Neurosurgery Should be Leading Light in Medicine and Community

The case load and distribution of neurosurgeons around the world

The other day someone showed a photo of an angry person with the caption of a neurosurgeon responding to the complaint of the neurological status of his patient. Since the days of the pioneers of neurosurgery including Harvey Cushing we as a specialty have always struggled to prove our relevance and necessity to society. Among our medical colleagues they often feel sympathy for our hard work but doubt that it really helps most of our patients. Similarly the public often views us at times heroically or other times seriously impotent to treat hopeless conditions.
In 2018 a global survey of neurosurgery (see the enclosed photo)showed growing around the world and even in developing countries. This is a good thing. At the same time over the past several decades there has been increasing emphasis from stakeholders and political authorities for medical providers to show the effectiveness of their work and costs. What doctors do is now called relative value units and it is matched against assigned niches for our small specialty in health care budgets (both public and private).
Since I was resident about 40 years ago wonderful developments have occurred such as MRI, intravascular intervention for aneurysm, spinal instrumentation, computerized navigation, endoscopic procedures etc. As a resident we are fascinated by these wonders and the science behind them but then when residency is over we do have to make our way in the real world. It is easy and totally understandable to be drawn to lucrative fields especially spine surgery as I was because it offers frankly good rewards for hard work as well as being so ubiquitous in the population. Unfortunately it is also the field most rift with poor science and loose surgical indications such that many of our medical colleagues tend to look down upon those whose career mostly deals with this field.
The enthusiasm for complicated cases of the brain and head injury treatment often wane as one passes from the academic training environment to the realm of sustaining oneself in the world which is understandable. In discussing this I am not passing any judgment just reflecting upon a fact of life.
My advice to young neurosurgeons including my residents and fellows as well as especially those developing their careers in countries where neurosurgery is relatively new is to try to balance your contributions to society with your own financial rewards. Stay involved in teaching and research. Joining with public health officials in documenting the needs of traffic and accident victims will make society see the need for advancing neurosurgical care. Cooperate with fellow neurosurgeons and the medical community to educate stakeholders and public about how emergency care and neurosurgical centers (including trauma centers) can save so many who will continue to lead productive lives. Promote professional standards about spine care and be wary of becoming too entwined in the medical legal system. During surgery on patients who are not a risk of neurological deterioration but are likely to continue to be chronic pain sufferers does not improve your reputation or that of your profession. Let neurosurgery be the light of your medical community.

The Need for Physician-Scientists in Ethiopia

Discussing multidisciplinary research at Mekelle University

Ethiopia is now at a point where non-communicable disease is overtaking the classic major infectious and malnutrition disorders which dominated the major morbidity and mortality for the country. Now more than ever with scant resources and unique cultural situations there is a need for effective clinically related medical research at the top universities in Ethiopia.  Effective clinically related medical research in Ethiopia requires that academic medical centers begin to train physician-scientists.

Unfortunately the model of how to do medical research and by whom it should be directed and/or overseen is outdated. Because medical schools lagged behind the development of fields like Public Health and Nursing these entities dominated the university structure. At the beginning there were no specialists and very physicians who were so overworked they really had no time for training in methods of research let alone doing it.

Today over 50% of the needs of Ethiopian doctors require specialist training. Additionally the experiments such as occurred in British National Health Service of relying on mostly non-physician scientists to direct and oversee medical research backfired. In the current system almost no funds are directed to physician directed medical research yet Ethiopia desperately needs physician-scientists to lead the way into dealing the health care needs of a growing population of over 100 million people.

We are currently advocating changing this system at Mekelle University. Similar changes are already occurring at St. Pauls Millenium and Addis Ababa University in Addis Ababa, Ethiopia.

The Alliance for Academic Internal Medicine has published these recommendations for training physician-scientists which I think should be strongly considered for adoption wholly or least substantially in Ethiopian university training centers.

Summary of Best Practice Recommendations for Physician-Scientist
(The American Journal of Medicine, Vol 131, No 5, May 2018)
Physician-Scientist Training Programs (PSTPs)
Curriculum and Infrastructure
A. Providing combined residency and subspecialty fellowship training is an attractive feature.
B. PSTPs should include training in study design, biostatistics, team science, ethics, scientific regulatory requirements,
institutional review board application, grant writing, time management, leadership, work/life balance, and mentor/mentee
C. Directors of PSTPs would benefit from organizing a formal alliance and meeting regularly.
Recruitment and Selection of Trainees
A. Candidates for PSTPs most likely to translate their training into successful careers as well-established physician-scientists
are those who have significant research experience and can demonstrate a balanced commitment to both science and
B. PSTPs should make increasing diversity among its trainees a stated goal, with active efforts to recruit qualified women and
members of underrepresented minority populations.
C. Initiatives to recruit qualified international medical graduates as trainees should be increased and additional sources of
funding for international medical graduates trainees should be pursued.
Mentorship Practices
A. Mentoring teams are essential for PSTP trainees and should be carefully crafted.
B. Mentors need to be formally trained in mentoring, and they need to be recognized for their contributions.
4. Funding of PSTPs and Their Trainees
A. The success of PSTPs and their trainees is highly dependent on strong institutional support.
B. The success of PSTPs and their trainees is also highly dependent on adequate levels of external funding including the
successful receipt of individual career development awards.
Tracking Success of PSTPs and Their Graduates
A. Success factors of PSTPs and their graduates should be tracked.
B. Tracked data should be coordinated with other PSTPs and shared in a national data base.
6. Sustaining PSTPs and Employing Continuous Improvement Practices
A. Sustainability is contingent on institutional support and an adequate census of qualified applicants.
B. Sustainability is also impacted by the percentage of trainees who successfully complete their training.