1426. Risks of Neurosurgical Subspecialization

Authors: Gary Robert Simonds, MD, FAANS; Cara Rogers; Eric Marvin (Black Mountain, NC)

Introduction: Neurosurgery is rapidly heading towards significant subspecialization. The SNS Committee on Advanced Subspecialty Training now accredits various neurosurgical subspecialty fellowships. For all intents and purposes, the ABNS now offers the opportunity for two thirds of its certifying oral examination to be taken in a neurosurgical subspecialty. The ABNS plans to offer acknowledgement of subspecialty “focused practice” in those subspecialists it certifies. We offer some cautionary concerns related to this phenomenon. Methods: We conducted an evidence-based evaluation of a series of potential risks associated with the subspecialization of the discipline of Neurosurgery. Results: Risks were found to included: Increased acute care call coverage deficiencies: Fragmentation of neurosurgery into 4-7 subspecialties runs a high risk of “subspecialists” refusing to cover call issues of other neurosurgical subspecialties. A need for a significant increase in neurosurgeon production would be required to cover a fragmented neurosurgical call demand. Unfair competitive edge : Subspecialization may be used to leverage referrals without associated proven improved value of care. Critical reduction in general neurosurgeons: competitive forces may result in reduced resident flow into general neurosurgery resulting in critical acute care shortages. Many healthcare markets may not be able to financially sustain a full array of neurosurgical subspecialists. Increase in unnecessary procedures: the strongest correlation with increased procedural output in a region is simply the number of specialists performing those procedures, not demographics or need. Increase in job dissatisfaction and burnout : as skill in an executive subset peaks, and intellectual/emotional challenge diminishes (as with prolonged repetition of a class of procedures), professional boredom and restlessness increases. Conclusion: The subspecialization of neurosurgery may have a number unintended detrimental consequences in surgeon functionality and resilience, value based care, and public health, and should thus be studied further.