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In my presidential address, I tried to focus on the question “Who are we?” I have

been blessed by serving so many roles on behalf of neurosurgery and our members

over the years that I have gained a unique perspective on exactly what makes us, as

neurosurgeons, so unique and special. I focused on our roles as innovators, our social

contract, the challenges to fulfilling that contract, our unique culture and also provided

some specific recommendations as a charge going forward.

As innovators, we have a most distinguished past, both in science, technical medicine and

education. Our boot camps have certainly led the way in U.S. medicine in that our incoming

residents receive their basic training in a totally risk-free environment. The AANS medical

student chapters are another remarkable development: We now have over 1,500 members

who are still in medical school and who are being attracted to the neurosciences. Our

Neurosurgical Summit, convened under the aegis of the Society of Neurological Surgeons

(SNS), allows our specialty, including our membership societies, our Board, our RRC

and our Washington Committee, to testify before Congress, the National Academies,

the Centers for Medicare & Medicaid (CMS) or any other regulatory environment, as an

Academy rather than a Membership Society, which is seen as conflicted. This structure

allowed us to respond over the past couple of years to severe challenges in the areas of

neurocritical care and endovascular neurosurgery in ways that are unprecedented in the

house of medicine. We linked the SNS CAST committee with the ACGME to enrich our

accreditation process for enfolded and post-graduate fellowships, and we linked CAST with

the American Board of Neurological Surgery (ABNS) to certify when necessary.

The neurosurgical social contract is one of the key differentiators that separates

medicine, particularly neurosurgery, from other sectors of the economy. If we think of

the current political discussions, it is starkly obvious that physicians are not treated the

same as, for example, politicians. Our public has certain expectations of us: primarily

that we will be there when they need us, and we will treat them with compassion and

beneficence. In return, they treat us with the great honor and trust that each of us

experience daily in our practices. Under our social contract, we are committed to all

aspects of patient safety and quality and also to serving as a court of last appeal for

patients with horrible conditions. We must be there for them.

I also discussed the challenges we face in meeting our social contract: de-professionalism and

commoditization of medicine and surgery, the loss of professionalism created by duty-hour

restrictions, the primary care-centric IOM GME report of 2014 and issues around “copy and

paste” in the new electronic medical records (EMRs), which are creating a new type of medical

error, e-iatrogenesis. I discussed my concern that the new area of subspecialty certification

puts us at risk of fragmenting our specialty as has happened in so many other fields. I urged our

Board and the SNS to certify only when absolutely necessary. In my view, we should focus only

on pediatric neurosurgery, neurocritical care and endovascular neurosurgery.