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Changing our culture

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Deborah L. Benzil

Today, a great challenge of our profession is to envision how we will deliver exemplary neurosurgical care in the future. To accomplish this requires anticipating how economic, political, and societal influences will affect our ability to provide the highest quality of patient care in an arena that will look increasingly different from today's world of medicine. Already, our profession is battling a relentless assault as numerous sectors implement change that impacts us and our community every day. Surviving this requires an effective strategy that will involve significant cultural change. To accomplish this, neurosurgery must take an honest look inward and then commit to being the agents of positive cultural change.

Such a path will not be easy but should reap important benefits for all of neurosurgery and our patients. Several practical and proven strategies can help us to realize the rewards of changing our culture. Vital to this process is understanding that effecting behavioral change will increase the likelihood of achieving sustainable cultural change. Innovation and diversity are crucial to encourage and reward when trying to effect meaningful cultural change, while appreciating the power of a “Tipping Point” strategy will also reap significant benefits.

As a profession, if we adopt these strategies and tactics we can lead our profession to proceed in improvement, and as individuals we can use the spirit that drove us into neurosurgery to become the agents of an enduring and meaningful cultural change that will benefit our patients and us.

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Susan R. Durham, Katelyn Donaldson, M. Sean Grady and Deborah L. Benzil

OBJECTIVE

With nearly half of graduating US medical students being female, it is imperative to understand why females typically make up less than 20% of the neurosurgery applicant pool, a number that has changed very slowly over the past several decades. Organized neurosurgery has strongly indicated the desire to overcome the underrepresentation of women, and it is critical to explore whether females are at a disadvantage during the residency application process, one of the first steps in a neurosurgical career. To date, there are no published studies on specific applicant characteristics, including gender, that are associated with match outcome among neurosurgery resident applicants. The purpose of this study is to determine which characteristics of neurosurgery residency applicants, including gender, are associated with a successful match outcome.

METHODS

De-identified neurosurgical resident applicant data obtained from the San Francisco Fellowship and Residency Matching Service for the years 1990–2007 were analyzed. Applicant characteristics including gender, medical school attended, year of application, United States Medical Licensing Exam (USMLE) Step 1 score, Alpha Omega Alpha (AOA) status, and match outcome were available for study.

RESULTS

Of the total 3426 applicants studied, 473 (13.8%) applicants were female and 2953 (86.2%) were male. Two thousand four hundred forty-eight (71.5%) applicants successfully matched. USMLE Step 1 score was the strongest predictor of match outcome with scores > 245 having an OR of 20.84 (95% CI 10.31–42.12) compared with those scoring < 215. The mean USMLE Step 1 score for applicants who successfully matched was 233.2 and was 210.8 for those applicants who did not match (p < 0.001). Medical school rank was also associated with match outcome (p < 0.001). AOA status was not significantly associated with match outcome. Female gender was associated with significantly lower odds of matching in both simple (OR 0.59, 95% CI 0.48–0.72) and multivariate analyses (OR 0.57, 95% CI 0.34–0.94 CI). USMLE Step 1 scores were significantly lower for females compared to males with a mean score of 230.1 for males and 221.5 for females (p < 0.001). There was no significant difference in medical school ranking or AOA status when stratified by applicant gender.

CONCLUSIONS

The limited historical applicant data from 1990–2007 suggests that USMLE Step 1 score is the best predictor of match outcome, although applicant gender may also play a role.

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James K. Liu, Scott Forman, Chitti R. Moorthy and Deborah L. Benzil

Optic nerve sheath meningiomas (ONSMs) represent 1 to 2% of all meningiomas and one third of all optic nerve tumors. The management of ONSMs is controversial. Traditional surgical removal often results in postoperative blindness in the affected eye and thus has been abandoned as a treatment option in most patients. Surgery may be unnecessarily aggressive, especially if the patient has useful vision. When these tumors are left untreated, however, ensuing progressive visual impairment may lead to complete blindness. More recently, radiotherapy has gained wider acceptance as a treatment for these lesions. The authors of some reports have suggested that fractionated stereotactic radiosurgery (SRS) may be the best option for treating primary ONSMs. In patients with documented progressive visual deterioration, fractionated SRS may be effective in improving or stabilizing remaining functional vision. The authors review the clinical presentation, radiographic characteristics, and management of ONSMs, emphasizing the use of fractionated SRS.

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Kaushik Das, Deborah L. Benzil, Richard L. Rovit, Raj Murali and William T. Couldwell

✓ Irving S. Cooper (1922–1985), the son of a salesman, worked his way through high school, college, and medical school to become one of the pioneers in functional neurosurgery. He developed several novel techniques for the surgical management of Parkinson's disease and other crippling movement disorders. A keen interest in the physiology of movement disorders was kindled by his doctoral research and continued during his neurosurgical training. He began to apply this knowledge to surgical practice in 1952 when he began his faculty career as Assistant Professor of Surgery at New York University. At the time, surgical treatment of parkinsonian tremor focused on various techniques used to interrupt the pyramidal tract. During a subtemporal approach for a cerebral pedunculotomy, he inadvertently injured and, subsequently, was forced to occlude the anterior choroidal artery. Much to Cooper's surprise, following emergence from anesthesia the patient's tremor and rigidity were abolished without any residual hemiparesis. This serendipitous observation, together with Meyer's earlier work on the role of the basal ganglia in motor control, helped focus surgical efforts on targets within the basal ganglia and, subsequently, within the thalamus to alleviate the movement disorders associated with Parkinson's disease. While at New York University, Cooper developed chemopallidectomy and, later at St. Barnabas Hospital in the Bronx (1954–1977), he used cryothalamectomy as a surgical technique for primary control of tremor in patients with Parkinson's disease. Cooper authored many original papers on surgical techniques and several textbooks on the lives of patients afflicted with Parkinson's disease and other crippling movement disorders. Although considered controversial, this fascinating and complex neurosurgeon made significant contributions to this field.

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R. Loch Macdonald

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Salvador Espinoza, Mehran Saboori, Scott Forman, Chitti R. Moorthy and Deborah L. Benzil

✓ Thyroid-related ophthalmopathy (TRO), a debilitating condition involving a range of visual and orbital symptoms, occurs in up to 40% of patients with Graves disease. The goals of treatment include correcting thyroid dysfunction, relieving ocular pain, preserving vision, and improving cosmetic appearance. Options for therapy include symptomatic treatment, glucocorticoid medication, radiation therapy, and surgery. Traditional radiation treatment uses small opposed bilateral fields consisting of retrobulbar volumes and customized blocks to shield periorbital structures. The combination of intensity-modulated radiotherapy (IMRT) and stereotactic technology facilitates the administration of radiation to patients suffering from TRO and provides greater safety and efficacy than traditional treatment. The authors present the case of a patient with severe TRO whose symptoms resolved rapidly after treatment with stereotactic IMRT. The outcome in this case supports stereotactic IMRT as an effective treatment option for patients with TRO who also undergo radiation therapy.

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Deborah L. Benzil, Mehran Saboori, Alon Y. Mogilner, Ronald Rocchio and Chitti R. Moorthy

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity.

Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures.

Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity.

Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

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Bradley R. Crammond, MBiostat, Neela Janakiramanan, Mario Ganau, Deborah Verran, Laura Lippa, Jonathan Braman and Katrin Rabiei

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Rimal H. Dossani, Danielle Terrell, Jennifer A. Kosty, Robert C. Ross, Audrey Demand, Elizabeth Wild, Racheal Peterson, Laura B. Ngwenya, Deborah L. Benzil and Christina Notarianni

OBJECTIVE

The objective of this study was to evaluate whether there are disparities in academic rank and promotion between men and women neurosurgeons.

METHODS

The profiles of faculty members from 50 academic neurosurgery programs were reviewed to identify years in practice, number of PubMed-indexed publications, Doctor of Philosophy (PhD) attainment, and academic rank. The number of publications at each academic rank was compared between men and women after controlling for years in practice by using a negative binomial regression model. The relationship between gender and each academic rank was also determined after controlling for clustering at the institutional level, years in practice, and number of publications.

RESULTS

Of 841 faculty members identified, 761 (90%) were men (p = 0.0001). Women represented 12% of the assistant and associate professors but only 4% of the full professors. Men and women did not differ in terms of the percentage holding a PhD, years in practice, or number of publications at any academic rank. After controlling for years in practice and clustering at the facility level, the authors found that men were twice as likely as women to be named full professor (OR 2.2, 95% CI 1.09–4.44, p = 0.03). However, when institution, years in practice, PhD attainment, h-index, and number of publications were considered, men and women were equally likely to attain full professorship (OR 0.9, 95% CI 0.42–1.93).

CONCLUSIONS

Data analysis of the top neurosurgery programs suggests that although there are fewer women than men holding positions in academic neurosurgery, faculty rank attainment does not seem to be influenced by gender.

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Jaclyn J. Renfrow, Analiz Rodriguez, Ann Liu, Julie G. Pilitsis, Uzma Samadani, Aruna Ganju, Isabelle M. Germano, Deborah L. Benzil and Stacey Quintero Wolfe

OBJECT

Women compose a minority of neurosurgery residents, averaging just over 10% of matched applicants per year during this decade. A recent review by Lynch et al. raises the concern that women may be at a higher risk than men for attrition, based on analysis of a cohort matched between 1990 and 1999. This manuscript aims to characterize the trends in enrollment, attrition, and postattrition careers for women who matched in neurosurgery between 2000 and 2009.

METHODS

Databases from the American Association of Neurological Surgeons (AANS) and the American Board of Neurological Surgery (ABNS) were analyzed for all residents who matched into neurosurgery during the years 2000–2009. Residents were sorted by female gender, matched against graduation records, and if graduation was not reported from neurosurgery residency programs, an Internet search was used to determine the residents’ alternative path. The primary outcome was to determine the number of women residents who did not complete neurosurgery training programs during 2000–2009. Secondary outcomes included the total number of women who matched into neurosurgery per year, year in training in which attrition occurred, and alternative career paths that these women chose to pursue.

RESULTS

Women comprised 240 of 1992 (12%) matched neurosurgery residents during 2000–2009. Among female residents there was a 17% attrition rate, compared with a 5.3% male attrition rate, with an overall attrition rate of 6.7%. The majority who left the field did so within the first 3 years of neurosurgical training and stayed in medicine—pursuing anesthesia, neurology, and radiology.

CONCLUSIONS

Although the percentage of women entering neurosurgical residency has continued to increase, this number is still disproportionate to the overall number of women in medicine. The female attrition rate in neurosurgery in the 2000–2009 cohort is comparable to that of the other surgical specialties, but for neurosurgery, there is disparity between the male and female attrition rates. Women who left the field tended to stay within medicine and usually pursued a neuroscience-related career. Given the need for talented women to pursue neurosurgery and the increasing numbers of women matching annually, the recruitment and retention of women in neurosurgery should be benchmarked and assessed.