Nelson “Nick” Hopkins, III, MD, FAANS(L) is revered as the father of endovascular neurosurgery. In addition to his many accolades and leadership positions in neurosurgery, he was a SUNY Distinguished Professor of Neurosurgery and Chair at the University at Buffalo (UB) from 1989 to 2013. Best venerated for his pioneering achievements in the field of endovascular neurosurgery, he innovated catheter-based minimally invasive treatment of vascular diseases in the brain and spine. He was my esteemed mentor and has trained countless other neurosurgeons throughout his career, many of whom have held the highest leadership positions in departments and academic organizations nationally and worldwide. Read More
As neurosurgeons, continuous improvement is essential to our growth. Self-reflection and self-improvement are core tenets instilled in us throughout training. During residency, this is built into our education, with discussions of quality, service and opportunities for improvement at the forefront.
But what about after residency? As we transition, we continue to refine what we do and how we practice, often adding new techniques to our repertoires. Residency and fellowship provide the framework to continue to grow, but the educational environment of practice may differ drastically depending on the practice setting. As of 2020, more than 50% of board-eligible candidates reported being in a non-academic practice setting.
To this end, the American Board of Neurological Surgery (ABNS) fosters excellence in patient care and supports our evolution in practice while maintaining high professional standards. The mission of the ABNS is to encourage the study, improve the practice, elevate the standards and advance the science of neurological surgery, thereby serving the cause of public health. There are three main areas where the ABNS continues to evolve to meet the needs of the field: primary examination, oral examination and continuous certification.
Primary examination. The ABNS continues to work towards evolving the primary exam to a mastery exam with clinically relevant questions that reflect current basic knowledge. In 2019, the neuroanatomy “mastery” module was introduced. Residents have four attempts to master the material, which is available for advance study. In the spirit of self-evaluation, residents and program directors are being surveyed for feedback to the ABNS about this module, and the ABNS is planning to closely follow primary examination anatomy scores for impact, with the anticipation that this module will help drive learning.
As of fall 2022, there were 118 Accreditation Council for Graduate Medical Education-accredited programs and 1,629 neurosurgery residents. In March 2023, a record 887 residents took the primary exam, of whom 249 took it for credit and the remainder were for self-evaluation. Question stems are released each year to support studying. The passing score (72% in 2023) is slowly increasing, and the ABNS directors and the National Board of Medical Examiners are completing more frequent standard setting for the exam.
ABNS Practice and Outcomes of Surgical Therapies (POST) and the Oral Examination. ABNS POST continues to evolve in response to current needs and feedback about the process. Current graduates now register and enter 10 cases into POST within the first six months of graduation for the ABNS to provide feedback and help track the transition to practice.
In response to the global pandemic, the oral examination changed to a virtual format for candidates. This was very well received and will continue with guest examiners traveling to pre-exam enrichment activities and conducting exams virtually. The ABNS surveys candidates and examiners for feedback about the exam process. In May 2023, 58% of candidates responded, of whom over 99% felt the application and registration process were clear and transparent, 98% felt the pre-exam session and materials were helpful, and 100% felt the exam was conducted professionally.
One candidate said, “The ABNS staff — along with the entire board certification application process — has been remarkably efficient, clear and professional. It is reassuring to see this kind of professionalism from the board, which represents our field. Overall, it was more impressive than I expected, and the level of professionalism of the staff and examiners made me proud to be in the field. Great work to the team(s) that put this together and make it possible.” Other suggestions for clarification and improvement are reviewed to help improve the oral examination process.
Continuous certification. Formerly known as maintenance of certification, the ABNS uses continuous certification to help assist diplomates in lifelong learning and self-assessment by encouraging, stimulating and supporting continued education in the practice of neurosurgery. Professionalism and participation in quality improvement are also assessed. The program is designed to allow diplomates to meet requirements, comply with state and hospital regulations, and reassure patients, families, payers, funding agencies and the public that ABNS diplomates continually improve their knowledge and practice in core neurosurgery. The ABNS has strongly advocated for continued learning instead of a high-stakes exam to better support the specialty’s needs.
Neurosurgeons continue to evolve and adapt to changes in our field, health care and the needs of our patients. Continuous improvement, self-reflection and self-improvement are essential. The ABNS aims to serve the cause of public health by our mission and values and by continually improving how we serve the field and our patients.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
After fast-paced, rewarding, but often exhausting years of completing highly technical neurosurgical training as a resident, the decision to pursue an additional one to two years of fellowship training is ultimately highly personal. As a mid-level resident, I weighed the pros and cons of this path after graduating in the context of my professional and personal goals.
Among the pros:
Greater job opportunities for those who have completed advanced subspecialty fellowship training;
Marketing opportunities in areas with significant market competition;
Exposure to and education on new procedures;
Refining surgical technique and learning variation in management;
Opportunities to educate residents; and
Expanding your professional network of mentors and advocates.
Among the cons:
The opportunity cost of delaying attending level salary;
Delaying building of your neurosurgical practice; and
Potential for another relocation following fellowship.
As a spine-focused neurosurgeon, I decided to pursue fellowship training at the Society of Neurological Surgeons Committee on Advanced Subspecialty Training-approved Stanford University School of Medicine program. I felt very fortunate to have worked with excellent spine faculty during my residency at the University of Michigan. I viewed the fellowship as adding to that foundation, particularly regarding the evaluation and decision-making for outpatients. As a resident, we would typically enter the elective spine care timeline near the end, with a pre-op patient ready to undergo a defined surgical procedure. The resident focused on the procedure’s safe and effective performance and high-quality immediate post-operative care. Time spent in the clinic can be variable and limited, particularly with a high-volume inpatient service. Yet, most spine operations are performed on patients who were referred to and evaluated in the clinic, and the vast majority of referred patients do not ultimately have surgery. It is paramount for the spine surgeon to identify who needs surgery to help them accomplish their goals, which operation is best suited to that objective, and how to maximize benefit while mitigating risk.
My fellowship, with equal time under the mentorship of Jon Park, MD, FAANS, FACS, and John K. Ratliff, MD, FAANS, FACS, was well-structured to address these topics and more. Following an attending meant following an attending’s schedule, providing a window into how independent practice feels over the course of a week, and an education on how to run a successful practice. We would typically spend two days per week in the clinic and two days in the operating room, with the fifth day available for add-on cases or academic work. Each of my mentors worked with talented advanced practice providers, so I gained insight into how this physician-led team-based approach made patient care more efficient. An efficient clinic means improved patient wait times and access. I saw how to communicate with referring physicians to coordinate care and develop professional relationships.
Perhaps most importantly, I learned a great deal about how to methodically evaluate the patients in the clinic to determine if they would benefit more from surgical or non-surgical care. It is helpful to remember that you can always bring patients back to the clinic to evaluate the results of additional testing or treatments. It is also useful to remember that there is almost always more than one reasonable surgical strategy if surgery is best suited to treating the situation. I developed new scripts to facilitate informed, shared decision-making regarding treatment options, elicit patient perspectives and address concerns. That has proven immensely valuable in independent practice.
The operative experience was valuable in learning new ways to accomplish operations I had seen or done before. For components of procedures that were already very familiar, fellowship affords more autonomy and a preview of what being an independent surgeon is. That made scrubbing into my first genuinely independent cases less stark of a difference. I had opportunities to “moonlight” on call, which also provided glimpses of independent practice. I also enjoyed operating with residents and learning how to teach in the operating room, which requires its own skillset. In weighing the pros and cons of fellowship, I can confidently state that the pros were undoubtedly more numerous. I will continue to benefit from a rewarding experience over the rest of my neurosurgical career.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
On Feb. 16, Medscape published an article, “‘Blog MD’: Medical Blogs That Physicians Love,” including Neurosurgery Blog on their list of 10 medical blogs for physicians. The article states, “the blog authored by the AANS and CNS tackles topics beyond brain surgery. Physicians and other specialists could learn from writings about a neurosurgeon’s approach to mentorship, artificial intelligence in the treatment of stroke patients, and creating a pathway for the next generation of neurosurgeons.”
In the last 12 years, the Neurosurgery Blog has published nearly 550 blog posts. The article notes that the blog’s mission is to investigate and report on how health care policy affects patients, physicians and medical practice and to illustrate that the art and science of neurosurgery encompass much more than brain surgery. Its health policy reporting efforts include multiple topic months and guest blog posts from key thought leaders and members of the neurosurgical community.
The Department of Neurosurgery at Stanford University is committed to inclusive excellence at all levels of education and training. Investing in outreach and pipeline programs exposes students to knowledge and opportunities otherwise unavailable. Our reach extends beyond Stanford and the surrounding community — we have reached students from all over the world who are interested in the neurosciences and are dedicated to learning. We are proud of the department’s work with outreach, including students locally, nationally and internationally. The future of neuroscience is bright.
Our multi-faceted initiatives aim to attract students to neurosciences throughout stages of their education, each with growing success in subsequent years. Through sharing our experience, we hope that others can create programs to assist with continuing to attract a diverse population to the neurosciences.
Stanford High School Neuroscience Forum The forum is an opportunity for students from around the world to share a project related to the neurosciences — neurology, psychology, mental health and more. The audience is local, national and International, including Stanford community members and students from around the world. This event allows connections of shared passions. This forum’s genesis, organization and implementation came from the idea and vision of four students who organize and moderate the events each year. For the 2023 Forum, we received applications from over 10 states, eight countries and four continents.
Neuroscience JClub Three young students initiated the Stanford Neuroscience JClub. This group intends to mentor high school students in critically analyzing a scientific paper and encourage participants to consider a career in the neurosciences. The club focuses on increasing access to the literature and the field. During the once-per-month meetings, students discuss scientific literature with expert Stanford scientists. We create a low-pressure and welcoming environment where students thrive, ask questions and learn. Since we have transitioned to a virtual setting, we have received interest from students from around the world. We had over 500 students apply to the 2023-2024 school year.
Harris Internship The Harris Internship is a school-year-long program that pairs students with Stanford faculty and trainees with expertise in neurosciences. The mentors are committed to the year-long program. The students have the opportunity to build a relationship with their mentor and receive guidance on navigating college applications and a future career in neuroscience. Students are also asked to promote increased engagement with women and/or underrepresented minorities. For 2022-2023, there are eight Harris interns. We have received triple-digit applications for the 2023-2024 school year. Twelve interns were selected for the academic year and have been paired with mentors.
Explore and inspire Explore & Inspire allows all college and medical students to join an intimate conversation with the Stanford Neurosurgery Department and team. The focus is on inclusive excellence. Career paths and overcoming obstacles are also discussed. We hope that students will receive guidance in navigating the neuroscience field and build a community of those interested in the neurosciences. Over 500 individuals registered for the event from approximately 36 states in the U.S. and 23 countries. We hope to continue hosting this event each year with different themes.
Summer of Neurosciences An innovative, multi-faceted summer learning experience aimed at allowing access and exposure to neuroscience and medicine in a virtual format. The Summer of Neurosciences program is designed to provide a learning experience and expose students to the many aspects and opportunities in Neuroscience. It includes career insights, grand rounds and a weekly journal club. In the summer of 2022, we hosted 50 participants from four countries, nine states, seven universities and 37 high schools.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
“You need to see a neurosurgeon.” Those words would likely make any person pause. Unlike the quip, it is brain surgery. Neurosurgery is a critical medical specialty — treating everything from tumors to strokes, Parkinson’s to cerebral palsy, aneurysms to spine fractures. The average neurosurgeon has spent at least 15 years in school and training after graduating high school — four years in college, four years in medical school and seven years in a neurosurgical residency. And that is the bare minimum, not including extra years of schooling to get a second degree — such as a master’s or doctorate — and subspecialty fellowship training after residency.
So, what exactly is the process of becoming a neurosurgeon? How do we “make” a neurosurgeon? Once a neurosurgeon is done with training, how do we ensure they continue practicing lifelong learning to stay at the top of their field? Our field is committed to ensuring that patients who need neurosurgical treatment are cared for by competent, empathetic and qualified neurosurgeons, implementing initiatives throughout medical education to ensure these goals are achieved.
Through this series, we will discuss how we “make and maintain” a neurosurgeon. How do we recruit a qualified and diverse workforce? How do we break down barriers for residency applicants to ensure that students match into programs where they will succeed? How do we adapt our training programs to changes in science and technology and adapt to ever-changing regulations? How do we learn from mistakes and teach future generations always to ask how we can be better? What are we doing to verify the quality of subspecialty fellowships for those who want additional training in a neurosurgical subspecialty? Once a neurosurgeon finishes training, how do we assess them? Our first several blogs in this series will highlight the work across the country in these many avenues.
Neurosurgery is dedicated to the practice of lifelong learning. So even when the formal education is completed, we continue to grow in our practices and careers. The second half of this series will follow neurosurgeons who can share their experiences. This includes self-reflection and assessment and a focus on continuous lifelong learning, considerations of adding new procedures with innovations in the field, moving beyond neurosurgery into other roles in medicine and a continuous reflection on our profession. Hence, we continue to evolve and evaluate the needs within our specialty and recruitment and maintenance of diversity in neurosurgery.
Just as science evolves, so must our field to ensure that we continue to provide the best neurosurgical care to our patients, founded on a solid educational background and with a mindset for continuous improvement.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
Dedicated to alleviating health care disparities, the Pathway to Neurosurgery program encourages high school students from underrepresented groups and/or disadvantaged backgrounds to pursue a career in neurosurgery. On Monday, Sept. 11, the Congress of Neurological Surgeons (CNS) Foundation will host the program at the 2023 Annual Meeting in Washington, DC.
Forty high school students from the E.L. Haynes Public Charter School will participate in a hands-on activity lab to give them insight into a day in a neurosurgeon’s life. Students will also attend lectures from leading neurosurgeons and hear from plenary talk guest speakers.
In recognition of this noteworthy program, the District of Columbia Mayor Muriel Bowserproclaimed Sept. 7-13 as Pathway to Neurosurgery Week. “The CNS is thrilled that Mayor Bowser has recognized the Pathway to Neurosurgery program. As CNS president, it has been a privilege to witness the growth and development of this critical mission-centric project, offering exposure to the wonders of neuroscience to these exceptional students,” states Elad I. Levy, MD, MBA, FAHA, FACS, FAANS, CNS president and professor and chair of neurosurgery at the State University of New York at Buffalo.
“African Americans, Hispanic Americans and women are significantly underrepresented in neurosurgery, and the CNS Pathway to Neurosurgery program aims to address this problem by promoting diversity, equity and inclusion in neurosurgery. Our goal is to inspire students to consider neurosurgery as a career option to foster innovations in patient care that can improve outcomes and reduce minority health disparities,” said Tiffany R. Hodges, MD, co-chair of the CNS Diversity, Equity, and Inclusion Committee and associate professor of neurosurgery at Case Western Reserve School of Medicine. Only 4% of practicing neurosurgeons in the U.S. are Black, 5% are Hispanic and 8% are women. In contrast, approximately 14% of the U.S. population are Black, 19% are Hispanic and 50% are women.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @CNS_Update and using the hashtag #PathwaytoNeurosurgery.
From time to time on the Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will interest our readers. We wanted to bring attention to a recent publication in Neurosurgery, the official journal of the Congress of Neurological Surgeons. The article, “Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk” was published as part of Neurosurgery’s High-Impact Manuscript Service (HIMS).
Published in the May issue of Neurosurgery, the article is a retrospective study conducted by an international, multicenter team. Lead author Hussam Abou-Al-Shaar, MD of the University of Pittsburgh Medical Center in Pittsburgh, Pa. and colleagues reviewed data from 12 surgical centers around the world and a total of 267 patients with 328 vestibular schwannomas who underwent stereotactic radiosurgery. They found that stereotactic radiosurgery is effective while preserving serviceable hearing and not causing radiation-related tumor development or malignant transformation.
According to the Wolters Kluwer press release, “Dr. Abou-Al-Shaar’s group concludes that their results point to the need for early treatment of vestibular schwannoma in patients with [neurofibromatosis type 2]. ‘Tumor volume appeared to significantly impact tumor control and freedom from additional treatment, advocating for early stereotactic radiosurgery to maximize benefits and delay clinical deterioration.’”
To read the Neurosurgery article, click here. The complete May issue is here.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NeurosurgeryCNS and using the hashtag #neurosurgery.
The Medicare physician payment system is on an unsustainable path that has failed to keep up with inflation over the years, threatening patient access to care. The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) are actively engaged in preventing steep Medicare payment cuts and preserving patient access to care through the Surgical Care Coalition. The coalition is in year three of its campaign to stop these cuts and implement lasting changes to the physician payment and quality improvement systems.
On Jan. 1, 2023, neurosurgeons face a minimum 8.5% Medicare payment cut, including a nearly 4.5% cut for all Medicare Physician Fee Schedule services and a 4% Statutory Pay-As-You-Go Act cut, triggered due to new federal spending. After successfully protecting patients’ timely access to quality surgical care in 2020 and 2021 by securing Congressional action to mitigate proposed cuts to Medicare, the coalition is fighting against similar cuts proposed for 2023. The AANS and the CNS are also working with Congress on long-term solutions to fix these broken systems. To that end, we submitted detailed comments in response to a Congressional request for information.
The people who the proposed cuts will most impact are our patients. Every day, neurosurgeons take care of some of the sickest patients who face painful and life-threatening neurologic conditions. Alexander A. Khalessi, MD, FAANS, John K. Ratliff, MD, FAANS and Maya A. Babu, MD, FAANS, share their experiences as neurosurgeons and how the cuts will impact neurosurgical practices and their patients. The videos are available as follows:
Editor’s Note:We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @SurgeonsCare.
From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that may be of interest to our readers. Today’s post originally appeared on AL.com on Nov. 1, titled “Why is it hard for grandma to see her doctor?” In the op-ed, Richard Menger, MD, MPA, assistant professor of neurosurgery and political science at the University of South Alabama in Mobile, Ala., discusses how steep Medicare physician payment cuts scheduled to go into effect on Jan. 1, 2023, are not a good prescription for a healthy physician workforce.
The average physician will receive 8.5% less for providing the same services they did last year. While adjusting for inflation, Medicare payments to physicians have declined 22% from 2001-2021. According to Dr. Menger, “The people most impacted by these cuts will be our Medicare patients. In the backdrop of inflation, practices will not be able to sustain themselves by treating Medicare patients.” Dr. Menger concludes by stating that this puts seniors at risk for reduced access to care.
Marjorie Wang, MD, MPH, FAANS
Jay K. Nathan, MD
The Department of Neurosurgery at Stanford University is committed to inclusive excellence at all levels of education and training. Investing in outreach and pipeline programs exposes students to knowledge and opportunities otherwise unavailable. Our reach extends beyond Stanford and the surrounding community — we have reached students from all over the world who are interested in the neurosciences and are dedicated to learning. We are proud of the department’s work with outreach, including students locally, nationally and internationally. The future of neuroscience is bright.
Julia Blanchet
Maria Ceja
Reena P. Thomas, MD, PhD
Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
From time to time on the Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will interest our readers. We wanted to bring attention to a recent publication in 
According to the Wolters Kluwer 
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NeurosurgeryCNS and using the hashtag #neurosurgery.
