The theme of the meeting is service, and I can think of no neurosurgeon that epitomizes and has personally demonstrated the concept of service to neurosurgery than our next speaker, Dr. Hunt Bajor. Not only has he served as president of the Congress, president of the CV section, president of the AANS, he has also been on the ABNS board and has been chair of Northwestern and currently UT Southwestern, literally demonstrating and practicing service to neurosurgery as part of who he is and what he does. And we're really looking forward to his discussion today, his talk entitled, Serving Neurosurgery a Primer. Dr. Bajor. Well, thank you so much, and is Clemens here? I appreciate his conversations with me about what he wanted me to talk about, he likes it general. But I'll start by offering a consultation. If you'll notice my Gucci appendage here, if you think that, you know, marathons are great for you, 20 is not the right number. Maybe two would be fine. So I'm having my second leg done, and thank God I counted up, and I only have two. So I think I'm done, I hope. Well, I thought what, based on what Clemens told me and what Josh, you know, confabulated over the phone, I was trying to understand it. I thought I would give you just a few thoughts. I've sort of had a lot of roles in neurosurgery that were not sought after, but have certainly been, they've been a great learning experience. I've been around so many fantastic people over the years, some of which are sitting in this room. And I thought I would share my thoughts about that, some of the tradeoffs that we all make, those of us that come to these meetings on Thursday and Friday, and work right through, and then go home to a complete fiasco. And then give you a little view of my thoughts about the way our specialty evolved, what it's like now, and where opportunities are for people that want to enter the service of the specialty. And first of all, I would say, why do it? You know, neurosurgery is busy enough, we train to be practitioners, we come out of the box ready to go. So why enter the service life of our, we're serving our patients as practitioners, but serving the specialty in medicine? Well, personally, my neurosurgical life goes back to about 1980, when I watched Kemp Clark, who was then, I think, president-elect of the WNS, and working with Charlie Plant, Katie's predecessor. And what I really was concerned about was that it looked like, as I saw Dr. Clark's friends and people that came through our department, who were testifying on Capitol Hill, for example, and doing other things, I really wanted us to be in a situation where actively practicing physicians were our spokespeople on the Hill. Not somebody who was trained to be a neurosurgeon, but hadn't been in many years. So that was one thing. And I think we have so many, I listed some of the areas that we can have spokes roles, and those are some of them, and I like the concept of us having real doctors communicating with our congresspeople and senators. It gives you an opportunity, and I remember as I was in my first 10 years of practice, I was feeling a little bit insular or constricted, and this was an opportunity to influence more than just the patients that you see in your clinic and on your call. Global medicine, we can influence that. We are trained to do that, and we can do it in various ways. The WNS, as you know, has outreach. The American board is now putting their products, their examinations overseas to improve care and improve education. The ACGME-I is active. We just accredited our first international neurosurgical program at American University of Beirut, which was excellent. And then in areas like the National Football League, you know, hundreds of millions of athletes at all levels of play around the world, world soccer, world football, et cetera, we can make a real difference in policy. There's an immediate trickle down from areas like the NFL to improve those things. And then, you know, I hear so much now at the ACGME board about physician burnout. What I don't hear it from is neurosurgeons. You know, our residents are a little fatigued, and, you know, okay. But one of the areas that you can eliminate burnout is by continuing the learning process. You know, how do we age well? How do we cognitively age? Well, it's an enriched environment that is exercise, that's new languages, new music, things that keep your brain alive. And that is one of the things that has really been interesting to me, learning about the legislative process, regulatory stuff, certification, accreditation, and all those things that are not intuitive to those that just practice medicine. Then when we have a major public health crisis, it could be a hurricane in the Caribbean, it could be head injury in sports or military, we can play a real role. We as neurosurgeons, and I find that a real asset. So how do you do it? You learn from mentors. I think that's the most important. And my opportunities came from really three people, I'll show you. Learn to say yes. And the problem is that at some point, you know, my staff in Dallas, they sit there now, practice for me. I want you to say no, just go, okay, no, no, I can't quite get it right. But learn a culture of yes and that will enable you. Get your family involved. You know, as neurosurgeons, certainly, a patient in need takes priority always. They get over that hump and they get there. But then they ask, you know, why does mom go to these meetings on Thursdays and it doesn't even start until Sunday? Why is that? Someone has to buy into what you're trying to do. Your partners and your institution, if that's where you work, also needs to buy in and understand that. Alex Velodka, when he was in Austin, Texas with Seton Health, they were so pumped that he was on the Washington Committee and chairing it that he would call me and say, I just can't believe it. I said, Alex, it's a patient safety matter. They want you on an airplane rather than on call. I didn't say that. So and then, you know, eliminate self. You know, as you're focused on your own career development and you take on responsibilities where you're responsible to our constituents, our specialty, our members, our public, and I'll explain the difference in a second. So you eliminate self. It becomes about everything else. This is an easy one for me. I'm in a cabinet of smarter people than me. So that's a pretty low bar in this case. But the advantage of that is you are around people with ideas that aren't afraid to express them and they answer questions and they come up with strategies. But just having them there is not adequate. It is critical but inadequate unless you listen. You got to listen. Avoid yes men and yes women. And as actively as you avoid those, avoid constant contrarians. And the reason is because their advice is not helpful. It's predictable. It's just not helpful or thoughtful. So you want people that will challenge convention and they challenge you and me. Then be efficient. You got to have a staff that works well. You cannot afford, if you're going to start doing jobs, you cannot afford to do things twice. And that you have to use your nights, weekends, holidays, and use planes and airports. What are the tradeoffs to this life? Family, children's ball games, children's dances, clinical practice takes away from it and the career satisfaction that all of us derive from that, income. In eat what you kill practices, it can be very costly. Rick Boop experienced that during his presidency of the WNS. And then what I call high quality airport time, not. I would rather have colonoscopy than listen to the screaming, you know, intercoms at airports and feeling like a cow going to slaughter. One of the real pleasures I had and certainly in recent years of sort of being chair of the RSC, president of the SNS and president of the ANS and running the NFL head, neck and spine all together, there was a certain sense that you finally, you got your arms around the whole thing. And that's a great feeling because of the information that you're carrying around, but it's, you wear out. You need a break from that and there is no break. No time to recharge the battery. And then one of the things that was one of my life surprises was at the end of my WNS year, which followed a bunch of other things in rapid succession, what I call my disaster five years. I got the dean's evaluations that the faculty submit on the chair. And it was unbelievable. It was about, you know, travels too much, out of touch with department, you know, on and on and on. And it was really not a pleasant experience. And whether I failed to communicate well or what, I don't know. Mentorship, Tom Quest, Ralph Dacey, Roberto. I just, they, over the years, they tended to, their name was always present when somebody called, you've been nominated for blank. It was one of those guys. And our travel club. This is a group of people that you all recognize. And we've been together for, this was our 25th anniversary in Mexico. And one of the set, and one of the great things about the travel club is it's a group of people that care about each other. Their children grew up together. And it is a time to exchange ideas. We meet in the morning. We play in the afternoon. We meet in the morning. And it's not presentations like you give at the WNS. It is, here's what I'm thinking. Is there a hole in this? Where am I going wrong? It's taking on problems that you have a brain trust, people you do trust to discuss with. Now, one of the sad things here that's illustrated well, you know, it's Dr. Barrow. And he sent me this photograph, Molly had taken the photo. And somehow he photoshopped it to, if you look, it's distorted where everybody there is shrunk down to Dan's size. So we'll start a run through of how we got to the kind of structure we have with some thoughts about that. And there's a manuscript I'd refer you to also, Carl Halber was the executive director of the WNS from the early 80s up until the mid-90s. And he and Chris Phillips wrote this paper. It's published in Journal of Neurosurgery called The Evolution of Organized Neurosurgery. It's worth a read. It's very instructive. And I'll hit some of the highlights and some of my interpretation of them. The Society of Neurological Surgery was the first organization in neurosurgery worldwide. It followed a decision by the American College of Surgeons that recognized neurosurgery as a new medical discipline that required specific training. Right after that, within four months, 11 founders under Cushing's leadership met at the Brigham and founded the Society of Neurological Surgeons. You see the list of founders there, Cushing, Sachs, Bagley, et cetera. Walter Dandy was invited, but he had personality conflicts with about half of those individuals above. So he didn't come. So the first meeting occurred later that year in November in Boston. Cushing was present, Ernie Sachs, Secretary Dean Lewis, Vice President. And the way the meeting was structured was that it occurred in an academic environment at that medical center. And the mornings they had surgical clinics where with amphitheater environments all the members could come and observe the host and his or her staff. It was essentially all his in those days. And they would do surgery all morning. And the naysayers are the ones that were not as prominent as Dr. Cushing described it as strutting their stuff. So there was not total unanimity about the success of this. And then they did didactics in the afternoon. Just to look at their bylaws when it was formed, the continuing development of neurological surgery, including graduate and postgraduate education, recognizing persons of ability by granting membership or appearance on programs. And they limited membership to 45. That will be a recurrent theme. Here was a growing discipline in America and the world. And they limited the membership of this august society. And it was to enhance the stature of neurosurgical programs in academic medical centers. So there's an important but a restrictive charter. This had changed a good bit by the time Ralph Dacey was a past president in 2015. Now the senior society was trying to align our organizations, establish the portal as a way of being a portfolio for lifelong learning, and creating a better mechanism of us accrediting our fellowship programs, which none of which are under ACGME supervision. And also to promote resident education and research. So out of those discussions and plans, and with Tom Naska's help from the ACGME, we have a system now that's working through its final, it's actually operational, where our SNS CAST committee, which borrows talent from the sections to form the fellowship review committee, they do accredit all of our fellowship programs. They are now coordinating with the RRC so that, let's say that you have a core training program here, that historically the CAST committee had no access to their data. But they're struggling in spine, okay? Let's just make that what's going on with that core program. And they've applied for a spine fellowship with two fellows a year. Well that's a problem. And now we know that. And now the core program knows exactly what's going on in the fellowship as well. So that's, I think, a real heads up. And our partners in other specialties are very jealous of that. One of the things about the gavel of the Senior Society is sort of the shock of looking at the first and the last name on that piece of silver. And the president of the Senior Society has one task, besides his others. Do not lose this gavel on my watch. This came from the home of William Mayo. It was a spindle on his banister that his daughter saved when they tore down the house. It's been there for well over 70 years now. The Senior Society formed the summit. The summit is also the envy of all of our colleagues across other disciplines. Think about this. Congress, when they want, when somebody needs to testify on behalf of neurosurgery to Congress, we cannot do that as the WNS or the CNS, because those are trade organizations to Congress. Those trade organizations are where dues-paying members elect officers to serve at their pleasure and in their interest. That is a trade organization. That is an invalid way to testify to Congress because you've got inherent conflicts. Under the summit, we go in as an academy. Academy is about research, education, and that could be education of the public. That could be education of Congress. And the president of the senior society presides over the summit meetings. We meet at the CNS, the WNS, and in the summer. Participating are the American Board of Neurological Surgery, our RRC, and our Washington operation. It is, of all the things that I've been involved with over the years, that is the most enjoyable, collegial, productive meeting that we have. When Sean Grady and I had to testify before the Institute of Medicine during the duty hours battles around 2006, 2007, 2008, you'll notice the letterhead here on the slide, Senior Society, but we were the chair and the secretary of the ABNS at the time. And that was when Just Say No to 56, the balance between fatigue and discontinuity of care, remember those arguments, and then what makes neurosurgery unique and challenged by duty hours regulation. Katie and I went to Capitol Hill with Atul Grover from the WMC. He's an outstanding person. And this was about the physician shortage and manpower discussions. And as you see the imprimatur here, that was really what I was testifying under. And Katie had this idea that, you know, all these work force projections by the primary care folks primarily, it was going to be, we were going to need a Brazilian of them in five years. And obviously mid-levels really tilt the balance here big time. It's unlikely that doctors are going to be taking blood pressures down the road, but Katie's point was, well, this is brain surgery, and it's unlikely that other healthcare workers are going to be doing that. We had to respond to the IOM and the Macy Foundation report on GME, which was an unmitigated disaster. It is still percolating up in pieces of legislation, but it was really about this portion of the graduate medical education funding, 90% of it, that is called indirect medical expenses, and that's been the target for a very long time. And in addition to other problems, and we wrote, Bob Harbaugh was president of the Senior Society, so he was the primary author of this response, actually written by Katie and signed by Bob, like normal. Is that right, Ann? That is how it works. So I want you to, you know, let's go back to the Senior Society. This is seven or eight years, nine years into their life, and this is a black-and-white photograph, but if you'll look carefully you'll notice that that group of individuals, as august as they are, are a little bit white. Their skin's a little white and their hair's a little white. And as Dr. Cushing had said, he said, you know, in 10 years we're going to all be a little bit gastronomical. And I'm not sure exactly what the definition, you sort of understand it, and I agree with him. And so a group of young soldiers decided that they would form a new society because they knew they were never going to get into the old boys club. So they went, hat in hand, to Dr. Cushing, afraid he was going to just blast them. And one of them had a great idea. Let's ask if we can use his name. And that sold the day. So Dr. Cushing said, absolutely, I'll host your first meeting. It's like an obstetrician giving birth to a new baby. But remember, in 10 years you're going to be gastronomically challenged too. You're going to be the old boys. This was that group, and there was a young woman, Louise Eisenhardt, whose lecture we heard this morning. Louise was not a neurosurgeon, as you know, but a neuropathologist. But she built the Cushing Tumor Registry, and she was the first woman president of the Harvard Cushing Society. So they had agreed in principle that they wanted board-certified people, even though they hadn't quite established the board yet. And they were going to limit themselves to 35 members. So here's a growing specialty. You've got the old boys club that's limited, and now you've got the young boys club that's also limited. One girl, excuse me. But we perpetuated that theme, and it became another inaccessible club as new people came into the field. This organization, the Cushing Society, transitioned into the American Association in later years, as I'll show you. Well, it wasn't but seven years later that another wave of young men and women – I don't know, actually I'm not sure. No, there were no women – came because they needed an education platform. You know, they had just finished training. They wanted to be around new ways of learning and meeting with colleagues and so on, and they formed the American Academy. And the core idea behind the academy was to foster research. That was going to be their primary domain, and still is, by the way. And even yesterday we heard some incredible ideas. Dan Barrow is now president, and Russ Lonzer chairs the research committee, and they are really making great inroads with the NIH on ways to facilitate NIH dollars via the academy with mentorship of young academic neurosurgeons. And they also made the point in their charter that they wanted social compatibility among their peers. And this is a classic from our early years where you have a room full of men in black tie, but there's nobody to dance with unless they start dancing with each other. And they looked a little serious. We came of age this year, 1940, when we formed our certification process. And the certification process, unlike a membership organization, this is about the public well-being, and this is the preamble to the bylaws. The broad aim of the ABNS is to encourage the study, improve practice, elevate the standards, and advance the science, and thereby to serve the cause of public health. And this hit me. I didn't read that when I started on the ABNS, but it hit me about six months later that this was really a fantastic job. My job is not to represent each of our diplomates. It is to say, how do we make sure that the best possible doctor in the white coat comes to Mrs. Jones in the emergency room? It was an incredible revelation. I'm slow. Most people pick it up when they start. The board sets educational standards. They obviously do our certification process and our maintenance of certification. They're a member of the American Board of Medical Specialties. We discipline. When physicians get in trouble, they come up through the board for action. And the sentence, the term for a director is six years. But this is a herpetic infection. It never goes away. They keep going, oh, you've got to come do the exams. It's fabulous. And this was the 75th anniversary, and Mary Louise is swan song. She made a fabulous contribution to our board. Another membership society came up in 1948. You have a wave of people coming back from World War II, from service. They want to be neurosurgeons. They get trained. Now where do they go? And all those other three societies are full. So the NSA, which everybody who's a member of that, it's their favorite society on Earth. And even nasty people become very nice when they get off the plane going to the NSA. And one of these guys, Jack Wolf, a founder, became a neighbor of mine in my first tour of duty in Dallas. And he hated Kemp Clark, so he left me his library. His very substantial library, which I still have. And it was for surgeons that couldn't find a home, an educational home. And the good thing about it is it was destined to be half private and half academic, which really, as Moose will testify, it creates great discussions during the meetings. Afternoons of families were encouraged and not charged, and afternoons were golf, tennis, and fishing. The scientific meetings were fun. They're not meant to be abusive or critical. And Josh Spiegel, one of the early members from Chicago, came up with the idea of three-minute presentations, two-minute discussion next, and that way you get a lot of information done and transmitted in the morning. But it perpetuated the same insiders-outsiders problem. Membership was capped. It still is. They have their own unique hardware, which is quite beautiful. Then something different happened in 1951. That was when I was born. That's 1951. I know you were thinking 18. This is the founding group. First meeting in Memphis, Peabody, a lot of members. And all were welcome. You didn't have to have boards. You could be pre-board. And leadership was kept. This had been discussed in the other societies. We had to make sure we keep bringing in young people. And you had to take over a leadership role before or not over 45 years of age. It's now 50. But among other things, it was to honor living leaders. It grew very rapidly. And I remember when I went on the CNS executive in 1990, the really revealing thing that I noticed most strikingly was the agenda book and the amount of material in the agenda book. It was really spectacular to realize what all is going on in the world of medicine. Our guest, there's one of them, Duke Sampson, there's one of them when I got to serve that way four months before Chris Getsch passed away. Hardware. Then the organization, the CNS and the Harvey Cushing grew very, very rapidly and sort of in parallel with variable types of relationships depending on leadership and issues of the day. But it became clear that we needed a voice. When somebody called neurosurgery, who do they call? Because we already had sprung up all these different names. And so Frank Mayfield, when he was in his leadership role with the academy, decided it would be the Cushing. And in his presidential address for the NNS, he said, I, Frank Mayfield, hereby proclaim the Harvey Cushing Society to be the official organization representing neurosurgeons in the U.S. That caused a series of name changes culminating in the NNS. So here's the way it looks today. It's a spokes organization for neurosurgery, a very broadly elected board with the CSNS having a very strong role in that, as are the sections. We have a 501C3 for our scientific educational mission, a 501C6 for our advocacy missions, which I'll briefly mention. NREF has had a great reemergence under John and Reg. Our registries are making national news amongst all of the specialties. I think this is really going great. And I'm so proud of our Washington operation. Once we got Ann Stroik out of a leadership role, this thing has just taken off. And these are entry points, as Ann will tell you and help you with. Each of these areas requires a little bit different skill sets. And Katie and the Washington chair survey our membership to find the right people. And as you know, I love Katie. And I love Charlie Plant, who I fortunately got to meet in my very early years. Charlie taught her the value of integrity with our legislature. When they come to our people, Katie or Charlie, they get the best researched opinion that is out there based on the facts. Sometimes we are going to like it and sometimes we don't. That's the deal. National affairs, people that are very interested have a portal of entry through the WNS. It's the Continental Society for North America. And the Harford Gushing cigarette box is also a beautiful part of the WNS culture. Our sections are critical. You know, we've got sections in every one of our sub-disciplines, which are a great portal of entry for anyone interested in service. We have many affiliated organizations that also are a route for people with different interests and different contacts. A word about the ACGME. This was formed in 1981 from the Liaison Committee for Graduate Medical Education. And in its early years, and it was the CEO of the ACGME always presents at our senior society meeting. And back in my early years, it was a slugfest. And the CEO had to wear Kevlar. It was a disaster. It was a gotcha organization. You know, did they have enough magazines in the call room? You know, or a boat citation. It's all different now. But what the ACGME does is they accredit institutions and core training programs looking at the environment of learning, not at the individual resident. It's the environment of learning, to assure that the board-mandated educational standards can be taught in the proper environment where the learners can get it and get it well. And the values of self-effacement, patient first. The RFC people work as hard as our board directors. It's a lot of work. Six-year sentence on that one. Tom Naska is a really fantastic person who's transformed the ACGME and brought on ACGME International and a dozen new programs, and he loves neurosurgery. And we've made him, actually, through the senior society, an honorary neurosurgeon. He's actually a renal doctor and nephrologist. And he said, I am so proud. And his son is training with Bob Rosenwasser now in neurosurgery. He said, I'm so proud to be an honorary neurosurgeon. And I said, well, Tom, you could have gone a lot farther than being honorary, except your IQ was too damn high. But I've had fun working with him. The council is another rich portal of entry that I've seen mature unbelievably. I remember the days where Cairns really ran it and Randy Smith dictated it. He was the little rocket man of the CSNS back when they were the JSAC. And this council has gone in sophistication ballistic, and I'm very proud of it and proud of our leaders that have done that. Two or more are right here. Three, sorry. At least three. So I'm very proud of Josh. And I would say in closing that leadership and service, while interruptive, is really a great honor. You meet great people and you learn a lot. When people call you in a bad year for you, okay, and there are no good ones for any of us, just say yes. There may be a reason because of your background or your skill set that they're nominating you. Just say yes. When you're in office, focus on things that are important. And, you know, interscholastic skirmishes don't reach the threshold of importance. Focus on issues that can be influenced. You have a brief period. You have a narrow window to get something changed and done. Don't try to move the rock of Gibraltar. To mentor and inspire the next generation is a great honor, and hopefully we're giving rise to the birth of a new generation that is going to really, really be great for our field. So that's a few of my thoughts. I'm happy to engage any answers or any questions. Thank you.

Dr. Hunt Bajor

service to neurosurgery

Serving Neurosurgery a Primer

physicians in policy-making

global medicine

NFL policies

public health crises