NUMBER 25
AMERICAN BOARD OF NEUROLOGICAL SURGERY 2007

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.

H. HUNT BATJER, MD CHAIRMAN

M. SEAN GRADY, MD SECRETARY

TAE SUNG PARK, MD CHAIRMAN, EDUCATIONAL REQUIREMENTS AND SUBSPECIALIZATION COMMITTEE

WARREN R. SELMAN, WEBSITE & MYMOC COORDINATOR

ROBERT L. MARTUZA, KEY CASES

RICHARD B. MORAWETZ, MD CHAIRMAN, CREDENTIALS COMMITTEE

MARC A. MAYBERG, MD TREASURER

H. HUNT BATJER, MD CHAIRMAN

I am honored by the opportunity to provide you a report on the activities of the American Board of Neurological Surgery over the past year. I will focus the Chair’s Column on the strategic initiatives and priorities of the Board, as well as the evolving Maintenance of Certification process, which has, interestingly, become tightly linked to a number of the Board’s strategic priorities.

The priorities of the ABNS over the immediate past, current, and upcoming years are direct outcomes of the strategic planning process initiated at the 2006Winter Directors Meeting led by Dr. A. John Popp. Substantial alteration of the Board’s Committee structure has been accomplished as a result in order to help the Board better cope with its increasing financial commitments, technological needs, and the vexing problem of subspecialization. Three key priorities for the ABNS are:
1. Subspecialization and Recognition of Focused Practice,
2. Residency Redesign, and
3. Clinical Data Reporting.

Strategic Planning
The primary focus of the 2007 Winter Directors Meeting was subspecialization and residency redesign. Dr. Tae Sung Park, who spearheaded the subspecialization agenda, noted that 39% of residents graduating in 2006 went on to pursue additional fellowship training. Only 41% of candidates for oral examination in that year recognized their own practices as general neurosurgery, 25% complex spine, and 7% pediatric neurosurgery.

Options considered by the Board include:

1. Developing additional general Certificates, which would require ACGME oversight,
2. Developing subspecialty certificates, which would also require ACGME oversight,
3. Recognition of Focused Practice via a MOC mechanism.

Ultimately, Directors decided that the MOC process represents the most favorable and viable alternative for our specialty. In followup discussions at the SNS meeting in San Francisco this spring, all of the subspecialty sections weighed in. Recognition of Focused Practice through MOC was felt to have value only for cerebrovascular/endovascular, pediatric, and spine surgery. At the present time, the concept of the requirements for recognition of a subspecialist include primary certification and a one-year fellowship either enfolded into residency training or postgraduate. In either case the fellowship must be accredited by the ACGME or the SNS Committee on Accreditation of Subspecialty Training. Also, the MOC process would have to be substantially altered and modularized such that CME requirements, Key Case data reporting, and the Cognitive Examination would substantially focus on specific areas of expertise. The Board is currently consulting with the AANS/CNS Sections for further input.

The need for clinical data reporting has been a consideration throughout the ABNS strategic planning process with regard to MOC, anticipated new state requirements for licensure, and hospital requirements for credentialing. More recently, the CMS Pay-for-Performance initia- tive has taken it to a new level. Clearly, data reporting is required by residents and fellows in training, training programs for accreditation, candidates for certification, MOC, P4P, comparative effectiveness, and ultimately, it is expected, for hospital privileging and malpractice coverage. In addition, our specialty needs access to reported clinical data in order to identify practice trends and the overall evolution of the specialty. The AANS/CNS Washington Committee, chaired by Dr. Troy M. Tippett, held a meeting on the subject in July. Dr. Robert E. Harbaugh, representing the Quality Improvement Workgroup of the Committee, and I gave a joint presentation to propose a mechanism whereby outcomes reporting could be utilized for multiple requirements, rather than forcing Diplomates to report the same cases over and over to multiple targets. The process-of-care reporting being discussed under P4P is of dubious value. Also, there are serious questions about whether data should be shared within neurosurgery or with the outside world. We are highly concerned that, at least in aggregate, it could be used in ways that would not be in the best interest of our specialty or patients. At the time of this writing, the ABNS is actively engaged with the ABMS in support of negotiations with CMS to allow an expanded MOC type of case reporting to fulfill P4P requirements. The ABNS is committed to the protection of all clinical reporting and the principle that neither the National Quality Forum nor the Federal Government will encroach upon the Certification process.

Significant progress has been made in the Board’s clinical data infrastructure. In association with Outcomes Sciences, NeuroLog has been established as the vehicle for data reporting by candidates for certification. Outcome is also developing the platform for MOC Key Cases and hopefully other future needs related to licensure, credentialing, and potentially P4P. The ACGME database will be used by residency training programs for reporting.

Maintenance of Certification
Since my report in the 2006 Newsletter, the MOC program has continued to evolve. As already mentioned, issues surrounding subspecialization and data reporting requirements may require our process to be substantially revised, modularized, and resubmitted for approval by the ABMS. Our Board has viewed MOC from the start as something that will evolve over the years. As of May 2007, 456 on-line applications for MOC had been submitted out of a total eligible pool of 858 Diplomates with time-limited certificates. An additional 36 Diplomates with non-time-limited certificates have voluntarily enrolled. It is virtually certain that developments afoot will require MOC for hospital credentialing, state licensure, participation in health plans, CMS, and malpractice coverage. It will likely become pervasive within in the next five to ten years.

Our Key Case modules for MOC Part IV, Evidence of Performance in Practice, have been expertly developed by Dr. Robert L. Martuza and should be online in February 2008. They are well constructed and easy to use. Each module questionnaire consists of fourteen to twenty questions. As Diplomates work through them, educational material pops up to clarify existing treatment guidelines and important scientific literature. Much of the content has been developed by the Sections.

It is important to note the Board’s close collaboration with the AANS for tracking Category 1 CME credits and with the CNS that has donated the Self-Assessment in Neurological Surgery (SANS) examination to Diplomates participating in MOC. Content for SANS now includes all of the non-clinical core competencies. On March 31, 2007, the first secure, web-based Cognitive Examination was administered. Twenty-seven Diplomates certified in 1999 and participating in MOC took it; all passed.

I want to make you aware of a new Category 2 CME opportunity that has been created by the ABMS. Their Patient Safety Improvement Program is now available on line at www.healthstream.com/hlc.abns. Diplomates will pay $150.00, the retail prices for the course. The material has been reviewed by our Board and is felt to be of high quality and good value.

2008 Winter Directors Meeting
At the next Winter Meeting, Directors will focus on three specific agenda items:

1. How to operationalize Recognition of Focused Practice through the MOC mechanism,
2. Infrastructure and privacy issues of clinical data reporting,
3. Residency redesign, including the PGY1 year.

By that time significant new information should be available from the educational operations groups identified at this summer’s Summit meeting, as well as the interface between the ABMS and federal government, regarding data reporting requirements. The Board will keep you updated on each of these important developments.

Directors
At our May 2006 meeting, Drs. Robert L. Solomon, Richard B. Morawetz, and Marc R. Mayberg completed their six years of leadership as Directors. Each will now serve an additional six years on the ABNS Advisory Council. Newly elected Directors are Dr. Mitchel S. Berger (nominated by the SNS), Dr. Matthew A. Howard, III (Neurosurgical Society of America), and Dr. Nelson M. Oyesiku (CNS). Officers for 2007-2008 are Dr. H. Hunt Batjer, Chairman and Dr. Kim J. Burchiel, Vice Chairman. Dr. Paul C. McCormick begins a three year term as Treasurer, and Dr. M. Sean Grady continues as Secretary. All directors serve without compensation, taking approximately one month out of each year for Board business.

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M. SEAN GRADY, MD
SECRETARY

The American Board of Neurological Surgery plays an important role in residency training by establishing the requirements a resident must meet in order to become certified. Our Diplomates may be interested in some of the following matters that involve both residency training and operative databases.

Residency Training
Eight hundred ninety-four residents were training in 97 programs during the 2006/2007 academic year.Ninety-four (11%) were women. Eighty (9%) were international medical school graduates.

The 2007 Neurosurgery Residency Matching Program filled 170 of 171 positions. This represents an increase of 36 over the past five years. These additional trainees will be reflected in the total number of ABNS certified, practicing neurosurgeons in the next seven to ten years. During the past five years, there was very little increase in the number of accredited programs; therefore, the larger number of trainees reflects increases in resident complements at several programs. TheMatch continues to be competitive. Approximately 83% of U.S. medical school seniors found positions this year; that percentage has been relatively constant since 2002. Over the same interval, their USMLE Part 1 scores have risen to a present average of 236. This represents a ten point increase and a highly competitive score.

The 2007 Primary Examination contained 375 questions. For psychometric reasons, approximately 40% are always used items. There were 551 examinees, 195 of whom took it for credit toward certification. The failure rate was 16% and an average of 74% correct. Since the internship year is being brought under the control of neurosurgery residency program directors, Interns will be allowed to take the Primary Examination beginning in March 2008.

Eighty-two residents from 59 programs responded to a post-training survey conducted in July 2006. Thirty-two went on to fellowship training (10 vascular, 8 spine, 5 pediatric) and 50 went into practice (20 partnership, 19 academic, 6 hospital). The survey will be conducted again this year with the intent of increasing the response rate and get a better picture of residents’ post training plans.

Residency redesign was identified as one of the strategic goals for the ABNS in 2006 and will be a component of the 2008Winter Directors Meeting. There are multiple stakeholders, including the RRC and SNS. Duty hours restrictions remain on the horizon for neurosurgery residencies, and increased attention in this regard may be focused on programs from institutional Graduate Medical Education offices. This is one of several impetuses for residency redesign.

Operative Databases:
Residents are required to maintain operative logs for both the ABNS and RRC. The Board’s NeuroLog database for resident case collection was discontinued as of July 1, 2007. The system developed by the ACGME is recommended as a replacement. Candidates for certification will continue to use NeuroLog to enter their year of operative data, which is analyzed by Directors in a web-based, review process.

Diplomate Numbers:
Seventy-four candidates were examined at the November 2006 Oral Examinations, with an 11% failure rate. In May 2007, 75 candidates were examined, and 16% failed. The average fail rate is 15%. During the last twelve months, the ABNS has revoked six Certificates and suspended three others.

As of August 2007, 3368 ABNS certified neurosurgeons are in practice. In 2001 a 10-year nadir of 2936 were practicing. The number today represents the highest on record. About 35% have time limited certificates and must participate in MOC.

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TAE SUNG PARK SECRETARY
CHAIRMAN, EDUCATIONAL REQUIREMENTS AND SUBSPECIALIZATION COMMITTEE

Trends in Subspecialization
Subspecialization in neurosurgery is already a reality. In the last three decades, new areas in all specialties of medicine have emerged due to remarkable advances in medical science and technology. In neurosurgery many Diplomates focus their practices on acute care, cerebrovascular/ endovascular, functional, neuro-oncology, pain, pediatric, peripheral nerve, spine, trauma, and tumor, etc. Of the candidates for oral examination in 2006, only 41% self-recognized their practices as general neurosurgery. Likewise, 39% of residents who graduated in 2006 went on to do subspecialty fellowships.

Recognition of Subspecialization
Recognizing that the trend toward subspecialization will continue, the ABNS initiated a close examination of the issues when developing a strategic plan at the 2006 jeWinter Directors Meeting. The 2007 Meeting was devoted specifically to discussion of subspecialty recognition. It was attended by current Directors, several members of the Advisory Council, and Dr. William Gay, executive director of the American Board of Thoracic Surgery.We reviewed the current status of subspecialty certification by the ABMS and its 24 member Boards, the logistical processes for establishing subspecialty certificates, and past subspecialty recognition initiatives by the ABNS. The pros and cons of recognizing subspecialties were considered in depth. There was also discussion about the unique characteristics related to different neurosurgical subspecialties. In addition, Dr. Gay presented the experience of his Board in setting up a subspecialty certificate for congenital cardiac surgery.

Opponents of subspecialty recognition are consistently concerned about fragmentation of neurosurgery into isolated components, as well as disenfranchisement of generalist practitioners. Proponents state that

• Diplomates already focus their practice,
  
  
• Hospital privileges may be denied to practitioners without subspecialty certificates,
  
  
• The public demands quality care and expertise in subspecialty areas,
  
  
• Neurosurgeons who wish to be acknowledged for their subspecialty training and skills may devalue ABNS certification by seeking certificates from splinter organizations.

At the 2007 Winter Meeting, Directors identified four options for dealing with subspecialty recognition:

1. Continue the current policy of not recognizing subspecialties,
   
   
2. Endorse fellowships accredited by the ACGME without subspecialty certification,
   
   
3. Establish subspecialty certificates approved by the ABMS,
   
   
4. Recognize Focused Practice through the MOC process.

After a broad-ranging, day long discussion, Directors reached the consensus that the Board needs to take measures to acknowledge subspecialization. The status quo is no longer acceptable. The following resolution was passed:

The American Board of Neurological Surgery will not pursue subspecialty certification through the American Board of Medical Specialties but will acknowledge the importance of subspecialization through the ABNS Maintenance of Certification process.

Thus, the ABNS will not issue subspecialty certificates nor endorse ACGME-approved fellow-ship training as a prerequisite for subspecialty certification. Instead, it will pursue "Recognition of Focused Practice" through MOC.

Many neurosurgeons develop expertise and proficiency in areas of neurosurgery as a result of years of focused or limited practice, for instance pediatric and spine neurosurgery. A process can be built into the current MOC concept to act as a mechanism through which this may be acknowledged based on clinical practice, rather than fellowship training. At their 2008 Winter Meeting, Directors plan to work on development of MOC Recognition of Focused Practice. It must be emphasized, however, that implementation of the resolution will be a long process and require clarification of the mechanism.

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WARREN R. SELMAN, MD CHAIRMAN, WEBSITE & MYMOC COORDINATOR

The mechanism for entering the Maintenance of Certification process can be found on the ABNS website, www.abns.org. The process for all Diplomates, whether holding time-limited or non-time-limited Certificates, is the same. On the homepage, open the MOC link located under Site Links on the left side of the page; then click the big blue MyMOC button.

In January 2007 a user name and password were mailed to Diplomates who should begin the process this year, in other words those certified in 2000, 2003 and 2006. Your user name corresponds to the email address you use for CME tracking by the AANS. If you have forgotten your password, click on the Email My Password button. If you still experience problems email the Board at abns.moc@tmhs.org. Please allow one business day for a response. Diplomates with nontime- limited Certificates who wish to enter the process also use the e-mail addresses they use for CME tracking but must e-mail the Board for a password.

Once logged into MyMOC, you will see the on-line application. A checklist of the information needed to fill it out is located on the login page. Do review this prior to starting the application process. The application has been designed for ease of completion and requires only 15 to 30 minutes of your time. It is selfexplanatory and aided by auto fill-ins and drop-down menus. After completing the application, you may return there to track your progress through the entire MOC process.

A requirement of Lifelong Learning and Self-Assessment is 150 CME credits per three-year mini-cycle. Category 1 CMEs, which require verification, are tracked by the AANS for the ABNS. Guidelines for entering Category 2 credits are found at MyMOC.

They are self-reported, self-entered.

Another component of the MOC process is the Cognitive Knowledge Examination, which must be passed once in every ten-year cycle. This web-based examination consists of 200 questions in thirteen categories: anatomy, anesthesia, congenital, degenerative, functional, general clinical, infection, neurology, pain, trauma, tumor, vascular, and other (safety, ethics, compliance, and evidence based medicine). Most of the questions within the categories are based on diseases practicing neurosurgeons often see. Candidates may elect to take all 200 questions in General Neurosurgery, or 150 General plus 50 subspecialty questions in Spine or Pediatric Neurosurgery. Many items are based on SANS content. The first Examination was given in March 2007.

The following table lists the number of participants with time-limited certificates enrolled in the MOC process as of mid-August 2007.

Year Certified	# Certified	Current 3-Year Mini Cycle	Participants	Not Yet Participating
1999	128	3	93	35
2000	124	3	46	78
2001	120	Start Cycle 3 in 2008	0	n/a
2002	143	2	84	59
2003	152	2	49	103
2004	139	Start Cycle 2 in 2008	0	n/a
2005	145	1	85	60
2006	128	1	37	91
2007	TBD	Start Cycle 1 in 2008	0	0
2008	TBD	Start Cycle 1 in 2009	0	0
TOTAL	1074	-	332	742

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ROBERT L. MARTUZA, MD KEY CASES

An important part of Maintenance of Certification is the self-reporting of a set of standardized cases and outcomes. ABNS Directors have chosen fifteen Key Cases representing the most common types seen by neurosurgeons. Reporting modules have been developed for each. MOC participants are asked to choose the case closest to what is most often seen in their practices and complete reports on ten sequential cases they have had of that type. This is to be done once during each three-year mini-cycle of the MOC process. In order to cover most of the various aspects of neurosurgical practice, the Board has included Key Cases on non-operative patient care, specifically medical management of low back pain and non-operative management of head trauma.

The Key Cases are accessed from MyMOC at the ABNS website, www.abns.org, for logging and submitting electronically. Diplomates will have access not only to their own data, but also in an anonymous fashion to comparative collective outcomes data as reported by colleagues choosing the same Key Case. They will be able to track their outcomes, compare them to that of others reporting on that Case, and even compare their own data over mini-cycles. As part of the experience of continuous education, each module contains several references from literature for further study concerning aspects of patient care pertinent to that module. Management of the data has been contracted to Outcome Sciences, and care has been taken at every stage to protect the anonymity of patients.

Data collection for all modules is standardized into three areas: history, treatment, and outcome. For each diagnoses, the data collected will differ somewhat, but the concept is the same. For example, if the Key Case chosen is Surgery for a Supratentorial Glioma, the following sets of data will be entered: patient age, gender, presenting symptoms, tumor location and size, operation date and type, complications, pathology, adjuvant therapy, and a six month follow up evaluation. Clipping of a Supratentorial Aneurysm includes family history of aneurysm and fundus-to-neck ratio, which are elements specific to aneurysm surgery but not relevant to a glioma.

ABNS Directors intend this process to be straightforward and to minimize the burden on MOC participants. We are receptive to suggestions for improvement in order to make the process as streamlined as possible and provide maximal benefit to each of you.

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RICHARD B. MORAWETZ, MD CHAIRMAN, CREDENTIALS COMMITTEE

At the May 2007 ABNS meeting, hearings were held to consider suspension or revocation of three Diplomates’ Certificates. In all instances, the Board’s actions were precipitated by State actions suspending, revoking, or requiring surrender of the Diplomate’s license or its conversion to inactive status. The decisions made by Directors following the hearings were: revocation of one certificate, suspension of another, and acceptance of an agreement to retire permanently from the practice of neurosurgery by the third Diplomate. A fourth Diplomate, who was at the end of his career, agreed to retire permanently from the practice of neurosurgery in lieu of a hearing.

We increasingly see States impose "probation" on licenses, but they use the term in different ways. In some instances, a Diplomate with a license on probation is allowed to continue to practice. In these circumstances the ABNS will typically place the certificate on probation and allow the Diplomate to continue to hold himself/ herself out as "Board Certified", although the Board’s action is reported to State licensing authorities and other organizations. Other States do not allow continued practice during the period of probation. Here, notwithstanding the terminology, the probation is effectively a suspension of the individual’s license, and the ABNS will usually suspend the Diplomate’s certificate.

When a license becomes unrestricted, the Diplomate may apply to the Board for an end to the probation or suspension of certification. Ordinarily in connection with these disciplinary actions, even Diplomates with non-time-limited Certificates will then be given time-limited Certificates. This requires them to participate in Maintenance of Certification. Similarly, the Board may decide to require a Diplomate to participate in MOC, when for example a State reprimands the individual for multiple wrong site surgeries but does not take action against the license. In addition, if in lieu of an adverse proceeding, a Diplomate surrenders his license at the end of his career, the Board may, at its discretion, allow him or her to enter into an agreement to retire permanently from the practice of neurosurgery and remain certified.

Each case brought to the Board’s attention is considered on its individual merits, but in general, the Directors’ votes follow the actions of State licensing authorities, i.e. revoking a Certificate if the Diplomate’s license has been revoked and suspending certification if the license has been suspended. The Board recognizes that States are in a better position to conduct thorough investigations; therefore, State disciplinary decisions are given an appropriate amount of deference. The ABNS always endeavors to protect the public and enhance the profession of neurosurgery.

Table 1 – 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

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MARC A. MAYBERG, MD TREASURER

The financial status of the American Board of Neurological Surgery remains solid. Despite increased expenses, mainly related to the implementation of Maintenance of Certification, the ABNS remains in good financial shape.

Over the past six years, expenses have increased twofold, from approximately $700,000 in 1999 to nearly $1.4 million in 2006. The inception, planning, and implementation of MOC were substantially the cause. Besides MOC related expenses, such as preparation of the Cognitive Examination with the NBME, other new costs included the NeuroLog data program and more office personnel to accommodate the growth in activities. The development of NeuroLog, an online database for tracking candidate practice data and implementing Key Cases for MOC, has represented an investment of nearly $500,000. It should, however, significantly reduce future costs related to data management and uniquely enable the Board and organized neurosurgery to track practice patterns, clinical outcomes, and utilization trends, all of which will become increasingly important for reimbursement. Partnerships with the AANS and CNS are under discussion to maximize the value and impact of neurosurgical practice data statistics derived through NeuroLog. To implement the project, the Board incorporated a free standing, limited liability corporation, Neurosurgery Data Management LLC, which directly interacts with Outcome Sciences, the company developing and maintaining NeuroLog. Establishment of the LLC enables the ABNS to maintain these financial relationships while minimizing liability and conflict of interest.

Prudent fiscal planning necessitated measures to accommodate MOC, while maintaining pre-existing services without interruption. Many expenses have decreased over the past three years, due in part to further automation of office procedures, increased use of digital information with resulting reduction in paperwork and postage, stabilization of professional costs such as insurance and legal fees, and favorable rental contracts. A decision was made to hold all oral examinations in Houston, as opposed to alternating sites around the country, and this has provided a substantial reduction through efficiency and proximity of the examinations to the ABNS offices.

The Board’s revenue is limited to fees for applications and the Oral, Primary, and Cognitive Examinations, plus the annual assessment of all actively practicing Diplomates. Application and examination fees are set to cover costs associated with those activities and do not provide excess net revenue. It, therefore, was necessary to fund the expansion of ABNS activities through an increase in the assessment to $275. This raise is approximately the cost per Diplomate for MOC activities. Undoubtedly additional financial challenges will arise in the coming years as the Board responds to demands from regulatory bodies; thus, Diplomates should consider that further assessment increases could be necessary in the future. Diplomates overwhelmingly continue to support the Board’s commitment to continuing improvement of the certification and MOC processes through this voluntary dues program. Thank you.

ABNS finances are audited by an independent auditing firm every three years, with reviews done for the intervening years.

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