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It’s Time to Fund MISSION ZERO

By Congress, TraumaNo Comments

It’s been five years since the National Academies of Science, Engineering and Medicine (NASEM) released a report titled, “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.”

Having led a model for military-civilian collaboration at the Army Trauma Training Center in Miami, Fla., I was invited to be a reviewer of this report. I appreciated the wisdom of focusing on military-civilian trauma collaboration to save more lives from injury — whether on the battlefield or at home.

Such structured collaboration:

  • Shares best practices for civilian and military injury care and prevention;
  • Preserves hard-won lessons of combat casualty care;
  • Improves civilian access to trauma care;
  • Sustains military trauma surgeon and team skills; and
  • Promotes national readiness, particularly in the reflection of COVID-19 recovery.

With three years of hard work in advocacy, the MISSION ZERO Act was signed into law in 2019 as part of (H.R. 269/S. 1379), the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (P.L. 116-22).

This Act:

  • Followed the recommendations of the NASEM report;
  • Created the Military and Civilian Partnership for the Trauma Readiness Grant Program (MISSION ZERO) in the U.S. Department of Health and Human Services; and
  • Authorized grants to cover the administrative costs of integrating military trauma surgeons and teams into civilian trauma centers.

However, although the program was created (i.e., authorized), it has yet to be funded (i.e., appropriated). In 2020, the House of Representatives did include funding, but the Senate did not.

Five years later, trauma remains the leading cause of death for children and adults under age 44.

We are working quickly with the new Congress to achieve funding for Fiscal Year (FY) 2022. There is already good news. On April 27, 34 members of the U.S. House of Representatives sent a letter requesting full funding for MISSION ZERO to the House Labor, Health and Human Services, Education, and Related Agencies Subcommittee leadership. Sens. Chris Van Hollen (D-Md.) and Bill Cassidy, MD, (R-La.) are leading a similar effort in the Senate.

May is National Trauma Awareness Month, which is an opportunity for you to take action.  So please ask your Senators and Representatives to support full funding at the authorized amount of $11.5 million for MISSION ZERO in the FY 2022 appropriations bills.

Fully funding this critical program will help improve injury care and public health response in our communities, states and nation, inclusive of our military health system.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter during National Trauma Awareness Month this May by following @Neurosurgery and @AmCollSurgeons, using the hashtags #TraumaAwarenessMonth and #Trauma.

John H. Armstrong, MD, FACS, FCCP
Chair, Advocacy Pillar, American College of Surgeons Committee on Trauma
Former Florida Surgeon General and Secretary of Health, 2012-16
University of South Florida, Morsani College of Medicine
Tampa, Fla.

May 20, 2021
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Prior Authorization Burdens March On, Even During COVID-19

By COVID-19, Guest Post, Prior AuthorizationNo Comments

For much of 2020, as COVID-19 case surges threatened to overwhelm the U.S. health system, physicians faced onerous, business-as-usual insurer policies on top of a public health emergency.

In December, as the Centers for Disease Control and Prevention (CDC) data showed daily new COVID-19 cases reaching the once unthinkable total of 200,000, the American Medical Association (AMA) surveyed practicing physicians to measure the impact of health plans’ prior authorization (PA) requirements on patient care and practice burdens. The results were grim: surveyed physicians reported completing an average of 40 PAs during the previous week of practice, and this weekly PA workload for a single physician consumed 16 hours — the equivalent of two business days — of physician and staff time.

The fact that these significant administrative burdens taxed our practices during an unprecedented public health crisis is extremely disturbing. While many health insurers modified their PA policies during the pandemic’s early stages, nearly 70% of surveyed physicians reported that PA requirements were relaxed only temporarily or not at all, illustrating the limited reach of health plans’ policy adjustments.

PA Hurts Patients

Beyond these practice hassles, the AMA survey also captured the harmful effect of PA on patients and their health. An overwhelming majority (94%) of physicians reported that PA can delay access to medically necessary care. These delays represent far more than just the inconvenience of waiting for treatment, as physicians linked PA to adverse effects on care delivery and outcomes:

  • 79% reported that PA can lead to treatment abandonment;
  • 90% stated that PA can result in negative clinical outcomes; and
  • 30% indicated that PA has led to a serious adverse event for a patient in their care, with 21% reporting that PA has led to a patient’s hospitalization.

These alarming data show the very real human costs of PA and raise serious questions about health plans’ claims that PA ensures appropriate, safe care and reduces costs. How can a process that so frequently leads to serious adverse events and patient hospitalizations reduce overall health care costs?

PA Burdens Are Growing

Despite the solid evidence that PA negatively impacts patients and physician practices, health plans continue to ramp up their utilization management programs. Health plans agreed over three years ago in the Consensus Statement on Improving the Prior Authorization Process — which was signed by America’s Health Insurance Plans and Blue Cross Blue Shield Association — to reduce the overall volume of PAs, yet they continue to introduce additional requirements. In the AMA survey, a strong majority of physicians reported that the number of PAs required for prescription medications and medical services has increased over the last five years. Even Medicare, which traditionally has not imposed PA, is now in the PA business: the 2020 Medicare Outpatient Prospective Payment System (OPPS) rule established PA requirements for five services that have cosmetic uses in addition to therapeutic indications, which burdens my specialty of plastic surgery. The 2021 OPPS rule hit close to home for readers of this blog, as it added PA to two neurosurgical service categories — cervical fusion with disc removal and implanted spinal neurostimulators. The AMA, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons and numerous other concerned stakeholders recently sent a letter to the acting administrator of the Centers for Medicare & Medicaid Services urging a delay in implementing these new requirements.

Take Action

We see the growing harm that PA inflicts both on our profession and our patients with every passing year. It is time we step up and demand change. The AMA Advocacy Group has been active in Washington, urging Congress to support the reintroduction of the Improving Seniors’ Timely Access to Care Act (H.R. 3107 and S. 5044 in the 116th Congress). If passed, Medicare Advantage plans would be required to make many of the critical PA reforms outlined in the previously mentioned Consensus Statement, such as improving transparency and streamlining the process. All of you can play a role here in contacting your representatives to do the same. Since the problem is broader than just Medicare Advantage, the AMA is currently investigating further legislative moves to address insurance companies’ onerous PA policies.

The AMA has developed model legislation for use at the state level. We urge you to also work with your state medical association to support state PA legislation — you can join grassroots efforts to draw more attention to this critical issue. Visit FixPriorAuth.org to share your PA horror stories, watch videos of other physicians and patients telling how PA harms care delivery, engage on social media and sign a petition pushing for change.

Please also share this information with your patients — this is their problem, too. It is going to take all of us to FixPriorAuth, and legislators are more likely to respond to issues about which their constituents complain.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @AmerMedicalAssn, using the hashtag #FixPriorAuth.

Russell Kridel, MD, FACS
Chair, AMA Board of Trustees

May 13, 2021
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Neurosurgery Rotation and Application Changes Due to COVID-19: A Medical Student Perspective (Part II)

By COVID-19, GMENo Comments

The COVID-19 public health crisis upended many norms in medical education. Most of medical school is built around significant in-person contact. During COVID-19, educators and students have had to adapt to the changing times to protect public health. Perhaps the most strongly affected individuals are those who applied for the 2021 match. Students and program directors alike were in an unprecedented time — trying to find the right resident “fit” without away rotations and in-person interviews. As an applicant to neurosurgery, I was looking forward to learning how different programs operate compared to my home institution while also furthering my education in my field of interest. While COVID-19 significantly affected this plan, the pandemic also allowed for changes and innovations to the neurosurgery match — some of which may persist beyond the 2021 match cycle.

Home neurosurgery rotations were extended to eight weeks due to the limitations of away rotations. I was fortunate enough to rotate at a high-volume academic program, and I felt that I had excellent exposure to the field. I also became more familiar with the residents, faculty and program at my institution. To accommodate canceled away rotations, I attended virtual sub-internships and Zoom happy hours for programs that I had previously applied to for away rotations. Additionally, I scheduled phone calls with individual residents at these programs, which proved incredibly helpful and insightful. Finally, I built a Twitter profile, which was a great avenue to virtually connect with other applicants and faculty.

The most significant impacts of this cycle may be felt by those in states with few neurosurgery programs in their area. Obtaining letters of recommendation — considered “make or break” during the match — is undoubtedly a challenge for applicants without home programs. Standing out as an applicant — even with a home program and stellar letters — was also a challenge during this cycle. There is certainly a unique pressure to beef up “on-paper” qualifications such as the United States Medical Licensing Examination and publications. For applicants — particularly those without home programs — focusing on getting to know your programs of interest virtually was helpful. The residents I interacted with were more than willing to share their stories and highlight as much of their program as they could over a phone call. It was also helpful to hear more about their surrounding area. These conversations were a great way to get to know new people in an era of limited in-person contact.

The COVID-19 era has ushered in a disruption of the neurosurgical match. Finding meaningful connections during this time was a logistical hurdle for every applicant — particularly those without home programs. I focused on building as many connections virtually as possible — and fortunately, there were plenty of opportunities. I think that some of these resources, such as the virtual sub-internship or neurosurgical education webinars, are great resources that should continue in post-COVID-19 match cycles. While we live in a unique time, I find that the sense that “we’re all in this together” has persisted through my virtual and in-person interactions with others in the field. We are, after all, made to be resilient to the many trials of medicine — both the expected and unexpected ones.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtags #Match2021 and #NeurosurgeryMatch.

Somnath Das
Medical Student
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, Pa.

May 10, 2021
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Congressional Docs Urge Americans to Take Action and Get the COVID-19 Vaccine

By Congress, COVID-19, Guest Post, HealthNo Comments

Last year, the entire world was forced to face the COVID-19 pandemic head on. And now, we — the American people — have the opportunity to achieve peace of mind and live life as free as before by choosing to receive a COVID-19 vaccine. Concerned for the health and safety of our nation, I recently joined some of my fellow colleagues in Congress — each of us are also health care professionals — in a public service announcement encouraging Americans to get vaccinated. Very soon we will have more COVID-19 vaccines than we have people willing to take it. In fact, almost half of adults in my home state of Kansas are uncertain about getting vaccinated.

Operation Warp Speed brought us safe and effective vaccines in record time. The process was rigorous and transparent, and a process that I personally followed very closely, resulting in a clear path to the eradication of the pandemic. The Food and Drug Administration (FDA) did not skip any steps. Instead, the FDA cut bureaucratic red tape — not corners — and got the job done in record time. By now, over 200 million vaccines have been given in our country.

Doctors, nurses and pharmacists nationwide recommend the COVID-19 vaccine to their patients, and over 90% of doctors in the U.S. have already chosen to get vaccinated. But, we have much more work to do. I encourage all neurosurgeons, primary care doctors, nurses, and community pharmacists to discuss the vaccine with your patients. Who better to have that conversation than someone who knows their medical history and has their trust? As a physician from Small Town, USA, I’ve given critical advice to my patients facing a number of issues including getting a vaccine for disease prevention. The most respected advice comes from a person’s own health care provider or pharmacist, and it’s conversations with them that help make the best health decisions.

I look forward to the freedom I, along with my loved ones, will regain once the vast majority of Americans are vaccinated. If everyone does their part, in the coming weeks we will once again be able to worship together as a congregation, gather with extended family, and travel near and far with friends.

Please join me in watching and sharing this important message!

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtags #VaccinesWork and #ThisIsOurShot.

U.S. Senator Roger W. Marshall, MD (Kansas)

 

 

May 3, 2021
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Neurosurgery Rotation and Application Changes Due to COVID-19: A Medical Student Perspective (Part I)

By COVID-19, GME, MedEdNo Comments

The COVID-19 pandemic has resulted in many changes in the neurosurgery residency application process. Early decisions by the Society of Neurological Surgeons led to the canceling of away rotations, installation of virtual interviews, and a required eight-week home rotation in lieu of visiting rotations. Despite being disappointed that I would be unable to visit programs physically, the neurosurgical response to the challenges as a result of COVID-19 was very proactive, and it was a relief to have a definitive idea of the process early on.

Standing out during the home rotation became essential. Letters of recommendation could only come from home programs, so I used the eight weeks to form stronger relationships with key faculty members. During my rotation, I went to clinic with two of my anticipated letter writers, which proved to be an excellent opportunity to prepare and showcase history-taking, physical exam and imaging interpretation skills. Standing out in the operating room did not change much, but the added time of the rotation allowed me to see a wider variety of cases than I would have on a four-week rotation. I have become more familiar with the inner workings of my home health system. As the eight weeks progressed, I was able to take on more and more tasks associated with running the clinical service. The wider breadth of these experiences helped me learn much more about how to function as a neurosurgical resident than I would on a shorter, four-week rotation.

Many neurosurgical programs have started webinars or meet-and-greet sessions, where applicants can learn about the program directly from faculty and residents. Some programs — my home institution included — have organized lecture series, where faculty and residents give didactic sessions about various neurosurgical topics. These are great opportunities for students to get to know both the logistical aspects of the program, such as rotation schedules, research emphases and to get a feel for the all-important “fit.”As the time to submit applications approached, I reached out to friends who applied last year, current residents and faculty members to better understand the programs and compile my list. While the process has certainly been different from years past, some positive things have come from these changes, including the longer home rotation, webinars and lecture series. To say that the virtual interview dramatically affected the ability of programs and applicants to gauge “fit” may be an overstatement, and the real drawback is likely from loss of longitudinal exposure during in-person rotations. Nevertheless, this year has been exciting for both programs and applicants, and I enjoyed seeing how programs showcased themselves through virtual interviews.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtags #Match2021 and #NeurosurgeryMatch.

Sean Neifert
Medical Student
Icahn School of Medicine at Mount Sinai Hospital
New York, N.Y.

April 27, 2021
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Connecting with the Neurosurgery Community in the COVID-19 Era: Lessons Learned at the University of Miami

By COVID-19, GME, MedEdNo Comments

The COVID-19 pandemic has challenged the neurosurgery community to utilize new technologies to create and maintain connections. With social distancing guidelines in place, much attention has turned to the virtual space to accomplish this. At the University of Miami, we have trialed several virtual initiatives to connect with the neurosurgery community across the country and the world — from medical students interested in our residency training program to attending neurosurgeons interested in hearing from the world-leading experts in various neurosurgical subspecialties. We report the lessons we have learned during these unprecedented and challenging times.

Virtual Sub-Internship

Typically, sub-internships represent the culmination of medical school studies where interested final year medical students rotate in our department to gauge interest in both neurosurgery and our residency program. However, given concerns for student safety with travel, the various travel restrictions in place, and differing hospital policies on rotating medical students, the Society of Neurosurgical Surgeons opted for a unified policy for programs and students to afford all applicants the same opportunities. In 2020, away sub-internships were eliminated, and the University of Miami created a 1-day virtual sub-internship. In these, attendees were exposed to different subspecialties via attending presentations, resident life via resident presentations and applying to our program via a question and answer session with the program director, Ricardo J. Komotar, MD, FAANS, FACS. The lessons we learned are:

  • We can host more attendees than we would be able to with in-person sub-internships;
  • Compared to before, attendees of the virtual sub-internship are objectively more familiar with the residency program, faculty, residents and daily life within the program; and
  • All prospective attendees agreed that a virtual sub-internship before in-person sub-internship applications would be of great use after the pandemic.

The Resident Hour

A challenge facing medical students learning about our residency program is getting to know the current residents when they cannot rotate in the department. Given how vital inter-resident personality fit is when planning applications, we sought to increase the exposure of our residents by introducing a monthly resident-run virtual initiative called The Resident Hour. In it, we had residents present on various neurosurgery- and residency-related topics, but in a more conversational manner. The lessons we learned here are:

  • There is interest in hearing from neurosurgery residents from both within the U.S. and overseas;
  • Interactive sessions that encourage conversations greatly facilitates getting to know residents; and
  • Residents enjoy the opportunity to share with the neurosurgery community their knowledge and opinions.

Online Symposia

In the current pandemic, multiple neurosurgical conferences have been canceled. Without these, the neurosurgery community has lost exposure to experts in the field and the most up-to-date didactics. In response, our department has been able to organize our lecture series utilizing virtual symposia, nicknamed Zoomposiums. In it, we can bring in world-renowned experts virtually to discuss in real-time many pertinent and contemporary topics — including brain tumors via the Miami Global Brain Tumor Symposium organized by Michael E. Ivan, MD, FAANS, and Cerebrovascular and Skull Base Symposium organized by Jacques J. Morcos, MD, FAANS, FACS. Attendance is free and open to anyone interested, and all of the recordings (including The Resident Hour) are available on YouTube. From these symposia, we learned:

  • Virtual symposia increase the breadth of neurosurgical experts’ ability to present their work, as well as the neurosurgery community able to attend;
  • There is great interest in these symposiums across the world, with attendees from over 50 countries registering for each symposium; and
  • Being able to store these symposia online, at no cost, dramatically increases the longevity and reach of their impact.

The COVID-19 pandemic has challenged the neurosurgery community to innovate new ways to become and stay connected. Here in the Department of Neurological Surgery at the University of Miami, we have embraced virtual technology and created initiatives to increase exposure and maintain a connection to our program, our residents and our expertise. We have learned several lessons with the overarching goal of increased accessibility at the forefront of our experience. We can implement these virtual endeavors within the neurosurgery community to become more connected than ever.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtags #Match2021 and #NeurosurgeryMatch.

Victor M. Lu, MD, PhD
University of Miami School of Medicine
Miami, Fla.

 

 

Ingrid Menendez
University of Miami School of Medicine
Miami, Fla.

 

 

Ricardo J. Komotar, MD, FAANS, FACS
University of Miami School of Medicine
Miami, Fla.

April 20, 2021
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Virtual Sub-internships and Remote Interviews: A Sudden Paradigm Shift in the Neurosurgical Residency Application Process Due to COVID-19

By COVID-19, GME, MedEdNo Comments

The year 2020 required constant adaptation to a rapidly changing environment in many facets of life. Few would have guessed that national travel would be severely restricted or that surgeons would be wearing face masks to the supermarket. As impactful as the COVID-19 pandemic has been on life in general, the effect on the neurosurgical practice has been similarly profound —  from shifting outpatient care towards a more remote, telehealth presence to restricting non-urgent surgical case volume. Perhaps the most significant, potentially long-lasting effect of the pandemic on the neurosurgical profession has been with the transition from medical student to resident physician.

Matching into a neurosurgical residency position in the United States has traditionally been an extensive process spanning months and costing applicants upwards of $10,000. Traditionally, students drawn to the field would rotate at a neurosurgical department associated with their medical school before embarking on sub-internship rotations in other neurosurgical departments across the country. This typically benefits the applicant by allowing him or her to observe the diverse practice of neurosurgery across different institutions. Furthermore, it allows the applicant to demonstrate his or her commitment and passion to the field to residents and faculty at these institutions. Moreover, this process is integral to generating letters of recommendation from respected members of the neurosurgical community. While applying for visiting sub-internship positions occurs in the fall to winter of the prior year, these rotations typically happen in the summer to fall of the application year. Once the Electronic Residency Application Service (ERAS) opens, usually in September, residency candidates submit applications to neurosurgery programs nationwide. Based on various selection criteria, applicants are subsequently invited for in-person interviews.

When the COVID-19 pandemic hit the U.S. in March 2020, health care providers nationwide, including neurosurgeons, began focusing all efforts and resources on treating critical patients affected by the SARS-CoV-2 virus. Furthermore, health policies were enacted in various hotspots to limit viral transmission, including stay-at-home quarantine orders, travel restrictions, and strict limitations on hospital visitors. Taken together, these had a noticeable impact on the ability of medical students to participate in visiting sub-internships.

Recognizing that these away rotations are a critical portion of a student’s application for neurosurgery residency, in late April 2020, the Society of Neurological Surgeons (SNS) released its official guidance on external medical student rotations during the COVID-19 pandemic. The SNS recommended deferring all visiting medical student rotations for the 2020 application cycle.  Instead, the SNS recommended that students rotate internally with their home institution for eight weeks. For students enrolled in medical schools without a neurosurgery program, the SNS recommended rotating at the nearest Accreditation Council for Graduate Medical Education-accredited program. Regarding students’ letters of recommendation, the SNS recommended obtaining two letters from neurosurgery faculty and one additional letter from a general surgeon faculty member. Lastly, to further discourage traveling rotations, the SNS recommended against letters from faculty at external neurosurgery programs. Overall, these recommendations served to level the playing field for applicants in regions harder hit by the pandemic (e.g., those with more significant travel restrictions) and students without a home neurosurgery residency program.

In early May 2020, a coalition comprised of the American Association of Medical Colleges, Accreditation Council for Graduate Medical Education (ACGME), American Medical Association and others released a set of recommendations for external rotations and in-person interviews during the COVID-19 pandemic. First, the group discouraged away rotations among all specialties, except for medical students without an ACGME-accredited program at their home institution. Regarding interviews, the coalition recommended that programs commit to virtual interviews and site visits for all applicants, including local students. Lastly, the standard timeline for the ERAS was delayed to account for students’ missing or delaying rotations.

Given that much of the neurosurgery residency match has traditionally depended heavily on interpersonal interaction, letters of recommendation and in-person interviews, these changes to the application process were quite unique. Anyone familiar with the neurosurgery Twitter-sphere can attest to the growing interest in virtual sub-internships and residency program information sessions. As a community, we continue to adapt to the challenges posed by the COVID-19 pandemic. In many cases, we are finding more efficient ways to educate students and promote residency programs, which may be a transition point away from the traditional — and expensive — model of rotating, applying and interviewing for residency. In this series of blog posts, we highlight the challenges in the application process experienced by neurosurgical programs, medical students and others in organized neurosurgery and showcase their innovative responses during this critical time.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtags #Match2021 and #NeurosurgeryMatch.

Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
Rainbow Babies and Children’s Hospital
Cleveland, Ohio

 

 

 

Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.

April 13, 2021
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