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Troy M. Tippett

Organized neurosurgery through its Washington Committee developed a number of principles against which all health care reform legislation was measured, and none of the bills were acceptable. The American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) worked through multiple venues to modify or reject the legislation. In the author's view, the American Medical Association (AMA) supported the bills because its board of trustees was too focused on eliminating the sustainable growth rate, or SGR. Physicians failed to shape the health care debate. The leadership of many medical organizations was not prepared for the debate. Many had no experience in this arena and thus were too willing to let lobbyists dictate their position. In the future there are 3 things organized neurosurgery must do: be prepared, never give in, and stick with their principles. Organized neurosurgery must be prepared by developing leaders that have experience in the full spectrum of organized medicine. Neurosurgeons must not count on others, and because the specialty is small all must be involved. Neurosurgeons must never give in. Organized neurosurgery started 2009 with little support for its positions but by the end of the debate had convinced many other organizations, representing almost 500,000 physicians, to take their position. From an organizational point of view, neurosurgeons should now do 3 things: 1) reform or reject the AMA; 2) develop a real surgical coalition; and 3) change the current political environment. Neurosurgeons must also follow their principles. In the author's opinion the most important principles are: health care as a responsibility, medical liability reform, and the right to privately contract. In the United Kingdom and Germany, where health care is considered a right rather than a responsibility, bureaucratic entities determine whether you have the right to health care just as the Independent Payment Advisory Board, established under the new health care reform law in the US, will soon limit by rationing of health care under the guise of cutting costs. If, however, health care is a responsibility not a right, the obligation is shifted from society to the individual. It puts the patient and the doctor in charge. It is a far better mechanism to control costs and preserve quality without rationing. It becomes our obligation to have health care, and it puts us in charge of our destiny. Proven liability reform was not included in the health care legislation despite the fact that up to $200 billion per year is spent on defensive medicine. Another and possibly the most important principle ignored in the legislation is the right for a patient and his/her physician to privately contract under Medicare without penalty.

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Alton Brown Sisco, Troy M. Tippett II and Charles E. Chapleau

✓ A modification of the shape of currently available curettes is described that facilitates anterior cervical procedures performed with the operating microscope.

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Carotid endarterectomy

Review of 150 consecutive cases in two small community hospitals

Troy M. Tippett II, Alton B. Sisco and Charles E. Chapleau

✓ The authors have reviewed 150 consecutive carotid endarterectomies in 140 patients performed by three neurosurgeons. These were performed in two small community hospitals. There was an overall mortality rate of 1.3%; major or minor stroke was seen in 2.7% of patients and transient neurological dysfunction in 2.7%. Preoperative symptoms included major or minor stroke in 39.3% of patients and transient neurological dysfunction in 43.3%; 17.3% of patients were asymptomatic. The patients were continuously monitored intraoperatively with electroencephalography. There were two operative deaths, both related to myocardial infarction and both on the 2nd postoperative day. These statistics appear to compare favorably with those of series reported by major institutions. The average number of carotid endarterectomies per surgeon per year was 10. These were performed over a 7-year period (October, 1976, through November, 1983). Previous series have implied the need for higher frequency in performing the procedure to assure low morbidity and mortality rates. This series appears to offer evidence to the contrary. A key to these results has been that in 148 of the 150 operations, the primary surgeon has been assisted by one of the other two neurosurgeons. This affords the primary surgeon the benefit of excellent technical assistance, and also broadens the experience of the assisting surgeon, thereby allowing maximum experience from the small volume of cases.