Author: Nathan R. Selden
In Latin, a competition is the act of “going out to seek together.” Competitors pursue excellence and, by surpassing each other, continually improve. To the ancient Romans, “competition” meant literally to “testify together.” Theirs was a testimony of excellence that depended for success on the strength and effort of both competitors. There are many reasons for neurological surgeons to work together at a national level: pursuing impactful ongoing education, analyzing new information and technology, advocating for resources, and defending our professional identity. At the same time, we need to renew personal friendships with fellow neurosurgeons and share our wisdom about the constantly evolving challenges of modern medicine.
There are equally compelling reasons, at times, for us to compete: to provide the most cutting-edge and innovative education flexibly available to busy neurosurgeons based on their own schedule and needs, to produce the leading journals of neurosurgical science and technique in the world, and to promote a culture of volunteerism unmatched in any specialty.
To do these things well, we rely on a handful of very different professional organizations. Generally speaking, we can divide these into groups responsible for specialty definition and training versus groups responsible for professional membership and lifelong learning (Figure 1).
Figure 1: Neurosurgical membership and lifelong learning organizations (the CNS and AANS) accept corporate educational grants and sponsorship, while specialty definition and training organizations (the ABNS, ACGME-RRC, and SNS) are separated from outside financial support by a COI “firewall.”
As for every branch of medicine, our specialty definition and training functions depend on a professional board, a residency accreditation body, and a residency directors’ organization. The American Board of Neurological Surgery (ABNS) certifies individual neurological surgeons. The neurological surgery residency review committee (RRC) accredits individual residency training programs. Finally, the Society of Neurological Surgeons (SNS) represents training program directors in the formulation of a national curriculum for the specialty.
Each of these specialty definition and training organizations is small, appropriate to their very focused missions. Each is also held to an exceedingly high standard of conflict of interest avoidance, in recognition of their profound influence on training and lifelong practice. None of these three organizations accepts industry funding, which in theory might compromise their independence and objectivity. For example, although a majority of its members are neurosurgeons, the neurological surgery RRC is constituted by, and answers solely to, the Accreditation Council for Graduate Medical Education (ACGME), a national multi-stakeholder organization for educational quality and safety.
By contrast, professional membership and lifelong learning organizations are large, in order to serve the needs of all practicing neurosurgeons. To provide robust educational and membership services, these organizations also accept industry and philanthropic funding. For example, surgical device companies have a shared interest with professional organizations in safe and high quality use of their technology. They facilitate those shared interests through educational grant funding. Although a potential for conflict of interest exists, it is mitigated through careful regulations and a mutual focus on transparency.
Unlike many medical and surgical disciplines, neurosurgery has more than one major national membership and lifelong learning organization: the Congress of Neurological Surgeons and the American Association of Neurological Surgeons. While the existence of two major neurosurgical organizations may be a historical coincidence, the reason we continue to support and depend on them both most certainly is not.
First of all, in many important national policy making settings, including the American College of Surgeons, the American Medical Association, and various federal regulatory panels, neurosurgery has dual representation. In other settings, such as the influential Council of Medical Specialty Societies, and our own ABNS, we have a diversity of neurosurgical representation by career stage and perspective, better representing the breadth of neurosurgical practice.
One of the most powerful advantages of two national societies is the tremendous volunteer power of two boards of directors. Together, CNS Executive Committee members and AANS directors contribute thousands and thousands of volunteer hours to our specialty each year. This type of innovative and creative energy, if billed as “consulting” services, would cost literally millions of dollars. The resulting productivity has expanded our influence on American medicine and surgery far beyond the numerical footprint of the specialty.
The CNS and AANS have also adopted contrasting corporate tax structures. The CNS is a not-for-profit 501c3 corporation, focused predominantly on neurosurgical education. The AANS has adopted a 501c6 tax structure, which allows it more flexibility in pursuing certain forms of advocacy. Most importantly, the CNS funds fully 50 percent of the joint CNS and AANS Washington Committee, our primary advocacy body.
The CNS and AANS also collaborate on important educational infrastructure. In 2011, the CNS joined with the SNS, representing residency program directors, to administer 6 regional courses for incoming neurosurgical residents each year. Now in their 5th year, these “Boot Camp” courses enhance professionalism and safety from the beginning of residency for every new resident in the United States, an unprecedented development for any U.S. specialty. The AANS joined this effort, administering a complementary course for junior residents with the SNS, beginning in 2013. For board-certified neurosurgeons participating in Maintenance of Certification (MOC), the CNS provides the Self-Assessment in Neurological Surgery, an online teaching and testing program, for free, while the AANS provides online CME tracking.
In other areas, the two societies’ programs complement each other. The CNS has created a center for practice guidelines formulation, which supports guidelines projects from every subspecialty section. CNS-supported guidelines have already been used in many states, for example, to maintain patient access to lumbar spine surgery. At the same time, the AANS launched NeuroPoint Alliance (NPA) to provide patient outcomes registry data also needed to justify high quality spine and brain care. Without both guidelines and outcomes initiatives, our specialty would be severely handicapped in putting surgeons to work on behalf of patients.
The CNS and AANS also compete in other helpful ways, such as putting on the two largest and most influential annual neurosurgical meetings in the world. Through a tradition of friendly, but avid, competition these meetings provide high quality education and are financially sound. The annual meetings also provide hubs for other crucial activities, such as updating equipment, attending business or committee meetings, performing outreach functions, and recruiting. Although many neurosurgeons attend both meetings, anyone can attend at least one meeting a year with coverage from their partners, allowing them to stay current in a complex and rapidly evolving specialty.
The two most prominent neurological surgery journals in the world are the competing CNS journal, Neurosurgery®, and the Journal of Neurosurgery, owned by the AANS. Both journals are thriving and deliver excellent science that advances the field and improves neurosurgical care around the world. Both journals contribute significant resources, both intellectual and financial, to neurosurgical education. North American neurosurgery is clearly better and stronger for the stewardship of these two journals by our leading membership societies.
Competition between the two societies also breeds efficiency. The total dues for membership in both organizations is similar to single society dues in other major surgical subspecialties. The CNS is particularly proud of the value offered members for relatively modest dues, with $400 of the $600 CNS annual dues supporting a discounted member subscription to Neurosurgery® and the CNS’ 50 percent participation in the CNS and AANS Washington Committee, the crucial advocacy arm of our specialty.
Remarkably, the remaining $200 covers everything else our organization does, including the Self-Assessment in Neurological Surgery (SANS); discounted member meetings, live courses, webinars, and online education; CNS international initiatives; CNS publications, including the Congress Quarterly and Clinical Neurosurgery; and countless other member benefits. In fact, for an ABNS Maintenance of Certification (MOC) participant (whose CNS-SANS subscription is free), the direct dollar value of the journal, Washington Committee contribution, and SANS: MOC far exceeds the price of membership (Figure 2).
Figure 2: Two-thirds of the CNS dues go to cover members’ subscriptions to Neurosurgery and to fund equal participation in the CNS and AANS Washington Committee, our primary national advocacy body. For SANS-MOC participants, CNS dues are a net savings.
In many areas, such as advocacy, neurosurgery must speak with one voice and pursue common goals together. For example, the CNS and AANS are currently collaborating with the SNS to create an online learning portal, which will organize digital education according to a national curriculum for core neurosurgery. Here again, neurosurgery is leading other specialties because of the cooperative vision of these three “Summit” organizations, with guidance and input from the ABNS and RRC. The CNS welcomes these opportunities for collaboration.
Like almost all of you, I am a proud member of both national neurosurgical organizations. I frequently serve on the faculty of the AANS annual meeting and have participated as a member of AANS committees related to outcomes registries. Neurosurgery succeeds when we all do what we can to help our specialty and the patients we serve.
Both the CNS and the AANS have proud and transformative historical legacies, which deserve our loyalty. This year, the CNS celebrates its particular association with Walter E. Dandy, emblematic of innovation, technological creativity, and of course, a certain rebellious streak. Founded in part by young men who learned neurosurgery serving their country in field hospitals during World War II, we have a tradition of resilience, self-determination, and looking towards the future.
The Congress of Neurological Surgeons’ mission is “to enhance health and improve lives worldwide through the advancement of neurosurgical education and scientific exchange.” We will continue the relentless pursuit of this mission through tradition and innovation, cooperation and competition.