Our current process for the training of neurosurgical residents is frequently heavily weighted toward the care of acutely ill patients and toward the development of technical expertise in the neurosurgical operative suite. It is indisputable that achieving mastery in both of these arenas is essential to the development of the well-trained neurological surgeon. A coincident cognitive skill must also be acquired,
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Editorial License
Is Ignorance Bliss?
Michael Schulder, MD, FAANS—In this issue’s Editorial License, editor Michael Schulder, MD, FAANS, addresses the implications of screening taken to the extreme.
“Gattaca” is a 1997 film, starring a nearly affectless Ethan Hawke, that poses the question of how much genetic screening is good for us. Set in “the near future” (I guess not quite 2015, as it turns out), it portrays a society where children whose genetic profile is somehow unfavorable are shunted off into lives with no promise, even though such discrimination is officially illegal. There is no happy ending to the movie, although the hero does manage to overcome his label as a “de-gene-arate” by a combination of determination, smarts and law-breaking.
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Practice Management
Neurosurgical Surveillance of Patients with Congenital and Chronic Illness
Catherine A. Mazzola, MD—We often don’t think of neurosurgeons as the providers of chronic care or as the gatekeepers of a “medical home.” But, in reality, we often are responsible for the management of comprehensive and collaborative care in interdisciplinary medical homes. Whether these “homes” are centered in one’s office, in a hospital or outpatient setting, we have all experienced the changes in health care — for better or for worse — that have affected our ability to manage our patients’ care. As a parent and as a pediatric neurosurgeon. I care about kids at home and at work. I have always been a responsible care-giver and health-care provider, for my patients and their families. During the 2014 AANS/CNS Joint Section on Pediatric Neurosurgery meeting in Amelia Island, Fla., guest speaker David L. Wood, MD, MPH, gave an outstanding talk on the transition of care for pediatric neurosurgeons. As pediatric neurosurgeons who provide care to children with spina bifida, hydrocephalus and cerebral palsy/movement disorders, we know what neurosurgical surveillance is and how to do it for our patients…
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Patient Safety
Screening Guidelines in Neurosurgery: Patient Safety First
Tyler Schmidt, DO; and Kristopher T. Kimmell, MD—Health-care reform has dominated the news over the past several years. Dire projections of escalating costs of health care have led to increased scrutiny for health-care providers. A frequent criticism of U.S. health care is that many tests and procedures are duplicative and frequently un-indicated. In particular, screening diagnostic tests to rule out diagnoses are widely felt to be over-utilized. There are a number of valid arguments on each side of this argument. For patients with a positive screening test that led to early diagnosis and treatment, such screening tests are life-saving. For patients with a false positive test who undergo further testing, the screening test exposed them to unnecessary potential risk. Many physicians would offer that they are compelled, by patient preference or medical-legal concerns, to order tests in situations where there is not good evidence for their use. Efforts to Limit Unnecessary Tests Despite these concerns, organized medicine has joined in national efforts to reduce health-care spending. One such effort is the Choosing Wisely initiative. First put forth by the American Board of…
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Bookshelf
A Physician’s Perspective on American Health Care: Disillusionment and Despair
Gary D. VanderArk, MD, FAANS—“Doctored: The Disillusionment of an American Physician.” Sandeep Jauhar. Farrar, Straus and Giroux. New York. 2014. 268 pp. There is no question that many doctors in the United States are unhappy. Sandeep Jauhar, MD, an Indian immigrant, has joined the ain’t-it-awful crowd and written a book about our disillusionment, deception and despair. In “Doctored: The Disillusionment of an American Physician,” he rightfully bemoans the waste in American health care and fails to see any transformation from volume to value. He observes that “when doctors are paid piecework for their services, the result too often is waste, disorganization, and overload.” Jauhar is a non-interventionist cardiologist at Long Island Jewish Medical Center. He is paid a salary that does not meet his family’s expenses so he sells himself to a pharmaceutical company giving drug lectures at $1,000 a pop or moonlights with a private-practice cardiologist, for whom he has no respect, to make ends meet. His experience at least gives him a guilty conscience. He complains that nothing influences physician behavior like hard cash and rationalizes that…
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International
Neurosurgical Travels in Kenya
William R. Copeland III, MD—Editor’s Note: In our international section, we typically take the opportunity to talk with surgeons from other countries about the state of neurosurgery where they are. However, how do you ask a neurosurgeon the state of their country where there are none? In this month’s International section, we take the opportunity to have William Copeland, MD, a resident who is facing the start of his career, discuss his experience with international neurosurgery in Africa. He has made the extraordinary choice to start his career for two years in Kenya prior to starting his career in the U.S. Here he informs us of this remarkable place, as well as how to become involved with international initiatives. I recently took a month-long trip that has changed the trajectory of my career. I have long been interested in international health care, so when I began planning for my elective time during my fifth year of residency, I decided to investigate what opportunities were available to spend time working in a developing country. During my initial search, I was somewhat…
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Medicolegal
No Lifeguard on Duty: Resident Supervision Required
Caitlin C. Podbielski, Esq.—Residency is an important part of the education of U.S. physicians, but because patient care is the vehicle through which residents learn, the limitations of a resident’s experience can pose significant patient safety concerns. Accordingly, the public and private regulators of the medical profession have been tasked with building a careful balance between experiential learning and patient safety in structuring residency programs. This article will explore the unique situation of residents within the law; provide an overview of the current structures intended to create a safe but educational experience for residents; and conclude with a discussion of how the law currently views the responsibility of resident supervision. Residents Under the Law Medical residents are uniquely positioned within state licensing laws. First-year residents generally are not eligible to receive a state license to practice medicine independently. In some states, this ineligibility extends through the first two years of residency. A resident ineligible for state licensure is not classified as a physician under the law as he or she cannot practice independently or perform the functions the…
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Practice Management
Navigating Prior Authorizations
David S. Robinson, BS, RMA—As health-care providers, we strive to provide our patients with the best medicine we possibly can. There are certain barriers that impede the process of quality health care. Having to obtain prior authorizations from insurance companies is one of those barriers. While this may seem like a simple hoop to jump through, it can actually be one of the most daunting tasks that a physician’s office undertakes. Gathering information to meet certain criteria that ensures the patient’s authorization will be completed with an approval is often nerve-racking and overwhelming. Services that usually require a prior authorization include: Imaging: MRI, CT scan, Pet scan Surgery: Any type of specialized surgery (i.e. neurosurgery, Gamma Knife, etc.) Prescriptions: Non-formulary is the most difficult and always needs a prior authorization. Authorizations can be obtained three different ways. Each vary by insurance or pharmaceutical company. Telephone: Expect to wade through menus and automated systems and then wait for at least 30 minutes for anyone to answer. Online: This process seems to be catching on in the insurance world faster than…
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Coding Clarity
How H.R. 2 Affects Global Periods
John Ratliff, MD, FAANS—On April 14, 2015, the U.S. Senate passed H.R. 2, The Medicare Access and CHIP Reauthorization Act, which finally fixed the Sustainable Growth Rate (SGR), after 14 years of threats to physician reimbursement. The act also overhauled the Physician Quality Reporting System (PQRS), replacing it with a new Merit-Based Incentive Payment System (MIPS). So what does H.R. 2 mean for physician reimbursement? In the near term, it prevents a 21-percent reduction in Medicare reimbursement that was threatened by the previous SGR legislation, the same threatened cuts that had produced nearly 20 previous “patches.” In the near-term, the 21-percent reduction is prevented, and physician reimbursement is provided a 0.5-percent increase for the remainder of 2015 and each additional year through 2019. The Effect on Surgical Global Periods I want to touch on how this bill impacted surgical global periods as well — the topic of the last two editions of Coding Clarity. What a huge difference a little time makes. For the previous two editions of Coding Clarity, we reviewed what a global period is and…
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