.neurosurgerywins.org/medical_student_corner.html.
This is only a small list of the support provided by the YNC to encourage medical students to pursue careers in neurosurgery, and the YNC is continuously working to develop more ideas. If anyone has any further ideas or suggestions to help promote medical students, please contact Chris Philips, Director, AANS Membership Services, at: cap@aans.org. Our taskforce is always open to ideas and would welcome any feedback that will improve our support of medical students.
Cerebrovascular Section Looking for Help with Its Website
To young members of the YNC or young neurosurgeons who are interested in getting involved in the Cerebrovascular Section, the leadership of the Section is trying to improve the content on its website http://www.cvsection.org. The purpose of the website is to provide a resource for the members of the section, and also provide information for patients with cerebrovascular disease that is vetted by the Cerebrovascular Section. Other projects include increasing CME content on the website geared towards cerebrovascular surgeons, and creating a section for residents to test their cerebrovascular knowledge. Anyone interested in helping out should contact Ed Vates, MD, the YNC liaison to the Cerebrovascular Section, at Edward_vates@urmc.rochester.edu.