NUMBER 24
AMERICAN BOARD OF NEUROLOGICAL SURGERY 2006

NEUROLOGICAL SURGERY is a discipline of medicine and that specialty of surgery that provides the operative and non-operative management (i.e. prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply; the evaluation and treatment of pathological processes that modify the function or activity of the nervous system, including the hypophysis; and the operative and non-operative management of pain. As such, Neurological Surgery encompasses the surgical, non-surgical, and stereotactic radiosurgical treatment of adult and pediatric patients with disorders of the nervous system: disorders of the brain, meninges, skull, and skull base, and their blood supply, including the surgical and endovascular treatment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; disorders of the pituitary gland; disorders of the spinal cord, meninges, and vertebral column, including those that may require treatment by fusion, instrumentation or endovascular techniques; and disorders of the cranial and spinal nerves throughout their distribution.

The broad aim of the AMERICAN BOARD OF NEUROLOGICAL SURGERY is to encourage the study, improve the practice, elevate the standards, and advance the science of neurological surgery, and thereby to serve the cause of public health.

ROBERT A. SOLOMON, MD CHAIRMAN

M. SEAN GRADY, MD SECRETARY

H. HUNT BATJER, MD CHAIRMAN, MAINTENANCE OF CERTIFICATION COMMITTEE

WARREN R. SELMAN, MD MAINTENANCE OF CERTIFICATION COMMITTEE WEBSITE & MYMOC COORDINATOR

RICHARD B. MORAWETZ, MD CHAIRMAN, CREDENTIALS COMMITTEE

MARC A. MAYBERG, MD TREASURER

ROBERT A. SOLOMON, MD CHAIRMAN

I am pleased to provide a report to you on the activities of the American Board of Neurological Surgery over the past year.

Resident Numbers and Neurosurgical Match
During the 2005-2006 academic year, there were 95 neurosurgical residency training programs in the United States accredited by the Residency Review Committee for Neurological Surgery (RRC) under the Accreditation Council for Graduate Medical Education (ACGME). Eight hundred sixty-six residents were in training (11% women), and 146 graduated in June 2006.

In January 2006, 352 individuals registered for the Neurosurgery Match Program. Two hundred sixty-one rank lists were submitted, an increase of 1.6% from the previous year. Two hundred eighteen lists were ranked and 165 matched.

PGY1 Curriculum
The ABNS has partnered with the RRC in an effort to improve the PGY1 experience in neurosurgery. The Board has endorsed the RRC plan for neurosurgical Program Directors to control the educational content of the year. The ACGME approved the plan, and it became effective July 1, 2006. The internship year may now include up to three months of neurology and three months of neurosurgery. At least six months must consist of surgery other than neurosurgery.

Resident Duty Hours
Neurosurgical Program Directors have largely come into compliance with the new ACGME guidelines on resident duty hours. A significant number of neurosurgery programs have an eight hour duty exception extending the 80 hour restriction for their senior residents. The ABNS is uncomfortable with the erosion of training opportunities that has already resulted from the work hours restrictions.

The European Commission and Parliament have launched legislation stating that no more than 48 hours of duty per week can be conducted. The European Union of Medical Specialist is highly concerned about the effect on surgical specialty training and has requested a significant increase in duty hours to 60 per week. The Board is deeply concerned that the "European Working Time Directive" may subsequently influence policy in the U.S.

The standards of neurosurgical practice in the U.S., which have been developed over the last 50 years, are already jeopardized by the existing work hour restrictions. The ABNS stands adamantly opposed to any further reduction in the resident training experience.

Primary Examination
The ABNS written Primary Examination is administered annually to neurosurgical trainees throughout the U.S. The multiple choice examination covers the breadth of neurosurgery’s clinical and basic science curricula. It may be taken for self-assessment, but the training requirements of the ABNS and RRC specify that the examination must be passed during training in order to complete residency. Many Program Directors require trainees to pass it before progressing to chief resident. In March 2006 the Primary Examination was administered to 525 examinees at 97 test centers. Two hundred twelve took it for credit and 313 for self-assessment. There was a 13% fail rate among the candidates who took the examination for certification.

Oral Examination
Oral examinations are the final step in the ABNS certification process. They are administered each spring and fall to neurosurgical practitioners who have applied for certification. Candidates must have graduated from ACGME accredited neurosurgical residency training programs, hold unencumbered medical licenses and hospital privileges, demonstrate good professional standing as assessed by mentors and peers, and show satisfactory practice performance by review of a minimum of one year of operative cases.

In November 2005, 73 candidates sat for oral examination with a 12% failure rate. In May 2006, 73 candidates were examined; the failure rate was 15%. Each candidate’s performance is scored numerically by six examiners. The pass/fail status is then determined from the grades by a computer program so as to maximize objectivity in the process. Standardized questions are used for a portion of the examination.

Maintenance of Certification (MOC)
The ABNS issued its first ten-year time-limited certificates in May 1999. Since then it has worked to develop all of the components of a neurosurgical MOC program that meets the requirements of the American Board of Medical Specialties (ABMS). The ABNS has now completed work on its MOC program and been given the approval of the ABMS Committee on Certification, Subcertification, Recertification and Maintenance of Certification (COCERT) for all four parts.

The ABNS has partnered with the AANS to develop "MyMOC", a web enabled, personalized site for members to monitor their progress through all components of the ten-year MOC requirements. MyMOC is accessed via the ABNS website. Dr. Selman is heading up this work.

ABMS
The ABNS remains committed to the efforts of the ABMS and participates in the Surgical Caucus sponsored by the American College of Surgeons (ACS). Dr. William F. Chandler, ABNS Past Chairman, is currently serving a three-year term as the ABNS representative on the newly organized ABMS Board of Directors.

Practice Data Project – NeuroLog
NeuroLog is an internet based, data collection tool developed by the ABNS to facilitate the gathering of information necessary for certification. The system is highly secure and HIPAA compliant. In August 2006 the Board began a process of transitioning the program from the previous relationship with DataHarbor to a new host, Outcome Sciences. At the same time several upgrades are going on.

Applicants for primary certification now use NeuroLog to record their practice data on all in-patients during a current, consecutive twelve month period. The program compiles the information and creates a summary report, which along with the data is reviewed for approval by ABNS Directors. This fulfills one of the requirements of the application for certification. NeuroLog provides all of the necessary data fields and is an online mechanism for the Professional Practice Data Committee to review the data thereby expediting that process.

Program Directors use NeuroLog to accumulate the data required for RRC accreditation. It tracks the necessary elements for residents and attending physicians in order to meet current documentation standards. The cataloging of operative data is streamlined and yields both CPT codes and appropriate ABNS and RRC procedural categories.

Strategic Planning
The ABNS initiated a Strategic and Long Range Planning process during its 2006 Winter Directors Meeting. A Strategic Plan was formulated to prioritize the activities of the Board over the next three to five years. The outcome of the meeting identified three goals:

• Financial stability for the ABNS,
• Modernization of information technology, and
• Subspecialty recognition and residency redesign.

The committee structure of the Board has been redesigned so that separate committees address the three goals. The January 2007 Winter Meeting will be devoted almost entirely to the issue of subspecialty recognition. Participation will include representatives from the RRC, AANS, Society of Neurological Surgeons (SNS) and another ABMS Board that presently confers subspecialty certificates.

Revocation of Certification
At its meeting in May 2006, the ABNS held hearings on revocation of four certificates. All four were revoked. One Diplomate returned his certificate rather than have a formal hearing.

ABNS Directors
At its spring 2006 meeting in Houston, Drs. William F. Chandler, A. John Popp, and Jon H. Robertson completed their six years of contributions and leadership on the Board. They will now serve six years on the ABNS Advisory Council. Newly elected Directors are Drs. Daniel L. Barrow, William T. Couldwell, and Craig A. Van Der Veer. New officers for the 2006-2007 year are Dr. Robert A. Solomon, Chairman, and Dr. Richard B. Morawetz, Vice-Chairman. Dr. M. Sean Grady remains as Secretary, and Dr. Marc R. Mayberg remains as Treasurer.

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M. SEAN GRADY, MD SECRETARY

OPERATIVE DATABASE
Allow me to update you on a few items currently of great interest to the ABNS.

Operative Database
As of August 28, 2006, after a lengthy development period, NeuroLog has been moved to be hosted by Outcome Sciences. Data entry forms have been modified to make them more efficient for users, reviewers, and program directors. Data are now placed in a comma separated value format that can be downloaded into Excel or other programs for analysis as desired by users. Further, the system incorporates a data analysis tool that is automatically available to Program Directors and can be purchased by individual users for $25 a month. Historical data should be loaded into the system for availability in October.

About 70% of residency programs use NeuroLog as their operative database. For Program Directors, the residency reports needed by the RRC will be in the identical format as those seen on the ACGME website. In the near future, a mechanism whereby data can be entered from a single source and sent to the ABNS and ACGME simultaneously will be identified and tested for feasibility.

At the conclusion of residency, trainees must submit their case logs to the ABNS to be added to their applications for certification later on. Since the NeuroLog system is only three years old, it does not capture the entire operative experience. Accordingly, this information must be summated onto hard copy. The format used is identical to the Resident Operative Experience Report required by the RRC.

Strategic Planning: Subspecialty Recognition and Residency Redesign
At the 2006 Winter Directors Meeting, a full day was committed to strategic planning. The Directors, led by Dr. A. John Popp, identified three strategic goals: financial stability, information technology, and subspecialty recognition and residency redesign. Financial stability is being reviewed by the Finance Committee. A new committee called the Committee on Administration and Technology was formed to take on IT strategy, and the Committee on Educational Requirements and Subspecialization is working on subspecialty recognition and residency redesign.

The focus of the upcoming Winter Meeting will be on the third goal, subspecialty recognition and residency redesign. The topic’s importance is underscored by the newly published requirements for endovascular neurosurgery established by the SNS Committee on Accreditation of Subspecialty Training (CAST). Issuance by the ABNS of subspecialty certificates holds numerous implications for Diplomates and has been a point of considerable discussion over the years. The ABNS will report back to Diplomates the outcome of these discussions.

Directors and Officers
ABNS Directors are often asked how they are selected. Briefly, six organizations sponsor Directors to the Board.

American Association of Neurological Surgeons Society of Neurological Surgeons Congress of Neurological Surgeons American Academy of Neurological Surgery American College of Surgeons Neurosurgical Society of America

4 4 3 1 1 1

Directors, who serve for six years, have staggered terms so that each year two or three new individuals are elected. About six months prior to the end of a Director’s term, the sponsoring organization submits a list of at least five neurosurgeons for consideration. These are sent out to the fourteen current Directors for voting. The ABNS Recommendations Committee – New Directors, with input from the Advisory Council, then makes up a slate, and at their May meeting, Directors vote. Selection is based on several factors, including the candidate’s interest in neurosurgical education, performance as a guest oral examiner, the expertise the individual would bring to the Board, and maintaining a balance of academic versus private practice, as well as a geographic balance. All Directors serve without compensation. The current Directors and their sponsoring organizations are listed on the back of this Newsletter.

Officers of the Board are elected annually by the then current Directors. A slate is put together and presented by the Recommendations Committee – New Officers with input from the Advisory Council. It also is voted on by Directors at their May meeting. The chairman and vice chairman/chairmen are usually in their last year of service to the ABNS, while the secretary and treasurer serve terms of three to five years.

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H. HUNT BATJER, MD CHAIRMAN, MAINTENANCE OF CERTIFICATION COMMITTEE

MAINTENANCE OF CERTIFICATION

MOC for ABNS Diplomates began in January 2006. As of this writing, 167 Diplomates have applied to the Board and initiated the process. While the ABNS only requires that Diplomates with time-limited certificates (individuals certified during or after 1999) participate in MOC, all Diplomates are encouraged to join. It is likely that in the future participation by all specialists will be required by the Center for Medicare and Medicaid Services, third party payors, State Medical Licensing Boards, hospital credentialing committees, and potentially even malpractice insurers.

The concept of MOC is based on the six general competencies: Medical Knowledge, Patient Care, Interpersonal and Communication Skills, Professionalism, Practice-Based Learning and Self-Improvement, and Systems-Based Practice. In addition, MOC has four basic components:

• Part I – Evidence of Professional Standing
• Part II – Evidence of Commitment to Lifelong Learning and Periodic Self Assessment
• Part III – Evidence of Cognitive Expertise
• Part IV – Evidence of Evaluation of Performance in Practice All four components are covered by the ABNS MOC Program, which has been approved in full by the ABMS.
• Part I – Evidence of Professional Standing will be assessed on a three-year cycle in the following ways:

All four components are covered by the ABNS MOC Program, which has been approved in full by the ABMS.

Part I – Evidence of Professional Standing will be assessed on a three-year cycle in the following ways:

1. Full unrestricted license to practice medicine in all jurisdictions in which the Diplomate is licensed
2. Unrestricted hospital admitting privileges to practice neurosurgery
3. Recommendation from the Chief of Staff of the participant’s primary hospital

Part II – Evidence of Commitment to Lifelong Learning and Periodic Self-Assessment will require on a three-year cycle:

1. 150 hours of CME: 60 hours of Category I and 90 hours of other Category I or Category II hours, 80% of the total to be neurosurgical. CME tracking is coordinated with the AANS
2. The Self-Assessment in Neurological Surgery (SANS) examination developed and administered by the CNS. The examination provides feedback to participants regarding the correct answer for each of the 200 questions.

Part III – Evidence of Cognitive Expertise will be evaluated through a secure, comprehensive, computer based examination every ten years. It may be taken in the eighth, ninth, and/or tenth years of the 10-year cycle. It is administered via the internet in a proctored setting at U.S. residency training programs. Development by the Board has been done in conjunction with the National Board of Medical Examiners (NBME), which will also administer and statistically score the examination. It consists of 200 questions, 150 of which are general neurosurgery. The additional 50 are from one of three modules to be selected to reflect the Diplomate’s practice: more general neurosurgery, complex spine surgery, and pediatric neurosurgery. A pilot examination was conducted in October 2005. Nearly 100 neurosurgeons volunteered to take it (ABNS current and former Directors, plus many Program Directors and Chairman). They found it to be very user friendly. There was a 1% failure rate. The first real Cognitive Examination will be administered in March 2007.

Part IV – Evidence of Evaluation of Performance in Practice will be demonstrated on a three-year cycle in the following ways:

1. Key Cases – Participants will select the type of case to be logged from an MOC list, which covers all of the subspecialties, currently consists of 15 procedures, including non-operative management of low back pain. Questionnaires on ten current, consecutive cases of the type chosen will be completed and submitted on line. The questionnaires reflect risk stratification for the individual’s practice, as well as outcome measures. Diplomates must use the same procedure for each three-year segment of one entire ten-year cycle. Feedback will be given via an internet based program that is in development with Outcome Sciences. Thus, participants should clearly see improvement in management parameters over time.
2. The Chief of Staff questionnaire, as outlined in Part I, assesses Diplomate’s Professionalism and participation in Systems Based Practice.
3. A communication assessment tool, most likely CAHPS, now being developed by the ABMS, will consist of questionnaires given to 20 consecutive patients who can complete them by phone or Internet. It will cover the neurosurgeon’s communication skills and other aspects of professionalism and feedback will be given to the participant.
4. SANS, mentioned in Part II, contains material to help assess competencies in Interpersonal Skills, Professionalism, Practice Based Learning and Self- Improvement, and Systems-Based Practice.

The Table below summarizes the four components of MOC, the assessment methods to be employed, and the frequency of assessment for each.

MOC for Neurosurgery Components Assessment Methods Frequency Professionalism Unrestricted License Hospital Privileges Chief of Staff Questionaire Every 3 Years Knowledge Secure Cognitive Exam SANS Every 10 Years Every 3 Years Lifelong Learning and Self-Assessment CME (150 Hrs.) SANS Every 3 Years Performance in Practice Consecutive Key Cases CAHPS Chief of Staff Questionaire SANS Every 3 Years

Commonly Asked Questions
The Board is frequently asked questions on MOC. Many concern the potential of requiring submission of practice data and the CME strategy for Part II.

• Practice data is a simple one to address. There will be NO requirement for submission of practice data as a component of MOC. The only similar requirement was described under Part IV, Key Cases.
• Regarding CMEs, the requirement for 60 Category 1 hours every three years is identical to the AANS and CNS membership requirements; however, the additional 90 Category I or Category II hours are incremental over the AANS and CNS. The strategy employed by the ABNS is similar to that of the AMA Physician Recognition Award.

The ABNS has developed a mechanism with the AANS that automatically downloads all Category I hours from AANS and CNS activities. All meetings "sponsored", "jointly sponsored", "or endorsed" by the AANS or CNS will qualify for Category I hours. In addition, enduring materials that are printed, audio, video, or peer-reviewed journal related also qualify for Category I. SANS adds 24 Category I hours. The completion of a tenyear MOC cycle will earn 25 Category I hours for the next cycle.

The 90 Category I and Category II hours may include more Category I offerings, as well as courses accredited by the ACCME and state or regional societies. Published articles and peer-reviewed journals will count. Presentation at regional and national societies will be similarly credited. Also allowed will be consultation with peers and experts, medical research, online study, teaching other healthcare workers and lay groups, reading peerreviewed literature, and attendance at local grand rounds or medical conferences not accredited by the ACCME.

MOC is mandatory for Diplomates with time-limited certificates. Those with nontime- limited certificates who wish to enter the process may do so at any time. Per the current ABNS Bylaws, Directors must participate in MOC. Come join us in the work!

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WARREN R. SELMAN, MD MAINTENANCE OF CERTIFICATION COMMITTEE WEBSITE & MYMOC COORDINATOR

MYMOC

As you know, participation in MOC is mandatory for ABNS Diplomates with timelimited certificates. Individuals certified from 1999 through 2004 will be phased in over three years. Neurosurgeons certified in 2005 began MOC the following year, in 2006, as will each succeeding year of newly certified Diplomates. The timetable for entering the process is illustrated below.

The mechanism for entering the MOC process can be found on the ABNS website, www.abns.org. In the meantime, I will briefly review it here for you. The process for all Diplomates, whether holding time-limited or non-time-limited Certificates, is the same. It begins with logging onto the ABNS website, clicking on Maintenance of Certification on the homepage under Site Links. Then click the big MyMOC button. In January 2006 a user name and password were mailed to the Diplomates who should begin the process this year, in other words those certified in 1999, 2002 and 2005. Your user name corresponds to your email address used for CME tracking. If you have misplaced the mailing or forgotten your password, click on the Email My Password button. If you still experience problems, email the Board at abns.moc@thm.thc.edu. Please allow one business day for a response. Diplomates with nontime- limited Certificates who wish to enter the process likewise use the e-mail addresses they use for CME tracking and email the Board at abns.moc@tmh.tmc.edu for a password.

Once logged in, you will find an online application. Filling it out and sending it begins your participation in MOC. The application has been designed for ease of completion and requires only 15 to 30 minutes of your time. It is self-explanatory and aided by auto fill-in and drop-down menus. A check list of the information you will need to fill it out is located on the MyMOC Login page.

After completing the application, you may begin to track your way through the entire MOC process, including Lifelong Learning and Self-Assessment CME’s. Guidelines for entering hours not automatically entered for you are also found on at MyMOC.

MOC Rollout Year Certified 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 1999 Y1 Y2 Y3 IO Y1 Y2 Y3 Y1 Y2 Y3 2000   Y1 Y2 Y3 IO Y1 Y2 Y3 Y1 Y2 2001     Y1 Y2 Y3 IO Y1 Y2 Y3 Y1 2002 Y1 Y2 Y3 Y1 Y2 Y3 IO Y1 Y2 Y3 2003   Y2 Y2 Y3 Y1 Y2 Y3 IO Y1 Y2 2004     Y1 Y2 Y3 Y1 Y2 Y3 IO Y1 2005 Y1 Y2 Y3 Y1 Y2 Y3 Y1 Y2 Y3 IO

RICHARD B. MORAWETZ, MD CHAIRMAN, CREDENTIALS COMMITTEE

In recent years State medical licensing authorities have become much more aggressive with regard to sanctioning physicians for practicerelated problems. In addition, they have developed mechanisms for rapid dissemination of information about these actions. ABNS Bylaws and Rules and Regulations require, and the public expects, that the Board will consider adverse actions taken by licensing authorities and, likewise, take disciplinary action with regard to the Diplomate’s Certificate when appropriate.

In recent years the ABNS, like the States and other certifying Boards, has become much more active with respect to disciplinary actions. At least 18 Diplomates have had their Certificates revoked, and several others Certificates have been suspended, typically co-terminus with the period of their State license suspension. Other sanctions can be imposed by the Board, for example requiring Diplomates with non-time-limited Certificates to participate in MOC.

The Board has developed guidelines for disciplinary action. In general, consideration of an action is triggered by revocation or suspension of a Diplomate’s license to practice medicine, or any limitation placed on a license so that it is no longer unrestricted. Diplomates should be aware that certain circumstances other than restriction of a license can also result in disciplinary action. These include criminal convictions, particularly any relating to patient care, and serious professional misconduct. Restriction of a State license, however, is the most common cause.

Diplomates should further note that ABNS Directors focus on the substance of a State’s action, rather than the form. Thus, even in situations where a Diplomate enters into a “Consent Decree” or other settlement with a State licensing Board and does not formally admit to wrongdoing, the ABNS will consider disciplinary action, particularly if the settlement results in a restriction on a license. Also, actions by States where a Diplomate no longer resides or practices but retains a license will typically result in consideration of an action. Diplomates may wish to consider this when deciding whether to enter into settlements with State Boards or contest actions in their non-resident States.

Disciplinary action is clearly something that the ABNS takes very seriously. The Directors do not impose sanctions lightly or without careful consideration of the facts and circumstances. Whenever the Board decides to pursue action against a Diplomate, the individual is entitled to a hearing and due process protection. In this regard it is the responsibility of each Diplomate to keep the Board apprised of his or her whereabouts at all times. If disciplinary action is being considered and the Diplomate cannot be located despite reasonable efforts to do so, a hearing will, nevertheless, proceed. In many cases, a potential disciplinary action is resolved informally before a hearing through the Diplomate’s responses to preliminary inquiries. If the Diplomate cannot be located, clearly there is no opportunity to resolve issues in this fashion.

The Disciplinary Guidelines, which provide substantial additional detail, will soon be available on the ABNS website for your review. They make up Article VI of the ABNS Bylaws and Section XIII of the Rules and Regulations. Any questions can be sent to the ABNS Office.

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MARC A. MAYBERG, MD TREASURER

The financial status of the ABNS remains sound; however, prominent changes in the nature and volume of the Board’s activities are occurring with the implementation of MOC. 2005 expenses exceeded revenues by a substantial amount. This was due to anticipated costs associated with the rollout of MOC, such as preparation and testing of the MOC Cognitive Examination and increased operating expenses in the Board office, ie: two additional office personnel, plus new computers and information technology. Initiation and implementation of NeuroLog also has been an expensive endeavor, an investment of approximately $500,000. These increased costs have been offset in 2006 by changes in the individual assessment and cost reduction measures. For instance, there has been a significant decrease in expenses per activity for office supplies, printing, and communication since improved office automation was initiated in 2002. Professional fees and insurance costs have stabilized for the time being. Long-term hotel contracts have been signed giving better rates, and Houston has been established as the site of all oral examinations. These measures have substantially reduced expenses.

The fundamental precept of the Board’s financial management is that the oral and written examinations are conducted on a budget neutral basis (i.e. examination fees are set to match expenses), whereas all other activities are funded through the annual assessment of actively practicing Diplomates. In the past, ABNS activities have primarily involved preparing the written examination, the credentialing process for certification, and administration and assessment of oral examinations. With the implementation of MOC this year, associated costs in personnel, technology, and related activities have all sharply increased, necessitating a new assessment for all Diplomates. One benefit Diplomates will see from this investment is in logging their MOC Key Case data in a readily accessible electronic format. These factor and additional budget items will raise ABNS expenses in the range of $300,000 to $350,000 annually. This substantial increase is an unfortunate consequence of the MOC requirements, which will most likely soon become an essential part of credentialing for licensure, hospital privileges, and potentially payor reimbursement.

Management of the reserve investment portfolio is now performed by UBS. Transfers totaling $300,000 were made to cash flow in 2005. Notwithstanding, for the past several years, the Board has been able to maintain its reserves.

The 2006 fee structure is as follows:

ABNS finances are monitored through a triennial audit (most recently 2005) and annual accountants’ reviews. Minor changes in the accounting processes have been undertaken to accommodate aspects of the Sarbanes Oxley Law, which are being extended to nonprofit organizations.

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