Thank you, everyone, and welcome to Los Angeles 2023 here in Los Angeles. We've got a great program for all of you. The science is going to be unbelievable, I promise. These late-breaking abstracts are very, very exciting, and it's going to probably change many of the practices that we now have as neurosurgeons. So very excited about our scientific program. And as you've seen from the, you know, the materials that we sent out to all of you, we also have incredible speakers. There will be things that we will talk about in the future of neurosurgery with some of the brain-computer interfaces and chip technologies that you can't even imagine what the future will be with that. So that being said, let's bring out the talent, and Dr. Anna Martha will be speaking next. Thank you. Good afternoon. The voice of Al Roden echoes in the collective consciousness of neurosurgery, both literally and figuratively. Dr. Roden understood that to do our job, we had to understand neuroanatomy. And so if I were to ask this room of neurosurgeons if anyone could name for a cup of coffee someone who helped to teach you neuroanatomy and helped you to understand how to operate better as a neurosurgeon, everyone would be able to do so. It gives me tremendous pleasure with the introduction of the Roden family lecturers to be able to just pick out two people who live Dr. Roden's mission and really work hard to understand neuroanatomy and do everything possible to make sure that the neurosurgeons coming up after us understand it even better. Andy Grand from the University of Minnesota and Jeff Sorensen from the University of Tennessee truly believe in the mission of teaching. And so I would like to introduce them as the 2023 AANS Roden family lecturers. Well, thank you, Adam. We'd like to thank Dr. Streunk and the AANS leadership and the organizing committee for this incredible privilege to present to you the history of the Roden collection. If you could play the video. The brain is really, truly the crown jewel of creation and evolution. It's our greatest unexplored scientific frontier. Some people say it's the seat of the soul. I don't know that it's the seat of the soul, but certainly through our brain and mind, we become aware of our own essence and our own soul. Pretty inspiring stuff. It's great to hear Dr. Roden's voice again. So tell me, Andy, how did you first get to know Dr. Roden? I met Dr. Roden through the Goodyear Neuroanatomy Laboratory in Cincinnati and my mentor, Dr. John Tu. At the time, he was trying to reinvigorate neurosurgeons to begin using radiofrequency rhizotomy again, and the three of us would go around and teach courses on radiofrequency rhizotomy. How about you, Jeff? How did you meet Dr. Roden? I met Dr. Roden through the Skull Base courses in Memphis, directed by my mentor, Dr. John Robertson, and I was completely blown away by his 3D lectures, and I wanted to hit a pause button so I could linger on each slide longer, and his teaching lab was excellent. But at the end of every course, inevitably, there was a push-up contest, and despite Dr. Roden's humble demeanor, he always won. So how did we meet? Do you remember? Yeah, it was the AANS-IT committee where we first met and we discovered our mutual passions for photography and gardening and art and technology, and it was there where you showed me this online digital platform for neuroanatomy and neuroeducational content, and we began exploring ways to utilize it. Yeah, I remember we were trying to use new technologies to kind of go beyond what the conventional textbook could do. And then serendipitously, the opportunity to work with Dr. Roden came about, and so we got even more excited about the concept. You know, Roden, like Vesalius, really appreciated the art of surgical anatomy, and his laboratory was his studio. I started this to make what is a delicate, fateful, awesome experience for my patients, accurate, gentle, and safe. The best image guidance that you can have is the knowledge of microsurgical anatomy. Dr. Roden's career began at the dawn of the age of micro neurosurgery, and he went to accurately describe the view that surgeons are seeing through the operating microscope. His fellows came from all over the world. Our goal in this is to make all of them Michelangelos of microsurgical anatomy. One of my mottos has been that there is no finish line. To me, the horizon for creating a better understanding of microsurgical anatomy and studying anatomy to improve surgical techniques has never been brighter. Dr. Roden was incredibly accomplished, but more importantly, he could inspire those around him to be their best, which multiplied his impact around the world. His book was widely available, but it is really important to him that his collection be available online for the world for free. This was accomplished through the Roden Collection, which was funded by the WNS through the leadership of Dr. John Robertson and Dr. Bill Caldwell. We made a lot of trips down to Gainesville to explore ideas and work on this project, and through all of it, the WNS leadership has been engaged and committed to the success of this project. In digitizing his slides, we found hundreds of these folders, and the slides had to be cleaned and digitized. We bought high-resolution scanners, and the WNS was kind enough to pay for someone to work in Roden's lab to accomplish this. After the slides were scanned, they were uploaded into the database so they could be searched by keywords such as structure or perspective. The website handles all 2D and 3D formats, which is important because Dr. Roden believed that 3D images made complex anatomy more easy to understand, particularly for people first learning it. Instead of cluttering the images with conventional labeling, structures are brought out by highlights, which are interactive. These highlights are created in the website with a drawing tool that's built in. Images and highlights can then be downloaded and used in PowerPoint presentations, and I've seen these images in lectures all around the world, even by ophthalmologists or otolaryngologists, so they're having an impact already. But you can also create slideshows within the website itself, as we did for Dr. Roden's lectures, and this has certain advantages, as you'll see. Below median anterior skull base, we see frontal sinus, ethmoid, sphenoid sinus. Here you see Dr. Roden's anterior skull base lecture that's been converted into an interactive learning module. On the right-hand side, you can click on structures. You'll see the highlights on the left and vice versa for self-paced learning. Alternatively, the slideshow can be presented for a didactic lecture when you enter into the presentation mode. As you advance slides, highlighted objects are automatically highlighted. If you have a 3D presenter, you can actually convert this into a 3D lecture on the fly. This would not be possible with PowerPoint. And if you don't trust your internet connection or don't have that, you can download a PDF of the presentation and deliver the presentation in this manner. If you record your voice into each slide, you can create 3D videos and 2D videos out of your slideshow, and the videos can be broken down into chapters, so you can find which part of the video you're looking for easily. And just like the slideshows, the videos can be watched in both 2D or 3D. The videos are edited online by moving the highlights to correspond to the timing of your voice, and this avoids all the headache of trying to use complicated software like After Effects to edit these 3D videos, so making this more accessible to people. The video is rendered in the cloud, which can be later downloaded. Art has always been used to simplify neuroanatomy in a way that cannot be accomplished with photographs. Within the Rodin Collection, there are thousands of these artistic drawings that accompany his dissections. We're currently scanning these with a high-resolution art scanner. These should be available on the website, and can be enlarged if you so desire. Dr. Rodin's collection contains many skulls and skull bones, which we're digitizing into 3D models using a technique known as photogrammetry, where images are taken from many different angles and then the 3D geometry is reconstructed from these images. The resulting 3D models can be then interacted with in virtual reality, or rendered into animations, which you can download for your presentations. They can be augmented with highlights for various structures and other structures such as nerves, arteries, and veins that further increase the usefulness of the 3D models. I think Dr. Rodin would be excited about these models that demonstrate three-dimensional relationships through movement and don't require a 3D viewer. Here you can see the beautiful dissection of the skull base and the cranial nerves in a unique fashion. We've also developed a tool that makes it much easier to perform these highlights and animate these structures so you can see them from multiple perspectives. And again, this makes it much easier to use these 3D models without having to learn how to use complicated software. So this tool will be available to download soon. This digital platform can be expanded and additional collections can be brought into it to enhance the user's experience. Some of these collections include the Rotin Top 100 by the ABNS, they include Gray's Anatomy, which is available online, or this 18th century book on lithography. It can include additional neuroanatomy laboratories from around the country, or it can include works of art such as the drawings from Dr. D'Agostino's Rotin Top 100s. And again, neurosurgery department content, pictures, lectures can be included. So complex subjects are often broken down into simple concepts before building them back up into complicated topics. So just as in subjects like mathematics, complicated things like this anatomy should be broken down into simple concepts. So Dr. D'Agostino, who is a resident at the University of Vermont, is doing just this with a lecture series built on the platform whereby she step-by-step constructs the posterior fossa, invites her viewers to make drawings along with her, and I think we can all agree if you can make a drawing of something, you probably understand it a lot better. So this is illustrating Dr. Rotin's rule of three, whereby the complexity of the posterior fossa divided up into three parts corresponding to the cerebellar arteries. If you build up this complexity of the posterior fossa nerve by nerve, artery by artery, you'll build an understanding that allows you to understand this just beautiful but complicated dissection from Dr. Rotin's lab. Well, let's try to understand the jugular foramen in this Rotin dissection in which you're looking from inferior, looking up at the temporal lobe. You can begin with a 3D model of the temporal lobe, and this model can be then rotated, animated, narrated. Individual structures are added one by one, and then the student can actually stop this in mid...stop it, rotate it, and really try to study and understand the anatomy. Once they understand the complexity of the anatomy here, they can overlay that with the Rotin dissection to better understand that dissection. Have you ever been to a meeting where there's a surgical video that's really interesting but kind of disorienting and you don't know exactly what you're looking at? I think a lot of seasoned surgeons have been through that and felt that experience. So, we can simplify this by breaking the complex video down into a series of steps using Rotin dissections and freeze frames from the video. So here is a transcarotid approach, and we're highlighting the structures, the velum interpositive, the fornix, the third ventricle. And once the steps of the operation are gone through anatomically and with still frames from the video, then the viewer is just much better equipped to understand what they're seeing in the surgical video. So hopefully this is another way to break down complexity using the Rotin collection. Jeff, as we've reflected on Dr. Rotin's career, he really was like the giant oak tree that he used as a metaphor so often to describe neurosurgeons. Dr. Rotin, you will not be forgotten, and through the Rotin collection, you'll continue to inspire neurosurgeons around the world. The great surgeon is like the giant oak tree that sends its roots deep into the earth to the source of love and kindness from which we constantly replenish our ability to treat our patients with compassion, and it makes us reach out with our limbs and branches to assist the world with skill and knowledge. Good afternoon. It is my distinct pleasure to introduce to you the Distinguished Service Award, which is going to Dr. Edward Laws. Dr. Laws has been a professor at four different institutions, Mayo, GW, where he was also the chair, University of Virginia at Stanford, and since 2008, he's been a professor of neurosurgery at the Brigham and Harvard Medical School. He's trained and mentored numerous residents and fellows. He has provided great leadership to organize neurosurgery. He was president of the Congress of the AANS. He was president of the American College of Surgeons. He has won numerous awards, including the Decade of the Brain Medalist, the Cushy Medal, and recently he was also awarded from the Pituitary Society the Lifetime Achievement Award. He has over 600 peer-reviewed publications, two numerous account-invited lectures, and I think he probably has the world record for the number of pituitary surgeries, 6,216. So please give me a congratulations, Dr. Edward Laws, for his service to organize neurosurgery as a Distinguished Service Award recipient. Thank you. As you can imagine, I am absolutely honored and deeply grateful for receiving this very special award, but I wanted to show you something about the AANS, and many people will not know that it began as the Harvey Cushing Society and then was changed to be the AANS that we know and love. But I couldn't resist with Dr. Cushing being the hero that he was, and this is my favorite picture of him, Dr. Cushing, at work. Well, the AANS could not have survived with the change that occurred, and it evolved over time as the prime focus of true advances in neurosurgery and neuroscience. And in order to do that, of course, he couldn't do it alone, and it depended on the mentors and leaders that came after that. And here are some of my mentors that meant such a great thing to me and to the AANS as it continued to foster neurosurgical advances. So, we see Dr. Yashagil, Dr. Al-Rodin, Dr. Zuhardi, Dr. Thorisont, and Dr. John Jayne, all of whom were so important to me and did such a great job. Now, in order to have a powerful and important AANS, we have to have great leadership, and we sure have it now. Our superb president, Ann Stroik, epitomizes effective leadership and innovation, and we will all benefit from her tenure in that job. Finally, I'd just like to mention and acknowledge the support that so many of us get from our families and the dedication that they have that keeps us viable as really great neurosurgeons. And we benefit so much, as does the AANS, from these people, and I hope they'll continue with the excellence that we've been used to. Thank you so much. Thank you. I'm Nina Marupudi, and currently a pediatric neurosurgeon at the University of Michigan. Today, it is my absolute honor to introduce the 2023 AANS Humanitarian Award recipient. This award was established in 1987 to honor a AANS member whose activities outside the art and science of medicine greatly benefit humanity. This year, the award recipient is an incredible woman who is not only a legend in Detroit, Michigan, but also one of the most brilliant, thoughtful, and caring minds in our community. This year's award recipient is Dr. Alexa Kennedy. Dr. Kennedy was the first African-American woman to become a neurosurgeon in the United States. She was born in Lansing, Michigan, and was an avid reader from a young age. While attending the University of Michigan School, medical school, her love of neuroanatomy grew into an interest in neurosurgery. Through much devotion and hard work, Dr. Kennedy completed a surgical internship at Yale, neurosurgery residency at the University of Minnesota, and finished her surgical training with a fellowship in pediatric neurosurgery at the Children's Hospital of Philadelphia. In 1984, she became the first board-certified African-American female neurosurgeon. Shortly thereafter, she became chief of pediatric neurosurgery at the Children's Hospital of Michigan. There, she grew the program into a national contender while publishing over 50 papers and giving over 130 scientific presentations. As much as her accomplishments as a neurosurgeon, her roles as a leader, mentor, and person equally changed the world. She gracefully influenced how the world perceived women and women of color. I'd like to share with you one example of this. One evening, while working at the Children's Hospital, Dr. Kennedy was called to consult on a patient. Dressed in scrubs and accompanied by one of the neurosurgery residents, she entered the patient's room. Before she could introduce herself, one of the family members said, well, it's about time somebody got up here to empty this trash bin. It hasn't been changed or cleaned in two days. As a lesson in teamwork for the resident, Dr. Kennedy took out the trash and asked if there was anything else that she could do for the family. The family said no. She then introduced herself as their neurosurgeon and began the consult. This left the family, obviously utterly shocked, but incredibly impressed by her grace and patient- centered focus. Dr. Kennedy was there to take care of everyone, even those who were prejudiced. This was not an isolated event and similar incidents are remembered as common occurrence by staff that had worked closely with her. While keeping a humbling memory of our society's history of unfair perceptions and bias and the fact that we still have progress to make, we have nonetheless made a lot of progress in the time of Dr. Kennedy's career, in large part because of the new paths she has blazed and institutions she has changed as a leader. Even in divisive situations, she brought together people. This is the true mark of a humanitarian leader. Despite the high expectations of neurosurgeons, Dr. Kennedy frequently managed to go above and beyond. Whether it was running a hydrocephalus family support group, paying for the dental work of a housekeeper, or organizing a food drive for her patients, Dr. Kennedy was generous with her time and money. As a master public speaker, Dr. Kennedy left behind quote after quote that continue to resonate with those who worked with her, for her, and around her. My favorites include the following. Never dismiss the symptoms of the child. Children don't make up symptoms. While we all think we are the center of the universe, the reality is that a hospital can run more successfully without a neurosurgeon than it can without housekeeping. And my most favorite, the most difficult part of doing something different is convincing yourself that it is possible. Please join me in congratulating Dr. Alexa Kennedy, this year's 2023 AANS Humanitarian Award recipient. Hi guys. A person is a sum of the people they've come in contact in their life. Mine started with my parents in the 50s who taught me never let anybody else judge your value. I had the privilege during my training of being part of several neurosurgical families, which I still feel close to. I started my training at University of Michigan. I wore my yellow jacket today. And I then went to Yale, where I was part of that program, went to Minnesota, and then went on to Philadelphia. So training in multiple places gave me different perspectives and lots of people who were helpful to me. The people most helpful to me in my life have been my parents. Also, Shelly Shu, who was the most incisive technician and also thoughtful man I've ever met. And Louie Shute, who in many ways was the opposite in Philadelphia, in that he knew how the world worked, how to build a practice, how to train residents, and how to take care of patients. So the synthesis of those two, I think, can turn out a pretty good doctor. The last person I have to think, of course, is my husband, who never once in all the years I've been married to him complained that I didn't get home on time. He always said, just don't tell me when you're going to be home so I won't have to sit around waiting. So thank you all. I appreciate the opportunity to be a neurosurgeon. It's been the best thing I've ever done, and if I had to do it again, I would. Thank you. Thank you to the organizing committee, and particularly to Dr. Stroink for inviting me to present some of the work from my laboratory, particularly the three individuals in yellow who really led this up. Frank Willett, Aaron Kunz, and Chaofei Fan, a terrific group of incredible researchers in my laboratory. Here are my disclosures. Importantly, this is an investigational device, which is limited by U.S. federal law to investigational use. It is not a commercial device. My laboratory has been interested in studying the neural control of behavior, and particularly recently, the fundamental neuroscience of an unbelievably exquisite motor control problem. I love looking at this MRI scan, which illustrates the coordination of these articulatory muscles, which is among the most complex movements that our body can make, and how in the world the brain coordinates these movements is a fascinating problem. But it's also very important from the standpoint of translational need. There are people who need to have restoration of speech if they've lost the ability, so turning attempted speech through neural signals into speech output. Much of the work that my laboratory has done is based on the groundbreaking work of Eddie Chang, who's our discussant today, and some of his work with the distribution of the articulator representations in the ventral precentral gyrus. This motivated us to study this area even more closely with microelectrode arrays consisting of silicon microelectrodes. These are dense silicon arrays that are implanted into the ventral portions of the precentral gyrus, right amongst these microelectrodes, and these microelectrodes of the precentral gyrus right amongst these somatotopic representations of the speech articulators. This is an interoperative photograph during the placement of these. You can see that here are the, here's the inferior frontal gyrus, a portion of Broca's area, which we also placed arrays, and this is just localization using the navigational workstation in order to very precisely map out the areas that we wish to implant. As you'll see, this particular site was unfortunately blocked by a blood vessel, so we had to move this array up here. These are each eight by eight arrays with 64 contacts for a total of 256 total neural signals from this region. So looking at the neural signals on these arrays, we can see that there's actually differences between the more ventral and the more dorsal array, with the ventral array showing a much higher proportion of tuning. Each of these individual circles represents tuning to conditions, and each one of these is a single neuron that is tuned differentially to words and phonemes in the more ventral array, and to orofacial movements in the more dorsal array. However, there's intermixed tuning throughout both of these arrays, with all things being represented in all portions, really refuting some of the somatotopic organization that we believed before. Looking at the articulatory representation from the neural data and comparing it to electromagnetic articulography, we can see that the similar phonemes, for example, the labials, which are made at the front of the mouth, are confused at the same rate as articulatory, meaning that we have a reasonable decoding of these phonemes. And if we plot these in a higher dimensional space and then visualize them using principal components analysis, they cluster in similar ways between the articulatory and the neural data. In order to leverage these signals, we designed a system that took the neural signals, our participant repeats words, and these are displayed on the screen as text, and then spoken by a speech program. This works by taking these threshold crossings and spike band power, running it through a current neural network, which then calculates the probabilities of each phoneme being emitted at any particular time. These phonemes are then processed by a language model, which then helps to correct the word level output. So what you'll see here is our participant with Bulbar ALS, who is reading these words off the screen. You'll hear her attempt to read them. She's anarthritic, but can still vocalize, and then her decoded speech will be played along the bottom. I don't want to call her a babysitter. That would be good. I did well in school. So not only can she repeat sentences with the system, but she can also generate her own particular sentences. So here, we're asking her what she's proud of, and she answers, as you can see. And finally, what we found was that she doesn't actually have to vocalize, that she can just merely mouth the words. And we're able to decode this actually nearly as well, and in fact, she prefers this because she gets fatigued with vocalization. So this actually allows her to accomplish more trials. I do not have much to compare it to. I don't read as much as I would like to either. So what we found was that we were able to decode general English at about 65 words per minute. So here, this is both the vocalization and the silent speech, and the word error rate, which is around 25%, and then approximately 65 words per minute in speed. And this is from a general 130,000-word vocabulary. This is taken from the switchboard corpus of English. So truly a general communication. This is compared to the prior state-of-the-art. We used the same 50-word vocabulary, which had been published previously, and word error rates were much lower, around 10%, and still with very high decoding speeds. And then this shows the prior state-of-the-art, which was about a 25% error rate and about a 15-word per minute decoding rate. So this continues the tradition of my laboratory to continue to advance intracranial BCIs for rapid and dexterous behaviors, including speech, in order to try to restore a function for people who have lost it. So with that, I'd like to thank all of the people in the laboratory who made this possible, particularly Krishna Shenoy, my long-term collaborator, who unfortunately passed away in January from pancreatic cancer. He and I had been close collaborators for the past 15 years. Thank you very much. Thank you. It is a real privilege to be a discussant for this latest late-breaking abstract. The only word that I have to describe these results is speechless. It's a joke. But here's why. The first attempt for a speech PCI occurred in a locked-in person, and intracritical recordings could decode some vowel sounds but not actually words. This was in 2009, using a totally different electrode approach. Our group showed the first successful demonstration actually of full word decoding using an electrocorticography-based approach, where electrodes are placed on the brain surface. This new work is a new major advance over Moses' all just two years ago. It uses and capitalized on the fidelity and precision of intracortical single-unit recordings from the speech motor cortex in order to decode words and sentences. This new work from Dr. Henderson and his colleagues is a major breakthrough for both decoding word speed and vocabulary. There are some considerations. It is unclear if the same performance will exist for people who are truly locked in. The performance with these kind of brain and computer interfaces and people who have some residual movement versus those who are completely locked in and paralyzed is to be determined, especially if there's no residual facial movements. Second, the intracortical Utah array is not new. It's a technology that's been around for almost 20 years. The major innovations and improvement in this new work and work from other groups is from higher channel count electrodes and also new machine learning to coding approaches. We now know that there are two solutions that are now available for brain computer interface technologies, both electrocorticography recordings from the brain surface, but also intracortical arrays. Each has pros and cons. Future gains will be made in this field as both approaches increase channel counts, and we will see side-by-side which of these approaches will be the ones that we should adopt for a clinically viable system, one that is safe, reliable for a decade or more, and also has high bandwidth to transmit the information in high fidelity from the human brain. One of the most exciting things that is happening now is the commercial development in devices that is currently happening in the field. These devices are coming online, and these debates between ECoG versus intracortical electrodes will no longer be debates, but will be borne out empirically by devices that we will have a role in administering in our patients soon. I hope from this work and other work that you now realize that the speech brain computer interface, something that only five to 10 years ago was thought unthinkable, is something that will now become a clinical reality. Thank you. So it is with great pleasure to offer the first inaugural AANS Distinguished Advocate Award to Troy Tippett. This award recognizes, well I guess the pointer's not working. This award recognizes an individual who has served as a strong advocate for neurosurgeons. So their patients and the profession at the national, state, and local level. Nominees will have demonstrated a commitment to promoting sound legislative and regulatory health policy by consistently engaging in legislative, regulatory, and political processes. This includes, but is not limited to neurosurgeons working with the Washington Committee, Coding and Reimbursement, the Council of State Neurosurgical Societies, the Neurosurgery PAC, and the Board of Directors. Troy Tippett seems to have it all. He is well recognized for his work on reducing burdensome regulations, steered changes to improve evaluation and E&M documentation, from a checklist, which was used to be, to a clinical vignette. And of course, he's been a tenacious work in medical liability reform for years. His motto is, kind of like Winston Churchill, never give in, never, never, never. And so that, Troy Tippett, please come up here to receive your award. Thank you. Well, good evening, or afternoon. I must tell you, when Anne called me about the award, first thing I thought about was the old country boy who was walking along the road and found a turtle sitting on top of a fence post. And being an astute country boy, he surmised that that turtle didn't get there without help. And that's certainly the way I got here. I want to thank all the people who have helped me over the years, but I particularly want to acknowledge three women. The first one, of course, is my wife, Diane, of 55 years, who's put up with a lot, as you might well imagine. And secondly, Sandy Mortham, who was past CEO of the Florida Medical Association, past Secretary of State of Florida, and she taught me about politics. And of course, the final woman that I want to acknowledge is my friend, mentor, and confidant over these past many years. You all know her, Katie Rico. She has been phenomenal, as you all know, and is responsible for keeping me out of a lot of trouble most of the time. And of course, I must, before I depart the stage, make one final comment. You as neurosurgeons give excellent care to all of your patients. That's what we're known for. But you know, I finally realized over the years, whereas I, as a single neurosurgeon, helped a whole lot of individual patients, if we were advocating successfully, we would help patients all over the country and potentially all over the world. It took me a while being a country boy to figure that out. But this is something that we all have to do. We have to be excellent at taking care of our patients, and we also need to advocate for our patients and our profession. After all, if you don't do it, who will? Thank you for this award. Those are the wrong slides. Those are for the talk. There you go. Thank you. Good afternoon. I'm privileged to introduce the new Charles L. Plant Lectureship and the inaugural lecturer. Charlie grew up in Minot, North Dakota. He earned his undergraduate degree from St. John's University in Minnesota, his BA or his master's at the University of Montana, and his PhD in international affairs at Georgetown University. Charlie was a firm believer in public service. He volunteered for the United States Army. And inspired by President Kennedy and Sergeant Shriver, he brought this ethos to his work as the regional director of the Peace Corps in the mission in the Philippines. And also on Capitol Hill, where he served three United States senators, two of which Senator Thomas Dodd and Quentin Burdick's chief of staff. Upon leaving Capitol Hill, Charlie formed his own healthcare lobbying firm called CLP Associates, where he represented a variety of clients, including the AANS and the CNS, the National Kidney Foundation, several biotech firms, and others. It was during this tenure at the helm of his own company that Charlie made lasting contributions to millions of Americans suffering from various health ailments. Anchored by a strong moral compass, Charlie was raised Roman Catholic and even at one time contemplated joining the monastery. He embodied what it means to have integrity as a lobbyist. Doing what is best for patients will always be the best thing for neurosurgeons, he often told me. His foundational work in organ transplantation policy was perhaps one of his greatest achievements. His efforts were critical to the passage of the Social Security Amendments of 1972, which created the end-stage renal disease program, providing Medicare coverage for dialysis treatment for millions of kidney disease patients who otherwise would face imminent death. He was passionate about scientific discovery and medical research, dedicating much of his professional life to increase funding for research at the National Institutes of Health. For example, joining forces with Representative Sylvia Conte and the National Coalition for Research in Neurologic Disease and Stroke, Charlie helped pass a congressional resolution that was signed into law by President George Herbert Walker Bush in 1989, declaring the 1990s the decade of the brain. This initiative provided a framework for significant funding increases at the National Institute of Neurologic Diseases and Stroke to support head and spinal cord injury, research, stroke, and other neurologic disorders. Charlie's efforts also helped raise public awareness about the role of neurosurgeons in treating neurologic diseases and disorders. One noteworthy accomplishment was the designation of the 45-cent Harvey Cushing postage stamp as part of the Great American Postage Stamp Series. Working with neurosurgeon Richard Davis, Dr. Cushing's daughter, Betsy Cushing Roosevelt Whitney, and First Lady Nancy Reagan, Dr. Davis's sister, the commemorative stamp was unveiled at a White House Rose Garden ceremony on April 8, 1987, the 118th anniversary of Dr. Cushing's birth. Finally, Charlie's leadership at the Washington Committee was instrumental in bringing together the work of two neurosurgeons, Dr. Fletcher Eister and Clark Watts, and that led to the establishment of the AANS and CNS National Head and Spinal Cord Injury Prevention Program, which is now known as Think First, and has reached millions of teens, children, and young adults with its injury prevention message. Charlie left a lasting legacy for those who intersected with him and the millions who benefited from his quiet good works. It is therefore fitting that the AANS has established the Charles L. Plant Lecture in honor of my mentor, Charlie Plant, which features an individual who impacted neurosurgical practice and patient care through advocacy and health policy. This year, the AANS has selected Dr. Tony Asher to deliver the inaugural lecture for his contributions to improving patient care for neurosurgical patients. Policy related to quality and safety in neurosurgery has been a core mission of the AANS and CNS for decades, and through pioneering quality data projects, Dr. Asher recognizes the power of outcome science to transform data into quality patient care. Tony's journey in outcome science began in earnest during his time in CNS leadership, where he created several novel education programs associated with data systems, including SANS, which was established to enhance medical knowledge and self-assessment in neurosurgery. Inspired by former AANS president Bob Harbaugh's statement that the only thing that matters is an outcome, struck a chord with Tony, and he became involved with NeuroPoint Alliance, Neurosurgery's Clinical Outcomes Data Registry arm. At MPA, Tony assumed the role of Vice Chair and Director of the Quality Outcomes Database, with a first focus in spine. He also developed or co-developed additional registries in tumor, cerebrovascular, radiosurgery, and the American Spine Registry, a cooperative project with the American Academy of Orthopedic Surgeons. Finally, Tony brought this visionary registry work to the American Board of Neurological Surgery, where he helped establish the POST system for collecting clinical practice data as part of the ABNS certification processes. Given his advocacy and commitment to improving the quality of neurosurgical care for the betterment of our patients, we welcome Dr. Asher to deliver the inaugural Charles L. Plant Lectures. Tony, please come up. Thank you. Thanks, Katie. It's an incredible honor to be the inaugural Charles Plant Lecture, particularly as I have so much respect for my dear friend and colleague, Katie Arrico, along with her innumerable contributions to our specialty. This lecture is primarily targeted to our younger members, to whom I'd like to say, the perilous and disproportionate global health impact of brain and spine diseases, combined with unprecedented innovation in the neurosciences, provides you the potential to produce greater benefit to society than perhaps any other class of professionals. But you also face challenges and real legs in that potential, chief among which are the following. A first perverse incentive system that enables waste, along with unsustainable growth and expenses, and often increases the risk of care without producing demonstrable benefit at least compared to the remainder of first world nations. Second, a morally intolerable lack of care equity and healthcare outcome equality, largely related to the first item. Lastly, a Byzantine regulatory system that stifles rapid innovation, complicates medical education, mires caregivers in below licensed activities, and prevents meaningful progress towards value and sustainability. Charlie Plant spent most of his distinguished career trying to remedy systemic issues such as these, and encourages medical colleagues to join him in that battle, but remains the case that physicians have, over the last several decades, largely abdicated operational policy and financial control of local, regional, and national medical administration to a separate professional class, many of whom have unquestionable domain expertise in a variety of realms of medical business, but possess no direct experience in healthcare delivery or medical academics. Colleagues, a relative dissociation from meaningful processes of change in a larger medical ecosystem only serves to perpetuate this unacceptable status quo. If we, as physicians, assume we have no power to influence these elemental matters, that assumption will become a self-fulfilling prophecy. Society will suffer as a result. The status quo needs to be altered post-haste. This is a call to action. I believe a collection of principles that define Charlie Plant's life and work provide us with a general framework around which we might start to affect transformational healthcare change. Those principles include the following. First, all strategies and aims must derive from a patient-first ethos. Charlie dedicated his career to tirelessly supporting the activities and values of physicians, and he did so to principally advance the needs of the patients we serve. This principle, that healthcare is an ethical issue first and economic second, must be the bedrock of physicians' greater influence. Second, collaboration is an operational imperative. It's hard to overemphasize this point. Charlie was fond of saying that seldom does anything meaningful happen because of one person. However, positive outcomes are achieved because of many people working together. Routine collaboration magnifies our potential and increases our collective wisdom. Third, humility. Charlie was supremely confident, but he was also keenly aware that no one possesses solutions for every problem, and he embraced intellectual humility as the only way to remain open to new ideas and to avoid irrelevance that often comes from believing only in our personal perspectives and intuitions. Next, persistence, an attribute which Charlie understood was a professional and personal characteristic for which there is no substitute and is an absolute requirement of effective leadership. And finally, faith in the scientific method to produce change. Charlie was a strong proponent of medical research, but an even stronger proponent of scientific principles as a method to continuously learn and grow in daily professional life. I have witnessed firsthand the application of what I'll term the plant principles for healthcare leadership and how they can dramatically facilitate physicians' ability to harness their collective potential and affect broad systemic change. I'll provide a few concrete examples from our national information projects to illustrate the point. First, in the mid-2000s, value-based reforms were being increasingly adopted by most stakeholders to help achieve sustainability of the U.S. healthcare system. A significant challenge to successful implementation of such reforms was the lack of valid methods to continuously collect and report high-quality data related to the drivers of healthcare outcomes. In that environment, leaders of our specialty recognized that clinical registries represented a number of advantages as a reliable source of such information. It was quickly resolved that we should create novel information systems to measure clinical outcomes, and people referenced Dr. Harbaugh's contributions in that regard, so that we could measure healthcare outcomes that were of relevance to all healthcare stakeholders. In 2008, a governing organization called the NeuroPoint Alliance was developed to shepherd the development of our first co-optive national data system. Relevant to the first three plant principles, it's important to know that organized neurosurgery approached this complex task with a collective humility. Specifically, we acknowledged a relative inexperience in this field. We recognized that development of a meaningful and sustainable national registry program would require broad collaboration and involve harnessing the data science expertise of individuals both inside and outside our specialty. We were incredibly fortunate, therefore, that several of the most influential leaders in registry science at the time, who recognized the potential impact of these proposed programs on patient care, willingly lent their time and knowledge to our efforts. Their selfless cooperation, conspicuously driven by a patient-first ethos, was essential to our success. The charitable and inclusive spirit exhibited by these collaborators was incorporated into our own culture, becoming NPA's defining attribute. We named our registry program the Quality Outcomes Database, or QOD. Our initial focus was on spine surgery, largely due to the predominant nature of spine care within our specialty. Spine care created data collection challenges that other early clinical registry programs had not faced or had chosen to ignore for practical reasons. Simply put, most spine care stakeholders were predominantly interested in assessing the sustainability of spine treatment effects and direct measures of patient experience as opposed to simply assessing major short-term morbidity, as was the case in most other surgical registries of the time. For the first time, we proposed, in a National Surgical Outcomes Project, the Routine Longitudinal Collection of Patient-Reported Outcomes, or PROs. That was a very high bar. Unfortunately, we had no idea at the time how high a bar we had set for ourselves. This leads me to the fourth plant principle, persistence. After years of preparation, the registry program was launched in 2011. Within weeks, IRBs in multiple institutions around the nation classified this program as human subjects research, requiring patient consent and IRB approval. They felt that the delay collection of PROs as an activity existed outside of the existing standard of care. We immediately engaged other medical specialty leaders who, like neurosurgery, recognized this interpretation of the human research protection policy, threatened the very existence of this program. It was a substantial threat to the realization of widespread outcomes-driven QI. It was practically impossible. Policy experts were retained and what ensued was a remarkable series of conversations over an eight-month period, culminating in a White House summit meeting during which the HHS offices of OHRP and OSR agreed, for the first time, to provide written and verbal guidance which largely exempted clinical registries like the QID from the jurisdiction of the common rule. Our persistence had the immediate effect of dropping unnecessarily regulatory burdens and facilitating longitudinal registry use across the nation and across all specialties. This effort gave birth to a multidisciplinary registry consortium whose advocacy work continues today. Finally, the last plant principle scientific methods embedded in daily practice. By 2012, the QID started in earnest. Technical aspects of this program are beyond the scope of this lecture, but what's important to note here is that the growth of this program was rapid. By 2019, it involved 106 national programs in 38 states, representing all surgical settings, private practice, academic, community, urban and rural. Consistent with our inclusive mission, orthopedic spine surgeons were engaged from the beginning. Practice administrators, in particular, were quick to realize the value of the data in value-based care and drove adoption of the program. Data coordinators from across the country organically formed a practice improvement work group which systematically improved our methods. For the first time in our history, a cooperative national data culture was created and brought from theory to reality, a concept we described over 10 years ago, the science of care or the science of practice, which anticipated a national community engaged in the systematic collection of data inseparable from clinical activity, along with the cooperative analysis of that data to generate new knowledge. What I just outlined were some of the transformational programs that were brought about by applying the same principles that Charlie Plant used to affect widespread operational, cultural and policy change. Here is a brief summary of the major outputs from those programs. In 2020, the American Association of Neurological Surgeons and the American Academy of Orthopedic Surgeons formed the American Spine Registry, or ASR, an unprecedented multi-specialty cooperative endeavor that prioritized patient benefit over competitive interest. Validation of the significance and importance of this partnership, which brought all North American spine surgeons under a common data platform, quickly followed in the form of substantive support of this program for bio-industry, requests by regulatory and oversight agencies, such as the FDA, the Joint Commission, to participate with the ASR in important national data collaboratives. The MPA portfolio has continued to expand rapidly and has now enrolled tens of thousands of patients in multiple sub-specialty platforms. Beneficiaries of these efforts now include patients, caregivers, healthcare institutions, bio-industry and regulatory groups. The data has been purposed by these groups to numerous functions, including evidence-based quality improvement, medical operations, advanced payment models, policy development, and research. With respect to the latter item, these programs have arguably given rise to the largest cooperative quality and research project in the history of our specialty. The total scientific influence of these programs was recently evaluated in a systemic literature review. To date, over 200 publications have been derived directly from the QOD dataset. Importantly, an additional 413 publications, many in other medical specialty journals, medical administration journals, and healthcare policy journals, refer to the MPA and its various registry programs as a standard for innovation and excellence. This is a testimony of the growing influence of our programs in the broader medical community. The general scientific impact of the registry-influenced investigations continues to grow, and the significance of this research has been recognized with numerous prestigious awards from multiple societies. Finally, the MPA and its programs have influenced and informed the development of other advanced specialty-specific data projects, one of which is the AB&S POST project, an advanced clinical data platform which importantly includes imaging data to aid with assessment of care appropriateness and care outcomes. To date, POST has now collected over 82,000 candidate case submissions. The program is now a core element of the AB&S certification program and continues to be refined by the AB&S to serve as a central mission to society and our specialty. In summary, we as neurosurgeons have great potential to change the world for the better, but we also face challenges, great challenges, in modern medicine. We stand at an inflection point in medical history. It's essential that we reaffirm now our commitment to providing meaningful leadership whenever and wherever possible in this current environment, and that we resolve to diligently strive to reclaim many of the essential systemic responsibilities we have abandoned as a professional group over the last several decades. I suggest this course not for the sake of claiming power for power's sake, but rather out of a conviction that caregivers possess a singular perspective related to what ails American health care and what needs to be changed. I attempted to offer today a brief review of our national data programs as concrete examples of how we can become agents of transformational change, applying the principles such as those that define the life and career of Charlie Plant. The challenges of modern health care mandate that we think differently about our work, both in type and in scope. To my contemporaries, I appeal to you that we are too few and our professional challenges are too great to not be united in our efforts to harness the power inherent in data from daily practice. Furthermore, our teaching and certification methods must routinely cultivate business, administration, policy and leadership skills. Procedural proficiency and technological innovation are necessary but insufficient for us to meet the comprehensive challenges of modern health care. To my younger associates, I ask you to consider the power of these plant principles, particularly those of patient first, routine collaboration and intellectual humility. Think differently about the skills you need to complement your clinical and academic expertise, particularly business skills. Identify a cause you're passionate about, study it, collaborate with like-minded individuals, gain new perspectives, base your decisions first and foremost on what is best for the patient and don't give up until you've made a difference. Those physicians who possess elemental academic and business capabilities along with patient first and collaborative sensibility are and will be uniquely capable of guiding medicine into its next chapter in cooperation with our administrative partners, our patients, bio-industry, purchasers of health care services and regulatory agencies. Only in that scenario can we practically hope to realize all the potential that is widely believed to reside in heretofore largely theoretical constructs such as truly equitable and truly learning health care systems. It's time to make those dreams a reality. Finally, friends, it's indicative of the scale of these truly remarkable collaborations that it's literally impossible for me to adequately and appropriately acknowledge the hundreds of individuals in numerous domains who made these programs possible. I'm going to very briefly a few names, one of which is Bob Harbaugh, who again introduced us all to the world of outcome sinus. We could have not made this happen without the Vanderbilt Institute of Medicine, Public Health and Departments of Orthopedic and Neurosurgery at Vanderbilt University. Doctors Jack Knightley, Kevin Foley, Chris Shaffrey, Dom Corrick, Clint Devon, Steve Glassman and the entire spine section leadership. You were invaluable. Doctors Bumaniti, Biden and Bisson running the core initiative for research. Perhaps some of the great collaborative research work that this specialty has ever seen. Katie Arrico, Kathleen Craig and Irene Zwang among many other administrators. Without them, this would not have been possible. The rest of you, friends, you know who you are. Please know I have deep personal respect and appreciation for what you've done and for what you continue to do every day for our patients, for society writ large. Thanks for your attention. Transcribed by https://otter.ai All right, so now we're having another interesting session called the Fireside Chat, Concussions in Sports, and it's what every neurosurgeon should really know. And our first speaker will be Commissioner Roger Goodell. Roger Goodell is a prominent figure in the world of sports, known for his passion for football and his keen interest in player welfare. As the current commissioner of the National Football League, he has been a leading advocate for the protection of players, particularly in the areas of concussion. Goodell has been at the forefront of all efforts to promote concussion awareness, research, and prevention in football. He works tirelessly to improve player safety and reduce the risk of serious injuries. His commitment to this cause has earned him both praise and criticism, as he has taken bold steps to enforce stricter rules and penalties for players who violate concussion protocols. With his relentless drive to protect players and ensure long-term sustainability of the sport, Commissioner Goodell has been an influential voice in the discussion of concussions in football and a respected leader in the sports industry. And are we bringing Commissioner up? And then our next speaker will be Dr. Alan Sills. Perfect. Sorry. Thank you. That's okay. Perfect. And then our next speaker will be Dr. Alan Sills, well known to us. He's a distinguished and well-known neurosurgeon and Chief of Medical Officer of the National Football League. With a keen focus on athletic wellness and safety, Dr. Sills has been an influential figure in the NFL community. Prior to joining the NFL, Dr. Sills served as Professor of Neurological Surgery and Orthopedic Surgery at Vanderbilt University Medical Center, where he conducted groundbreaking research on traumatic brain injury and innovative surgical techniques. Today he continues to apply his extensive medical expertise to create effective strategies for reducing the risk of neurological injury in football. Dr. Sills. And next, but not least, is Margot Patoukian. Dr. Margot Patoukian is a well-respected figure in the sports medicine field as the Chief Medical Officer of the Major Soccer League and serves as a member of the NFL on the Head, Neck, and Spine Committee and the USA Lacrosse Sports Science and Safety Committee. As an avid sports fan and a medical expert, Dr. Patoukian has focused much of her career on researching and treating sports-related injuries with a particular interest in the management and prevention of concussions in soccer players. Her commitment to enhancing athletic safety and optimizing healthcare outcomes in the world of soccer has made her a highly recognized leader in the sports medicine community. Dr. Patoukian. I am the host with the most. So that being said, Commissioner, you know, players seem to be speaking more openly about concussions, you know, in the last five to ten years. Are players likely to report concussions and if they do, how are they doing it and why is that? Well, it's intentional to start with. You know, we really, when we began this journey, we really wanted to make sure that the players were educated, they understood what to look for. We don't want them to try to be doctors, but we certainly want them to be able to say that somebody doesn't feel right, either themselves or if they see somebody who looks like they're struggling in some way to make sure they raise their hand and I think people doubted whether our culture would actually change that way. We really felt confident that that would happen and it has. Not only are the players coming forward, but they're talking about a teammate that says doesn't look right or a coach. We obviously have a lot of other what we call spotters and UNCs that are there that I think are really helpful in trying to identify when somebody's struggling and make sure we get care immediately. So I'm really, really pleased with the fact that players are coming forward and saying I don't feel right. Yeah, and in fact now, Ann, 30 to 40 percent of all of our concussions have some component of self-report, you know, where the player themselves, 30 to 40 percent, which is a dramatic change from maybe 10 years ago and again, as Commissioner said, sometimes that's a teammate speaking up about a teammate. We've even had head coaches. Several examples last year where a head coach would bring a player and say I want you to check this player out because they may be injured. Our game officials on the field will do that. So it's really an overall climate of awareness about the injury, what are the signs and symptoms and a willingness to report and that's obviously, as you said, something that we work really hard to create that culture. Yeah, you're right because culture sometimes is hard to change. Margo, what have you experienced with soccer players? Yeah, I think it's the same. I think when you end up looking at, you know, there's a trickle-down effect for all the major sports and it's not only the players that are more likely to come forward and sort of say, hey, will you check me out for a concussion or, you know, you need to check on a teammate, but it's also, I think, the medical providers, too, have an increased awareness of how important this injury is. So I think it's across all sports. That's good to know. Yeah, Commissioner, we talk a lot about rule changes and how we filter that through the lens of health and safety and, in fact, we often talk about the fact that there have been 50 rule changes in the last few years just driven out of health and safety. Talk a little bit about that process and, you know, what's driven that? Has there been resistance to that? Has that been hard to do from a league standpoint? How have coaches and others and fans sort of responded to that and how do you balance that because you're trying to speak to all those constituencies? Well, I think it starts with making it clear that health and safety is a priority. If you start with that, then you have to look to say, what are the steps we need to do to make our game safer? And as you know, rules are a part of that. Changing equipment, providing additional medical care, all of those are elements that we focus on. But with rules, I think people doubted us initially because they didn't think we could make the game safer and not destroy the game that everyone loves so much. And I think we've been able to achieve, with your help and so many others, many that are in this room, that we can make our game safer and we can make it better at the same time. And so our rules process starts immediately after the season is over. Data is a key component of that because we want to make sure we look at the data of where we're seeing injuries, what we can address through rules, and then work with our competition committee. And I think the data is so overwhelming at times that it makes the coaches and the general managers and our competition committee look at it and say, this is an appropriate change. We can take this technique out of the game or this exposure and reduce the risk for our players. And we've seen that over and over again. Again, I think it's made our game better. Okay, I have a question for you, Dr. Margo. So if you talk about what are the sports that you think are at risk for concussion? That's the first part of this question. And for both males and females, which are some that have some biases maybe that we should be aware of or consider? Yeah, I mean, I think we typically think about, you know, you think about boxing or some of the martial arts, combat sports, and American football, hockey, soccer, lacrosse, right? Those are typically the ones that come to mind. But at the same time, if you think about the, there are a lot of biases that occur as it relates to why those sports? What about equestrian, which is numerous times greater the risk for concussion than American football, right? What about rugby, right? In our country, we don't follow it, we don't follow it like at the collegiate level or at the high school level, but rugby's got a significant risk. And then what about, you know, rodeo or, you know, some of these other BMX, right? You can name it, right? We don't think about those sports, but they have an appreciably higher risk. And it's because we follow the sports that we track at the high school and the collegiate level. But there's also a significant bias as it relates to, you know, where do you have medical staff, right? And there's a lot of compelling data that tells us that if you have medical staff available, the quicker that they're an athlete seen, the more likely they're going to report their concussion. So if you don't have athletic trainers there, then they're not going to, they're going to go unreported and under-recognized. Got it. Well, speaking of that, and this is both to you and, you know, Dr. Sills and Dr. Padokian's opinion on this, is concussion the same in males as it is in field males? And are there some differences that the treating physician perhaps should be aware of? Go ahead. I'll let you start. Well, we're just coming off of the heels. Dr. Sills and I were both involved in the concussion and sport conference that was in Amsterdam. One of the systematic reviews that I led was on return to play, return to school. And you know, there are a lot of, again, there are a lot of biases that, you know, what's been out there is that it takes longer for kids and it takes longer for girls. But in our systematic review, when you actually look at the studies and you look at comparing younger kids to younger kids, girls are the same as boys. And then when you look at the college age and the adults, girls are the same as, women are the same as men. So there does not appear to be a gender difference as it relates to concussion. And probably what's more important is to think about the individual athlete. A colleague and friend of mine used to say, if you've seen one concussion, you've seen one concussion. And so it's really more important to address each individual athlete and what they bring to the injury. How many concussions have they had? What's their history of migraine or what's their history of depression? And what do they bring to the table? And then treat them individually. But I think, you know, embedded in your remarks is there are age differences. So while there aren't necessarily gender differences, you know, younger athletes are very different from older athletes in terms of symptom constellation, in terms of recovery, and obviously then these history factors that get in. So I think we are rightly more conservative with younger athletes, not because we are rushing people back once they're in their 20s or 30s, but it is a little bit of a different trajectory if you look at recovery. And so gender differences probably not there, but age differences definitely are something to be aware of if you're treating concussed athletes. Okay. And so we're sitting here with a whole bank of neurosurgeons out here, right? And so how can we as neurosurgeons help promote sports, safety in sports? What would you suggest? Well, I would start on one thing. To me, and it's a big thank you to the people who are in this room that have really made our sports safer, I often say you could get better medical care than you do in the NFL, and it's because of so many people that have participated in that system and really put us in a position where we can say that with great confidence. But I worry, and not only is health and safety important to me in the NFL, but it's important to me particularly when you look across youth sports, which I think has a long ways to go still. We spend a lot of time sharing all the things that we learn at the NFL level with not only other sports at all levels, but to make sports safer, because I'm a believer that kids should play youth sports. Obviously, there's risk-reward there, but I think the reward that comes from playing sports, particularly team sports, where you learn how to play as a team, you learn how to make sure that you understand what resilience really is. And I use those lessons every day, and so I want kids to be able to do that, but do it safely. And there's so many things that I learned through my journey through youth sports playing that there really wasn't medical care when I played. The coach was actually the doctor, and that's not a good place to be, just like me being up here speaking to a neurosurgeon. I'm out of my element here, but I would tell you from youth sports, I just think we have so much more work to do to make sure that parents understand that participating in sports is well worth it, and the alternative inactivity to me is absolutely worse. Yeah, Dan, I just want to echo and amplify something that Roger said. First of all, neurosurgeons have been really the backbone of our care for concussion in the NFL, and that goes back to Rich Ellenbogen and Mitch Berger and Hunt Bajer and Joe Maroon and Bob Cantu and Hank Foyer and people like this who are pioneers really in sports neurosurgery, and then in helping us set up our NFL, our unaffiliated neurotrauma consultant program. And it's been a tremendous source of pride for me as a neurosurgeon to see neurosurgeons serve in that way. I mean, every one of our 32 clubs virtually has a neurosurgeon who's working on the field during games as a sideline neuroconsultant or an independent neuroconsultant, and that's been a tremendous blessing for us and has really helped us, as Roger said, achieve this level. But back to your question, how can neurosurgeons impact at the community level? I think it's about getting involved. I mean, who knows more about brain and spine trauma than neurosurgeons? I would argue no one does. And while it's not typically part of our formal training, maybe the way that it might be in orthopedics or primary care sports medicine, we still have a ton to contribute to the care of athletes with brain and spinal injuries, whether that be pre-participation screening for certain conditions or whether that be around spine injuries or certain brain injuries or concussions. So I just want to encourage neurosurgeons to get involved and particularly at the community level. The AANS offers some courses in this regard for learning about sports neurosurgery. If there are residents or fellows in the audience, take those courses. Learn about it. I didn't learn anything about sports neurosurgery in my training, zero. So everything I learned about sports had to happen after I got out of my residency. And so I think if neurosurgeons will get involved, go back to the community and offer their services. I can't imagine a school, a league, a university that would turn down the ability to have someone engage with them. So I think it's just about making yourself educated and then available. And I just want to put a plea out to everyone because there is a lot of need still there. And I just think that we have so much to contribute as specialists to this issue. And we should. We should be the leaders in the care of athletes with traumatic brain and spine injuries because that's what we do every day with all of our other patients. Well, thank you, because that's music to my ears hearing that. But, Margo, what do you think about that? No, I agree. I think that neurosurgeons can play a significant role. Not only, you know, I think in my experience at Princeton, there were several occasions where, thank God for the neurosurgeons that were helping me. And, you know, one scenario was one of our football players who, at practice, basically presented one of his teammates, said, hey, you know, you got to check him out. He had a headache. It was the beginning of practice. And long story short, he had an AVM that bled. And fortunately, you know, we sort of sent him to the right spot. And Dr. Binning was the neurosurgeon that was on call and took care of him. But the other role that I think neurosurgeons can play is really helping the team doctors work with situations that you mentioned, you know, the incidental finding that you pick up when you get an MRI and all of a sudden you see that they have, you know, an arachnoid cyst or something like that, right? Or the scenarios where you're trying to make return to play decisions. You know, the player that I described that ended up having an AVM that bled, it was treated surgically. And a year later, the kid wanted to play football again. So we're leaning on, you know, a lot of the team doctors are leaning on the neurosurgeons and their expertise to help us with those complex decisions. If I could just emphasize one other point, which I think Doc alluded to, both doctors did. The parents have a lot of really important questions about whether their children play sports. And I think it's really important to educate them because I think they get a lot of bad information, frankly. We hear that all the time. And for me, you all are the best to do that and to be able to hear from you and have parents be able to ask those questions. So when you do go into the community, participating in that so that the parents have the benefit of incredible information and experience that you all have. So I hope you will do that. Well, Commissioner, that kind of segues into my next question because I was going to say, how do you balance sports safety, regardless of the sport, against the benefits of participation? And are there some who say that sports can never, ever be completely safe? Well, I don't really know of anything that's completely safe. I think we all live in a world where there are risks and there are rewards. As I mentioned previously, I think the benefits of playing sports, particularly as you're going through your adolescence and you become a younger person that is starting a career, you'll learn lessons and you'll have values, I think, that are really, really important that you can only really learn on the field. Sports were probably one of the biggest motivating factors to me in trying to become who I was. And I learned so much about myself. I learned how to work with people. And as I say, those values I use every single day. I think you can take it one step further, which is I would agree. I learned so much about myself as playing soccer. But you could take it one step further and say, what's the risk of not playing sports? That's even worse. That's even worse. Yes, but we're seeing that today. It's obvious. And there are a lot of entry points, too. I think, like, for example, we're seeing tremendous growth in flag football now for both males and females. Females flag football is growing like crazy. And we think that's a wonderful thing. I mean, our league is very much behind that. You may want to speak to our teams that are supporting that. But, again, it's about getting people active, getting them in that team environment, and choosing multiple entry points. And so, you know, if you go to a baseball field and they set a ball on a tee and a kid hits it, you don't call it something else. It's still baseball. And so to us, flag football is just as much football as what our guys do on Sunday. Yeah. And, again, it's a great way to engage with the sport, to get that physical activity. The young women who are participating in particular find it a chance for them to compete at a different sport than they have traditionally been accustomed to. And, you know, I think we have now eight states that have actually accredited that as a high school sport. And we're working to try to do that on a national basis because we really believe that the sport could be an alternative to lacrosse and soccer and some of the other sports that young women are just flocking to. And on a global basis, by the way. Interesting. Well, sports participation numbers among kids and youth, however, seems to be declining, certainly in some areas. And so how do we continue to keep kids involved in sports? Yeah. I think it's obviously multifactorial. Education is a big part of it. Educating parents and kids about these benefits and emphasizing what we're doing around safety. I mean, I think it's our job to make sure that we understand what reservations people may have and then to show how we're proactively addressing those issues. But, again, as we just spoke about, there are many different avenues to get into sport. Margo named a number of these earlier. And we should be promoting them all. And certainly we do. And that's the important thing about our work because it's not just about making football or the NFL safer. It's about making all level of sport safer for kids. But as the commissioner said, there are risks and rewards. We spend a lot of time talking about the risks. We really need to talk about the rewards. And there's good data about kids doing better in school. They have better mental health. They have better outcomes. They have more achievement when they participate in team sports. We need to emphasize that. And that needs to be part of that discussion about this risk-benefit ratio calculation. I think there's one other element that I think would be taking it one step further about the lack of inactivity. But I think what you see a lot in youth sports now is what I call specialization. So kids aren't playing three different sports a year. They're playing one. And they're playing it year-round, which adds additional exposure to overuse injuries. And, you know, I think that's really they don't get the benefit of sports as much when you don't play multiple sports. And, again, you learn different things from a team sport versus an individual sport. And I think all of that's important for young individuals' development ultimately. Excellent. Okay, Commissioner, many of us have watched Jamar Hamlin's incident on live TV. What were your thoughts that night? And what are the lessons that we could have learned from that event? Well, it was difficult for all of us to watch. The thing that gave me great confidence was, and this began several years ago with some of the people that Dr. Sills talked about, but is grown through Dr. Sills' leadership in the sense of making sure we're prepared for that moment. And we were prepared for that moment. Dr. Sills put in recently that we actually rehearsed that in every stadium with all the personnel prior to the season. They meet 60 minutes before the start of every single game and communicate to everyone about their key roles that each of them are going to play, and they know each other. Because, as you all know, there's no time. You need to react, and you need to react quickly. It was difficult for all of us to watch, but I couldn't be prouder of the medical people who, you can be trained as much as you can, but then you have to execute. And they did that in an incredible way, to the point where Jamar is actually beginning to start football again this week. That's a real tribute to the medical professionals who, I think, saved his life that day, but also gave him an opportunity to resume a career that he really wants to do. It's interesting because Commissioner mentioned our 60-minute medical meeting, and I think neurosurgeons will relate to that, our pre-procedural timeouts that we do in the operating room, going through that checklist of all of those essential elements of the procedure and introducing all the personnel. So I always say our 60-minute meeting, to me, is probably the most important thing, I think, that happens on game day. No disrespect to all the rest. But because it is where we go over that emergency action plan one more time and really think through and introduce everybody. So nobody ever sees that. It happens under the stadium. It's out of sight. There are no cameras. But it's a critically important preparation step for us, not just for cardiac arrest, but major long bone fractures or airway issues or a number of other emergencies. So that's been key. But I want to go back to something and say I think the lesson, really, the takeaway for everybody from the Jamar Hamlin incident is not that we have 30 medical professionals at every game, 30, between the sideline staff and the independent medical staff. We've got an airway specialist there. We've got an emergency resuscitation specialist. We've got paramedics. I mean, we've essentially got everything you'd have in an emergency room at the field. And so that's not going to be present for youth sports. We know that. But what can be present is people that are trained in basic CPR, people that know how to use an AED, and some degree of prior planning about that. And I still hear horror stories every year of a youth athlete collapsing on campus at a school, and the AED is locked up inside the school, and nobody knows how to get it. I mean, that just shouldn't happen. That's preventable. And so I think the lesson is not what we do necessarily at the NFL, but it's trained personnel, immediate recognition, and having a plan. And so a couple of weeks back, we at the NFL and all the pro sports leagues, the Corey Stringer Institute, the National Athletic Trainers Association, we announced this Cardiac Safety in Sports Act, and we're lobbying states now to prevent cardiac arrests in athletes by having three best practices, to make sure they have an EAP for all their venues, to make sure that they have an AED at those athletic venues, and to make sure that there's CPR education, primarily for coaches. Because, again, we know in a lot of youth sports there may not be physicians. So I think that's the really key takeaway lesson is these events can happen anywhere in any sport. They're not unique to football. In fact, they're a lot more common in other sports, and they're also more common at the youth level. And so you're not going to have the resources we may have at the NFL, but you can have a plan and you can be prepared. And so, again, I think that's a great message for us as neurosurgeons to go back to our communities and really deliver that. And the last thing I'll share, the inspiration for that 60-minute meeting came from a sports emergency physician in West Virginia. He was covering a bunch of high school football games every Friday night that didn't have a doctor and didn't even have an ambulance, and he said, I feel unprepared. And he came up with this initiative where an hour before game time they would meet at the field, the coaching staff and the trainers, and go over some emergency basics. And I heard him speak about that and said, you know, that's a great idea. That sort of reminds me of our pre-procedural timeouts. You know, we ought to take that and adopt it for ourselves. And so my point is just it's not about the resources we have. It's about that planning and it's about anticipation and training. And so we're going to continue to talk about this. We're going to continue to try to get coaches to be trained in CPR. We also had an incident last year that you didn't hear about in the news. We had a coaching staff in town for an away game the night before the game. They went out to get dinner and see a show together, and a coach collapsed, went into cardiac arrest. And another member of the staff recognized it, started CPR, applied an AED, and saved his life. Didn't happen on national TV, but it was no less miraculous than what happened to DeMar. And, again, it wouldn't have happened had not there been that level of training among that staff. So I think that's the lesson we can all take away from that incident. That's great. Just to add one point, when incidents like that happen for us, we work with our partners. In this case, Doc mentioned many of them, but the American Heart Association, the Red Cross, are two huge partners in that effort to make sure we are using AEDs, to make sure people are trained in CPR. But we take it as our responsibility, and I think the other leagues are going to join us in this, because it is a frequent occurrence, unfortunately, in a lot of youth, athletes and non-athletes. But how we can help make sure that we can be in a preventative position here, where people can be prepared for this, they understand what to do when it happens. Absolutely. All right. Commissioner, I'm going to go off script for a minute. Can I do that? It depends what you're going to say. You do sign my paycheck, so, I mean, there's a little risk here. Yeah. Thursday night, next week, NFL draft. You're going to be there, as you always are, announcing those draft picks, and those giant 300-pound guys are going to come out there and hug you like nothing's doing. Does that hurt? I mean, what is that like? The answer is sometimes. You have to be – it's actually a defensive night for me, because I'm actually very wary of it, because I think people underestimate the emotion that these young men feel when that moment comes where they have realized their dream. They've now been selected by an NFL team. They get to walk across that stage, and the emotion comes out. Unfortunately, I'm the one that gets the first shot at that. But it is actually really a privilege for me to be able to do that, because you're there in that moment that's so important to them. So while I do it with caution, I couldn't be happier doing it. All right. Well, everybody now is going to be watching that and thinking of that and looking at you and kind of pulling for you. So just know that you're going to have that. Back to the regular schedule programming, what's next for health and safety? I mean, what do you think the game is going to look like, let's say, in five years? How will it be different, and what can we anticipate as far as the future of football? Well, I think the game looks a lot different today. I mean, people talk about that all the time, the game. It's changed. The rules have changed. I think our equipment is significantly better. We focus a lot on helmets. We now have a system that we've established with our medical experts but with the union support to identify the better-performing helmets and make sure that players have to wear the better-performing helmets. We invest in helmets to make sure that those helmets continue to have the kind of research and data so that they improve in performance. And we also see, I think, real changes in that where I think you're going to see more and more specific-positioned helmets. So a quarterback helmet this year that we're putting out, which has additional padding in the back of the helmet, which a lot of the concussions actually occur when they go back and their head hits against the turf. And I think those specific-positioned helmets we have for the offensive and defensive linemen are designed really to get not just prevent concussions but to reduce head trauma and head contact. So we'll continue on that path. We're changing a rule this year which is intended to reduce those, what I would call non-concussive, but those hits accumulate. You all know better than I do that it can create long-term damage. And so we want to prevent those. We are changing the way we do our training camps. And we're working to try to make sure that our teams understand that you can't run in after six months off and just ramp up to 100%. You have to do that on some type of a schedule to allow the athletes to continue to adapt to the circumstances, to get prepared for the heavier activities, including contact, and to do that over a gradual period. And that has been incredibly effective to me. So I think the game will continue to have a physical nature to it. I think people will enjoy that. But there are techniques that we can take out of that game. There are equipment that we can use to make it safer for players. And then we have medical experts that I think can treat players in ways that they've never been treated before. And that'd be at the leading edge. And so I think this game is in the good hands. And a lot of those hands are right here in this room. Margo, how about that in the air sports? Yeah, no, I think, I mean, there have been significant changes that have been made. And I do think there's a fair bit of trickle for every condition. So not just, you know, head injuries and, but even the cardiac safety. You know, we've had a lot of situations in our sport where we've had, you know, a sudden collapse and enough that our referees are trained. If there's a non-contact collapse, it's cardiac until proven otherwise. And the medical staff doesn't have to be wait, wait, you know, they don't have to wait, wait to be waved onto the field. But there are a lot of measures as it relates to health and safety. And I was just thinking, you know, as we're back in the room there, how far it's come related to football. And, you know, it was 2010 and there was no standardized protocol. There wasn't a game day checklist, you know. And so there are a lot of those things that I think occur and they occur in our sport as well. That pre-match medical timeout, it's essential. And we don't have the same resources on an MLS game that you do on an NFL game, but we have people that are CPR trained and know how to put an AED on and know how to recognize these situations when they occur. So I think that, you know, it's a matter of us all sticking together and moving the field collectively forward. Yeah, and that's one important point I'd emphasize too, Anne, is the collaboration among the sports league. So, you know, Margot is Chief Medical Officer of Major League Soccer, me from the NFL, our colleagues from the NBA, the NHL, Major League Baseball, we meet regularly and share as we do around the world. We meet with world rugby and we meet with Australian football and Canadian football and international ice hockey and many others. So there's a tremendous amount of sharing of the data and the findings that we all have. And I think that's something that has benefited all of us. And we see it as a public health mission, really, again, the better and the safer we can make our sports, the more we can use our platform on behalf of advocacy for youth sports, because that's ultimately what we all want to do. At the end of the day, we're all physicians. We want our patients to be safer and to have a better future in sport. Sure, and I get it. I mean, it makes sense. It's nice that everybody's working cohesively because we'll learn from each other. So I really appreciate that. We also, we put a lot of time and energy and money into research. I think we've, just in the last 10 years, probably the period of time Margot's talking about, have spent over $200 million on research. And all of that is done transparently. It's there for the medical experts to debate. And we think that when that's shared in that kind of forum, it makes all of us better. It gives everyone an opportunity to be able to take the benefits of some of that research and make each of their sports or even beyond sports. We share our list with the military. The military has been a big part of this. We talk about return to play. They talk about return to the battlefield. And all of those things are really important, again, in creating that cultural change that it's okay if you're not feeling well to say that and raise your hand. Well, you know, this has been a great conversation. We didn't have a fireplace because I couldn't get them to do it. I really, really enjoyed this fireside chat with you. I learned a lot. Well, thank you. And I think my colleagues did as well. Yep, thank you. Thanks for having us. Thank you for having us. Okay, thank you. Thank you. Thank you so much. Thank you so much for having me. Oh, my pleasure. Glad to be here. Thank you. I appreciate it. Thank you. Thanks. Let's have even more fun. Next, everybody knows Dr. Glaucon Flecken if you use social media, right? So Will Flannery is an ophthalmologist and a comedian who moonlights in his free time as Dr. Glaucon Flecken. He's a force as a social media personality who creates medically themed comedy shorts to an audience of over 3 million across the social media platform. His humor has been shaped by the tribulations of medical school and residency, but also has his experience as a patient. Will is a two-time cancer survivor, as well as a survivor of a cardiac arrest where he was saved by his fearless and heroic wife with her timely CPR. Initially used as a creative outlet to cope with these health challenges, Will's comedy has evolved over time to incorporate a biting satire on the US healthcare system and academic publishing interpersonal conflicts that are pervasive in the medical system. He's a frequent keynote speaker who encourages his medical audiences to embrace humor in everyday life. I, along with my neurosurgery friends and colleagues have enjoyed the spoofs. Sometimes I get a little worried about them, but so far so good. And it has been really centered on our profession. And I think many of you are very familiar with some of these comments and spoofs, but we're excited to hear what he's going to bring with his humor here tonight and endearment to our audience. Let's give a big welcome out for Dr. G. Thanks. One or two? One or two? I had to get an I joke in there somewhere, you guys. I'm going to come over here. How about that? I'll take OD. All right. I am so impressed by all of you. I mean, you only get three days off of work per year and you're spending them here. That's to learn, to educate yourselves. That's, you should be very proud of yourselves. So when I first got invited to speak at this conference, I thought it was a joke. Like, really? You're telling me that every year, thousands of neurosurgeons voluntarily leave the operating room, travel across the country to go to a conference at a place where, as far as I can tell, there are no operating rooms. And so my next question is, well, why? Why did you come here? What is it that brought you away from your work? You guys love to work so much. I know it's not me. You're like, you're not here for me. Like, no neurosurgeon in history has ever been that interested in what an ophthalmologist has to say. But I am excited to be here. This is my first time at a neurosurgery conference. I'm a little nervous, but I've been preparing. For the past three weeks, I've been telling everybody I know that it's not the shunt. It's not the shunt. Unless it's the shunt, but it's not the shunt. But I'm here, I'm ready. I've got dexamethasone in my pocket. I am good to go. So when we were planning all this, the organizers reached out to me. They asked me how long my speaking engagements usually last. And I told them, you know, 45 minutes to an hour. And they said, you know, I don't know how long my speaking engagements usually last. 45 minutes to an hour. And they said, perfect. We'll give you 15 minutes. Specifically, they gave me, you can see on the schedule here, 6.49 p.m. to 7.04 p.m. I love this, just the precision to the minutes of this entire schedule. It cracks me up because as we all know, surgeons are famous for being able to keep track of time. But I wanna take a little closer look at this schedule because I have a few suggestions, like just a couple things that could have been done a little bit differently. Just keep this in mind next time you invite an internet comedian ophthalmologist to come speak, okay? Look at the bottom of that schedule. There's a reception, like right after this. Can you imagine like why that might not be a great idea? You're supposed to start drinking before I get up here and tell jokes. This is backwards. It doesn't make any sense. Like right now, I'm the only thing standing between all of you and cocktails. That is not the place that a comedian wants to be, all right? The other thing is, do you know why headlining comedians, they always have an opening act? It's to loosen up the crowd, to get them having fun, laughing, you know, just feeling good, and then the headliner comes up. Well, you know what's not a great opening act? A panel discussion about brain trauma. It's a tough act to follow. I'll do my best though. So I was a little surprised when I got this invitation. Those of you who've seen my videos, you know like I don't exactly portray neurosurgeons in a positive light. This is, in a few of the videos, this is what you look like. And yes, I did hire a professional photographer to take this portrait. But the truth is, I love making fun of you guys. You don't realize this, but you guys, you're the low-hanging fruit of medical comedy, okay? There's just so, it's you and orthopedic surgeons, like the material is just, it's endless. Think about it, you're obsessed with surgery, like to the detriment of every personal relationship you've ever had. Everybody's scared of you. Your training lasts roughly forever. Like you graduate residency, and then you immediately retire because you're 65 years old. I mean, for God's sake, yesterday, there was a session called, You're Never Too Old for Surgery. Now, obviously it was about patients, but for a split second, for a split second, I really thought it was about encouraging neurosurgeons to operate until you're dead. But you know, these are all tired, old stereotypes. I'm sure you all heard these a million times. They're 100% true, but they're stereotypes nonetheless. And they don't apply to every single one of you. But there is one stereotype about neurosurgeons that does apply to every person in this room. You all have massive egos. It's true, but it's okay. You're doing brain surgery. If there's one type of doctor who deserves to have an enormous ego, it's the person operating on a brain, okay? I'm just saying, it's fine, it's fine. Listen, if I'm gonna have someone digging around in my thalamus, all right, I want that person to think that they're the greatest surgeon on earth, okay? You need to have a God complex. Actually, no, no, God's not powerful enough. Just call it a neurosurgeon complex, okay? You all need to have a neurosurgeon complex. So in my opinion, if you wanted to yell at people in the operating room while you're working for three hours on a centimeter of brain tissue, please, by all means, you're neurosurgeons, it's fine. But I don't wanna sit here and just give you a bunch of compliments, all right? Because I know that there's no compliment I can give you that you don't give yourself all the time. So as much as I'd like to spend the last seven minutes and 45 seconds making fun of you, I do have actually something of value to offer here. This is an academic conference, after all. The theme of this year's conference is neurosurgeons as advocates. I love that. We all know how important it is for us to advocate for ourselves, for our profession, for our patients. We know how important it is to lobby for changes in healthcare that benefit our profession on the state and federal level. I think we underestimate, though, the impact and the importance of advocating on social media. Yes, even TikTok, all right? And I'm going to, some of you are probably rolling your eyes but I'm gonna tell you an example. So if you see my videos, especially over the last year or so, you know, I really love making fun of health insurance companies, like almost as much as I love making fun of neurosurgeons. Like it's like one and two right there. And I do it a lot. Where these, you know, United, Aetna, Cigna, Blue Cross, every action they take, every decision they make has a negative impact, it seems, on our jobs, on our patients' lives. And so in late 2021, Aetna decided to do a thing because they're always doing things, you guys. There's always something going on. What they did was they decided to require prior authorization for every single cataract surgery on their customers. Every single, you know who gets cataracts? Everyone, everybody gets cataracts. Those of you who are over 60, you got cataracts. I'm sorry to tell you. So this would be like if every single person on earth at some point in their life required a laminectomy. I don't know if I used that right. I learned that word for you guys. I'm sorry if it didn't make any sense, but you get the point, okay? This is a huge burden that they dropped on every ophthalmology practice in the country. And so I was furious about this like every ophthalmologist and I did what I always do. I went on social media and I made a video about it. And I'm gonna play that video here. Hey, Timothy. Yeah, boss, what's up? Why are we spending so much money on cataract surgery? It's a really common surgery. Well, can we not do that? Can we not cover cataract surgery? Yeah. No, people need to be able to see. Well, can we do that thing where we get to practice medicine without a medical license? Prior authorizations? Yeah, yeah. What if we require prior authorizations for every cataract surgery? Do you have any idea how many cataract surgeries there are every year? I don't know, like 100? 4 million. This would be a huge burden on patients and doctors. Oh, come on, doctors won't care. You're forcing eye doctors to ask a room full of business majors for permission to do eye surgery. I think they'll care. We have to do this. Why? Look, I don't wanna alarm you, but I went through our finances. We only made 8 billion in profit last year. Okay. So I was thinking, if we can just delay all the cataract surgeries for a few months, we can hold on to all the patient premiums and make more money. Can we just, for one day, not be evil? Jimothy, you knew what you signed up for when you started working here. Not evil. It's literally our mission statement, see? So what happens when we keep denying cataract surgery for an 80-year-old, she can't see, she trips, falls, breaks her hip, now we're paying for hip surgery and cataract surgery? Oh, that's actually a good point. Thank you. We need to require prior authorization for hip surgeries. So, thank you. So I posted that video and it got, it went viral. It was, you know, lots of people, it got a lot of views. And I posted it out of frustration, right, for this terrible thing that was happening. And I didn't think much of it. You know, I, whenever I, in the past, when I'd post something like this, I never really thought it would create any kind of momentum for change. It was just kind of like shouting in the wind. And then, you know, I posted it It was just kind of like shouting in the wind. And then a few weeks after that video was published, I got a message from somebody who knows, who has a family member who works in the C-suite at Aetna. And they said, a close family member of mine works at a large insurance company. The company's CMO saw the Glockenflecken video on Prior Roth and held a huge internal meeting about it. The CMO was angry about how the company was portrayed and wanted the video taken down. That's not how the internet works, by the way. The PR folks told the CMO that they couldn't, and so the company decided to review their policies, though no one internally seems to believe there will be significant change. This was shocking to me, because what it taught me is that these companies care about social media. They care about their image on social media. And I think it's because they can control every aspect of the legislative process. They can own legislators, but they can't control social media. And that's where patients are. That's where their customers are. And that's why we all need to have a social media presence. We need to get on there in whatever way you want to do it. You don't have to dress up as different characters and record yourself alone in your bedroom like I do. It's not necessary. Any way you want to do it is fine, but we all need to be out there talking about these issues in whatever way you'd like, because it's not going to be like one person, one video. It's going to be all of us sharing our voices, sharing our expertise about these issues that can create change. And that's what happened here. I posted that video, and a lot of other ophthalmologists and eye care professionals also were talking about this and explaining why it was a terrible thing for patients, and people were contacting congressmen and everything. And then a few months later, Aetna rolled back that policy. And so it was... So I just, the takeaway with this is that there's lots of ways to advocate and think outside the box, but keep doing it, because it's important for our profession. It's important for our patients. Thank you so much for your attention. We are building a brain bank for former contact sport participants. We're inviting anybody who ever played any type of contact sports. We want researchers to be able to access this tissue and better understand the mechanisms underlying the brain injury. Anytime you donate an organ, it's always a difficult choice. Donating my brain to the University of Pittsburgh National Sports Brain Bank, it became an easier decision based on two things. First of all, you have to have full transparency and integrity, and that's what they have. So we would like to acknowledge and thank donors to the University of Pittsburgh's National Sports Brain Bank, who are here with us today. Former NFL running back Merrill Hodge, and our colleagues over here, if you'd please stand. Joe Maroon, Regis Hayden, Julia Cofford, and Donald Whiting. So they will all be available in the exhibit hall to answer any questions and also sign autographs if you'd like. The exhibit hall is now open. So when you came in here, you went past the exhibit hall, and the exhibit hall now is behind you. And please take time to visit with our exhibitors. They're coming up, showing us the best that they have and what's new in technology, what's the latest and greatest that drives the business of neurosurgery. You will have ample time to meet and enjoy your friends while enjoying drinks and a light dinner of hors d'oeuvres. See you there. Thank you.

fireside chat

concussions in sports

Commissioner Roger Goodell

Dr. Alan Sills

Dr. Margot Putukian

player safety

rules and protocols

collaboration

neurosurgery conference

Dr. Will Flannery

neurosurgeons

social media

TikTok

advocating for change

brain tissue donation