1425. Rethinking the Subspecialization Paradigm in Neurosurgery

Authors: Gary Robert Simonds, MD, FAANS; Cara Rogers; Chris Busch; Michael Benko (Black Mountain, NC)

Introduction: The discipline of neurosurgery is rapidly moving towards marked subspecialization. Momentum currently is moving towards a paradigm where all trainees funnel into 4 to 7 subspecialized fields, and limit their practices predominately to the care of disorders of their chosen subspecialty. Production of general neurosurgeons would diminish. Practice standards, new technique and technology dissemination, and value of care analysis, would be concentrated, within the subspecialty fields and their loosely affiliated national “sections.” Subspecialists scattered across geographic regions would function in competition rather than collaboration. We sought to analyze a different approach to subspecialization and its scientific, health care delivery, and socioeconomic effects. Methods: We hypothesized a new approach neurosurgical training, subspecialization, organization, and coordination. In this paradigm, training would involve six years of general neurosurgical residency. Subspecialty fellowships would be limited and right-sized to national/geographic needs. High-end subspecialty care would be concentrated to specific geographic regions. Subspecialty research and development would be coordinated nationally. All but high-end subspecialty techniques and technologies would be readily disseminated to the general neurosurgeon population. We sought to evaluate the impact of such a dramatic shift. Results: Were such a paradigm enacted we predict: reduction in training costs, reduction in neurosurgical procedural costs, reduction in overall procedural volume, rapid dissemination of new techniques and technologies, reduction in research expenditures with greater meaningful production, reduction in journal inflation, reduction in proprietorial and competitive behaviors, improvement in regional acute care call coverage, improved outcomes at reduced costs, and more. Conclusion: The current paradigm of unrestricted fragmentation and subspecialization of neurosurgery carries many potential detrimental sequelae. We offer an alternative model with an aim towards the coordination of care and research, regionalization of high-end subspecialty care, dissemination of subspecialty knowledge-base and techniques to a broad network of general neurosurgeons, and the increase in value-based care.