The Times They are Still a-Changin

It seems that much of the world is uneasy with societal and political change. These issues seem to be topics of daily conversations in many countries. Of course, this is not new in world history, but it seems new in our time, especially for younger people. Despite being in an era of great technological change, innovation, access, and in some countries, real freedom, not all seems well. Not all is reliable. What does this have to do with neurosurgery? A lot. Does your department or practice, your university or your hospital, have a hiring freeze? Are there pressures on research funding? Pressures on incomes? Pressures on time commitments? Pressures on travel for education? Do you feel that we are in a holding pattern, waiting to see what might happen? What does this have to do with society? Society, and the public at large, have certain expectations of neurosurgeons. Not only are we fortunate to be held in high regard as physicians, in comparison with many other professions, our subspecialty has a special place in the medical pantheon. Society expects us to solve their problems, and to do so efficiently and safely. The patients we care for have problems related to their function as human beings, or potential problems that we hope to prevent. What is more important than preserving that function, and by extent, their personhood? Does the public really want us to slow our research, reduce our educational experiences, and delay or impair the training of the next generation of neurosurgeons. I don't think so. And yet these are the things that are at risk. This is not a new problem to be sure. As one example, when physicians in the United States adopted Medicare (government) reimbursement in the 1960s, with the noble goal of efficiency, we put the government in charge. Change can be slippery. Rules, regulations, mandates, and eventually a massive medical administrative middle-management bureaucracy was created with an onerous and oppositional insurance payer system. Eventually, we were tasked with endless annual training modules on topics that varied in importance. This slippery slope seems to have no end. This is a global issue of course and there are many other examples. The British National Health Service or the provincial health authorities in Canada, all try to provide health care and research with budgetary restraints and fiscal policy tightening. Noble goals. Neurosurgery has always worked to forge its own destiny. We were created out of a combination of courage, innovation, and practice. Our foundation is original research that translates into meaningful clinical care. As a technical specialty, much of our innovation requires corporate interest, investment, and adoption. Our top peer-reviewed journals act as arbiters of these innovations, promoting awareness and discourse. Local, regional, and international education programs work to disseminate the clinical advances derived from research so that all of us, at any stage of our careers, can offer the public real progress. If governments decide to limit investment in neurosurgery, then we must convince them otherwise using every means possible. Perhaps there is a “culture of fear” where many in positions of leadership choose to remain quiet.1 Hopefully, new emerging leadership will listen. If the usual government lobbying proves too slow a process, then the corporate world needs to step up even more. Removing neurosurgeon innovators and collaborators from the equation would seriously undermine the pace of progress in the neuroscience-related portfolio of the biomedical industry. Onerous regulations reduced corporate funding of events and conference travel support, whereas universities created ever more draconian disclosure forms and restrictions. Have these measures led to any clear benefit? Our patients, if they happen to live in a country where they have the opportunity to vote, typically do not vote to restrict medical funding. Can you recall such a thing ever being an election issue? If you feel that you as a surgeon, you as a surgeon scientist, you as a patient, or a potential patient, are not happy with the way the times are currently changing, then do something about it. The opportunities are plenty. Our leaders are not here for very long. Sometimes for a few years, sometimes longer in different parts of the world. But rest assured, they will go away and be replaced by new ones. In 1963 Bob Dylan called for people to “gather round,” for writers and critics to “prophesize with your pen,” and for senators and congressmen to “heed the call.” The times, they are indeed always a-changin. Douglas Kondziolka, MD, MSc Editor-in-Chief, Neurosurgery Publications New York, New York, USA