Unwrapping a Not-for-Profit Healthcare System: Building a New Neurosciences Program Free

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- Colleagues and friends, thank you for joining us for another session of the Virtual Operating Room. My name is Aaron Cohen. Today our guest is Dr. Michael McDermott. He's the Chief Medical Executive of the Miami Neuroscience Institute as part of the Baptist Health in South Florida. Dr. McDermott is an incredible visionary neurosurgeon. He was previously professor of neurosurgery at University of California at San Francisco. He has really built an incredible neuroscience program at the Miami Neuroscience Institute in Florida. And I really would love to hear his thoughts about how you build such a system, what are the challenges? And he's also going to cover some of the major concepts about neurosurgical employment and how the neurosurgeons can deal with it, large health corporation. Michael, I want to thank you for being with us and very much look forward to learning from you.

- Thank you, Aaron. Well, I arrived in Miami February 24th of 2020, and who knew what was going to come in the next 18 days, but we made it through. So I've been here three and a half years, and I'm going to outline for you my experience to date with my efforts to build a neuroscience program, and reflect back on my previous 30 years at University of California San Francisco in the Department of Neurosurgery there. This is my disclosure slide. None of these positions are related to this presentation. Now, when I was at UCSF, I'll go over that in the background. I'll talk about what my vision was for the Baptist Healthcare system, and implementation of how we got the vision underway. And then results to date with some recent updates, 2022 compared to 2023. Originally I graduated from University of British Columbia neurosurgery training program. I was born and raised in Toronto, Ontario, Canada. Did my medical school in Toronto. Was asked to stay to do neurosurgery in Toronto, but for a variety of reasons, went to Vancouver, which was a much smaller program, not academic, but I worked hard, and I did a fellowship at UCSF from '88 to '90 with Phil Guten as my mentor. And the second year I got to operate quite a bit and I covered some of the chief residents, Josh Bederson, Jonathan Hodes, when they were out looking for jobs. And so the surgeons there got to know what I could do. So one day got a call from Charlie Wilson who asked me if I'd consider coming back. And I said, "Well, I'll have to check with my wife." And he said, "Yeah, Michael, please do that, but call me tomorrow." So, made a quick decision, and I worried about leaving, going back to UCSF, but ultimately it was the right decision to make for many reasons. I was predominantly clinical from '92 to '97, then some basic lab collaborations, and then we were able to hire postdoc. But I was really a clinical surgeon that cooperated with the basic scientists. And the basic scientists, they need our input as to the problems that we need to solve and potential opportunities to do that with laboratory work that translates to the clinic. I had a lot of clinical care responsibilities as the Director of Patient Care Services, OR committee, Block Time Committee, Transfer Center Committee, Bed Allocation Committee, ER services, et cetera. Participated for several years in the Department of Finance Committee, which consisted of four people, so it wasn't big. And the department chairman took tight control of the finance committee, but I believe I had a positive influence for the faculty. When Nick Barbara left to go to Cincinnati, I took over the residency program. The year after I took over, we ranked number one, and remained so for eight years. We got our top three selections every year for the eight years, so I was there and I enjoyed the opportunity to do that. For a variety of reasons, I decided to move on to something different and move to Baptist Health South Florida. Bill Caldwell looked at this position for about a year before I came here. And so he kind of set the stage for me in many ways, and they were ready for an academic neurosurgeon's arrival. So Aaron Cohen does have an MBA, but I do not. And looking back, did I need one? No. And I think because I was educated on the job over 30 years at an academic medical center and neurosurgical department. Now, if you ask me 10 to 15 years ago, would I have been ready, the answer would've been no. And the MBA might've helped me a little bit with talking about year-to-date and different profit margins and et cetera with the finance people, but I don't think it's really hurt me. But the thing that's important, I'm 65 and a half now. When I left UCSF, I was 62, and every neurosurgeon has to plan for a slowdown in their career. And I realized I couldn't do 350, 375 open cases, 200, 230 radiosurgery cases a year forever. That was just not possible. And I think the decision to incorporate radiosurgery into my tumor practice was a good one because it would allow me a nice transition in my later years of neurosurgical practice, something less intense. And I always felt that I could mentor younger surgeons, and I've done that here. I've operated with every faculty person, whether it's brain or spine, just to get a feel for how they do things. And I think also on the cranial side, to transfer some of my knowledge to them. So I still feel a little bit like a teacher, but I have to be careful, obviously, respecting my colleagues' experience, some of who are very experienced and technically excellent. I went from 21 residents and several fellows to none. We have two fellows in neurointerventional, but we have none in neurosurgery. And I went from greater than 500 combined cases a year to somewhere between one 40 and 180. My emphasis on my job has changed, obviously, in this position of responsibility. I'm in charge of neurosurgery, neurology, physical medicine, and rehabilitation. And so the satisfaction is a different kind of satisfaction in achieving positive results for the system. Similar to the difference between the way you feel about taking out a sphenoid wing meningioma successfully versus getting a paper accepted for publication. Those are both gratifying, but they're different experiences. So my work experience now has changed, and frankly, I'm enjoying it. So I hope that you out there, if you're younger in your careers, think about the future. I'm 20 years down the road, what are you going to be doing? You're not going to be doing giant trigeminal schwannomas every month, and you shouldn't be, 'cause you will not be the future of neurosurgery at that time. So a little bit about the financials, which is what I spoke about primarily at the Congress of Neurological Surgeons recently. Nino Kyoko was my academic affiliate, giving the counterpoint presentation to something from a nonprofit system that's affiliated with Florida International University in our case. Now at the university system there's a tax on the fees generated by surgical endeavors, and there's usually a department tax on your collections as an individual, and those go on to the greater mission of the institution and department. Now, most systems in the academic model, but ours as well, have moved to the RVU system. And the reason that this came about was largely because of the development of the hospitalist program and the need for university centers in large cities to be able to pay a living and reasonable wage to their non-proceduralists, like internal medicine, psychiatry, pediatrics, and emergency medicine. So the relative value unit paid was negotiated between the hospital and medical school and the department. And it was higher for proceduralists, it was highest for neurosurgery and cardiac surgery because of the risk profile associated with our procedures. But if you looked at the difference between the income on collections versus RVU payment, and let's say neurosurgeons got paid $84 per RVU, there was a big difference given our payer mix in California between whether you're a cranial surgeon on the collection model versus a cranial surgeon on the RVU model. On the collection model, cranial surgeons did really well. Mike Lotton and I, I was number one, Mike was number two, kind of went back and forth some years. Chris Ames was number three. But if you went to the RVU model, then the income generated on the RVU model was highest for the spine surgeon. And I went from first to third and it was a 30% swing for me, collection model versus RVU model. So that was a big difference. What we did at UCSF was if we were going to calculate incentive bonuses, we took 50% from the collection summary versus, and 50% from the RVU model. So everybody got I think, a fair shake. Now direct- you'll hear the accounting people talk about directs and indirects, directs are the money that you make for the hospital and the school of medicine from your professional services. So you do a craniotomy, do a spine operation, you code the operation, you submit it to the insurance company, they pay you something, those are directs. The indirects are what the hospital sees on their side for services, such as admissions to an ICU, admissions to a regular ward bed, operating room time, payment for anesthesiologists, nurses, post-op scans, post-op laboratory tests, et cetera, et cetera. And then the indirects are basically what you generate for the hospital. And that's a huge amount of money compared to what the clinical collections are. Now, cranial surgeons turn out to be actually more valuable in many ways than spine surgeons for the hospital on the indirects because the hospital's responsible, not the patient per se, for paying for the hardware. So if you do a C7-S1 fusion for adult spinal deformity, the hardware cost can be up to $120,000. And on the commercial model, the payers stop paying after the second level of your spine operation on the collections. But in the RVU model, it keeps going. There's a decrement every single level after that, but it never goes to zero. So you have a 10% reduction per level for every additional level. It's just like a fraction, no matter how big the denominator gets, as long as the numerator is one, it'll never be zero. Cranial operations are also very economical for the hospital because the costs are low. We don't have many implants, we take out stuff, but the only things we leave in are plates and screws, sometimes aneurysm clips, and an aneurysm clip costs, for a single clip can be 3,000, multiple clips up to 8,000. So if you look in general, and these are figures that I roughly recall from the finance committee at UCSF, somebody who does not do many cases, kind of like me now, is worth about one to 3 million in indirects for hospital services. But if you have a really busy surgeon, it's not completely linear, there's a bit of a sag. But somebody who's doing 300 to 350 complex cases a year is worth about eight to $10 million to the hospital on the indirect side. Now, the contribution margin for the hospital in an employed RVU model is the net of collections and indirects. So you get a combination of the collections you make, the indirects minus the salary that they're paying you, and that's their net contribution margin. But for the salaries for non-proceduralists are lost to the system in general. But the contribution margin is not great because there aren't procedures. But for example, without giving specific figures, for 23 neuroscience employees across neurosurgery, neurology, and physiatry, the net contribution margin for our neuroscience institute was north of 150 million net per year. So that's a big contribution. So when I came here, the only other university in town, or the only academic program in town was University of Miami. And I didn't really feel I was coming here to compete with them. I felt that I was coming here to provide the community with the opportunity for another academically-oriented, data-driven, medical decision-making, and practice service. So there's no way the Department of Neurology at University of Miami has 85 neurologists, 25 researchers. We have three neurologists so far. Our hiring plan is that by 2031, we're going to have up to 40 neurologists. So that'll be a big shift. But you know, there's a national shortage of neurologists, so it's really hard to find new people to employ. When I arrived, there were only seven employees and I was number eight. And as of the end of this month, we are now 33, we have nine neurosurgeons, and then the rest are physical medicine rehab, which is the biggest group, pain medicine group, and the neurology group. There is a plan to start residency program. The healthcare system invested in a commitment to graduate medical education. So there'll be 23 programs by the end of 2028, including neurosurgery. You have to have internal medicine, anesthesia, neurology, general surgery, and emergency medicine before you can apply for neurosurgery residency. And then we'll have residency programs in neurosurgery, neurology, and PM and R. And so I've been self-appointed as the Chair of Neurosurgery for at least for my first five years. The system wanted validation of my vision, so they spent a considerable amount of money getting a consulting group called ECG to develop a comprehensive plan for the neurosciences. And I told them ahead of time, I don't want all this marketing fluff about, conceptual ideas about how to make things better and bigger. I said, "I want demographic information, I want information on local competitors. I want expected growth rates, et cetera, et cetera." They did a really good job, I must say. So they identified us programmatic opportunities similar to what I had outlined, validated it, felt that the growth in encounters would be steady about 4% per year. And I just got the 2022 versus 2023 comparisons, and our year end is the end of September. So year 2022 ends in September '22, and annualized to the end of September for 2023, all our services and encounters are up 31.4%. So every service is up, including neurosurgery, 18.4%. So seems to be that we have an overshot, and we're positioned appropriately in hiring for the proper subspecialties. The Baptist Health Board, one of the things that they kind of forget is that once you start hiring people, they need an office if you're going to have an academic program, and they need nurses and we need exam rooms. So we needed to expand. When you go from eight to 33, you need more space. And we had to get them to commit to building more space. We're the only clinical center of excellence without a designated building, but that will change. And in the future we'll have a four-story building on campus next to the ER across from the Cancer Institute. And this has been approved in a master plan submitted to the city and the county. This past year, whatever metrics US News and World Reports uses, we got ranked 39th, which was a big deal for the system because no other clinical program has been ranked in the top 50 since the institution opened in 1962, and so I think we're on the right path. Now if you look at some of the areas for focus, and this is from the consultant's report, for brain surgery, brain tumors, vascular, et cetera, it's about 20% of the local market share. Spine, we're about 16%. We're smaller per players, and some of the neurology specialists, 'cause we don't have employed neurologists, but we're working on that. And then if you look at the projected growth, you can see over time, this is baseline 2019, before I came 2022, 2 years after I started, 2026, they're expecting a 44% increase. We had 31% increase between '22 and '23, much more than they expected. So the trends are good. And here are the projections for the increases in the subspecialties. And I think I have a slide to show you the expected expansion of the services. One thing I did was similar to what we do in academic center. When I arrived I told our faculty, "Look, you can't be doing general neurosurgery. We're going to hire more neurosurgeons. You need to focus on something. If you want to do spine, what's your thing? Are you adult deformity or you minimally invasive or you degenerative spine, simple degenerative spine, and or are you a functional neurosurgeon, et cetera, et cetera." So that's what we did. And I appointed each of the neurosurgeons and gave them a title, Director of Adult Deformity Spine Surgery, Director of Cerebrovascular Surgery, Director of Adult Brain Tumor Surgery, et cetera. I'm not the director of anything. I'm Co-Director of Radiosurgery Program with my radiation oncology colleague, but it's my job to make all my faculty famous. And that's what Charlie Wilson said to me in my three-minute introductory welcome greeting when I arrived at UCSF in 1992. So here's a little bit of a timeline. The first employed neurosurgeon was back in 2007. And then there's some technology that we acquired. We have an IMR system of both a CT and MR. And then I came along here in 2020. We got accredited again as a primary stroke center. Our stroke volume is huge. It'll be over a thousand endovascular procedures this year, over a thousand stroke calls. And you'd expect that in Florida with a bunch of old people. So we've expanded the endovascular service by hiring an open and endo neurosurgeon. We have a radiologist and neurologist who did fellowships in endovascular, and their numbers are up 54% comparing 2022 to 2023. So it's pretty dramatic. And that's partly because we hired the third person. We have some other things like transcranial magnetic stimulation, we have the omniscient functional imaging, which we use. And this is a little bit of the timeline. So when I first came, here's four nurse, there's three physiatrists. I arrived and then we hired some other people. Now we have a Director of Neurology. And as I said at the end of this month, we just hired five additional physiatrists at the end of this month. So now we're up to 33. Here is the kind of outline of the physician ramp up for hiring. You can see here that it goes up. We have pre-approval to hire this many neurologists. You can see here the big number of neurologists, five in stroke, two neuromuscular, et cetera, et cetera. And then seven brain tumor surgeons, eight spine surgeons. Currently we are four, so we're halfway there to the spine surgeons. And the metric I use is that if the most recent hire is doing over 200 cases and has greater than a two-month waiting list, we need to hire another spine surgeon. And that seems to have worked out okay. And you can see that the distribution and pain management, physical medicine, and we're going to hire, we have one psychiatrist, we're hiring a psychologist, and we plan to hire two more. The reason that we need the psychiatrist is for obvious reasons, interactions with movement disorder patients and our pain patients, and as well they can be responsible for supervising transcranial magnetic stimulation program. Just psychiatrists and neurologists can supervise, neurosurgeons cannot. And then these are some of the subspecialties areas which we're going to be focusing on, particularly for the subspecialties in neurology. We just opened an epilepsy monitoring unit with six beds this month and hired a fellowship trained neurologist just out of fellowship to lead that effort. Now with everything else, we have a very big network of acute care centers, a smaller number of hospitals. We extend from the Keys, which is Fisherman's and Mariner's, which is like, for example, Fisherman's is about a two and a half hour drive. They have a helipad, so does Mariners. We have a helipad on the emergency room. And you can see in green is what our current footprint is for staffing physicians, and in blue what the future holds. So a lot of these physicians in blue are going to be physiatrists, neurologists, not neurosurgeons, but I would imagine at West Kendall, probably five to eight years from now we'll have two full-time neurosurgeons. And then beyond that, I think the future looks bright. I have a great support team. These are names that are probably not relevant, but it's a collaborative effort. Everybody's been supportive. To date, they're very pleased with the clinical results, the ratings, and the revenue. And this is what the organizational chart looks like. These are the docs down here, and we have a different structure for the hospital versus the clinical services. And I'm right here and I report up to Jack Ziffer, the Executive Vice President of Clinical Operations for the entire system. About three years ago, Baptist Health South Florida bought Boca Raton Hospital, and the co-founder of Home Depot, Bernie Marcus, made a significant donation. And the result was that there was an institute built there called the Marcus Neuroscience Institute. And Warren Salman's going to be coming in early November to function as my equivalent up in Boca. So we're very excited about that, and he's going to hit it off right away with developing the physiatry services up there. So what kind of volumes are we doing? Just to give you some examples, this is our minimally invasive spine surgeon. So over nine months, this many clinic visits or encounters, 145 operations. One of our functional surgeons who does a lot of kyphoplasty saw 2,700 patients in nine months, and surgical encounters, 356 procedures. So that's a huge volume. Let me see, this is our complex cerebrovascular and skull-based surgeon, 195 cases, and he does about 250, 280 per year. Here's look at the neurologist, 2,284. These are the stroke neurologists, over 2,000 in nine months. So they're extremely busy. They all meet their minimum RVU requirements. They're all going to make incentive bonuses pretty easily. When we get to physiatry, physical medicine, and rehab, office encounters, can see total for one of them, 2,000, 1,800, 1,400, 1,800, 2,000, 1,900. The pain medicine people, total encounters including surgery, 5,200, 3,000. It's crazy. And we just hired four more physiatry people. So I think our total encounters next year for fiscal 2023 will be over 23,000 patients, which is pretty incredible. And if you look for example, at some of the operational figures, this is South Miami Hospital, which is where our four spine surgeons are. They have two operating rooms, which they use. Total encounters, both outpatient, ambulatory, and surgical, up 27% in one year. And then the surgical volume's up 14.7%. So we're heading in the right direction. And if you want to try and look at what the results are, financial, I couldn't share dollar numbers for obvious reasons, but what I did was I based them on what Baptist Health charges for an MR plus the radiologist review. And I expressed that as the dollar cost of one MR unit. And then thereafter I expressed all the financials in terms of MR dollar units. So if you look at the revenue for spine, operations, surgeons, outpatient visits, 7,200 MR units. And projected by 2031, it basically doubles. Brain, same. Stroke, same. Neurology, because we only have three and we'll soon have 39 or 40, you expect it to double. So there's a good steady growth plan and we've already seen that in the last year. And then contribution margins, which is the net between direct, indirect, minus the physician salaries, you can still see that over the projection between '19 and '31, it's still very positive for the medical center, in our case, the hospital. So when you hear your administrators whining about, how their margins have decreased, remember they don't make any money for this system, they just push it around. So without neurosurgeons and proceduralists, the hospital's really not going to make much money. But apart from the financials, obviously being raised in an academic system, I really wanted to continue to change the culture at this place. They weren't used to doing evidence-based medicine so much. They never had grand rounds, didn't have M and Ms. I set up a invited lectureship program, and actually Dan Yoshor's coming tomorrow as the Irma and Kalman Bass lecturer on innovation. He's going to present "The Journey Towards Artificial Vision for the Blind." And all of those invited lectureships were, and the budgets for those lectureships, were approved by the Miami Neuroscience Foundation. We raised $3.8 million last year, and that money's available for advancing research and development in the neurosciences. We have three summer research scholars, and that was approved for 10 years at a cost of $104,000. So undergraduates and medical students between first, second and second, third, can do a three-month rotation with us. We went through our first class this past summer, very successful event. And our research studies for 23, it's now up to 48. So compared to '16 and 2019, we've tripled the number of research programs, and those numbers were just revealed the other day. I have state funding for $1.25 million for the use of low intensity focused ultrasound for Alzheimer's patients. It's about $62,000 per patient for all the work that we have to do. And we have some industry sponsored trials for endovascular and for stroke. And we don't have any NIH funded trials yet. Well we do in stroke, actually we do, but we don't have any basic scientists. But that relationship with Florida International University is going to be strengthened once they sign a master agreement. So essentially we'll be the same model as the academic model. There'll be a dean's tax from FIU on the clinical revenue per for the system, all divisions in all departments. So that's how the medical school accrue monies so they'll be able to hire additional researchers. And FIU, much to my surprise, has one of the largest undergraduate population of students at 56,000, which is more than UC Berkeley, was ranked fourth this year in public universities. It was ranked first in diversity in public universities, and was ranked sixth in funding for public universities. So, who knew? But looks like they're doing really well. And this is the schematic of everything's been pushed back to '25 because of finances, et cetera. But this is the plan for the residency training programs. And you can see this is neurosurgery here. We're going to start with one, but probably ask for two, one alternating with two since we're going to incorporate the Boca program into our science rotations. This is the master plan for the campus. There's a lot of parking. This is where I am right now, in this medical arts building. It takes me 13 minutes to walk on the outside over to the cancer building, which is here. So from my office here, medical arts, all the way over to MCI is 13 minutes. If it's raining like today and I go inside the hospital, it takes 15 minutes. So you can imagine if you go back and forth multiple times per day, that's a couple hours of wasted time. So I wanted our building positioned strategically, not over here, but here, right in front of a new patient bed tower, which will take the patient capacity to over a thousand. This is the emergency room, neuroradiology is back here. Operating rooms and neuro ICU are back here. So this is a much better positioning for a building for us. And this is not the architectural plan, but just a schematic to get some donors excited. The first floor will be physical medicine, rehab, some imaging. And on this corner we'll have the ZAP radiosurgery system. We are privileged to have every radiosurgery and radiotherapy delivery platform available at the Cancer Institute. We have Gamma Knife, Cyberknife, TomoTherapy, MR, LINX, ZAP, TrueBeam times three, and IBA proton therapy, three patient portals. So we're lucky we're going to put the ZAP here because we want to be able to train some of the underserviced countries in the Caribbean, central South America. And I'm going to Lima, Peru this weekend to talk about that kind of thing. Second floor of the building will be neurology. Third floor will be neurosurgery. And then we want to establish a Baptist Brain Tumor Center. Fourth floor will be a lecture theater, reception area. We have multiple training courses per year for radiation oncology. And that training course revenue is almost a quarter million dollars per year. And we want to be a training site also for ZAP. We're going to put an employee wellness center up there, which means a workout gym with male, female lockers, conference rooms, siesta rooms. So looking forward to that finally getting built. So in summary, I think I had enough experience at a very high-end academic neurosurgery center where I had significant clinical responsibilities for the clinical programs. And that's where I basically learned my medical MBA. If I didn't have that experience and was younger, then an MBA, I think, would've helped me and would've positioned me well for an academic chairmanship down the road. If you're going somewhere, I think you need to have a vision, and you need support from independent consultants to validate that vision, always helps. That way the executives won't be doubting whether you're on the right track or not. If a consultant say, "Yes, you're right, and in fact you need to hire more," then it's a good thing. The implementation of your vision can be helped by the consultants' report, of course you need institutional support. And so far in the last three and a half years, the results have been positive, and I'm looking forward to the master agreement being signed so that we can be called Baptist - FIU, so we'll be a true not-for-profit academic center. So that's all I had to say.

- Really appreciate it Michael. And a lot of pearls right in there. What would you say is the top three pearls of success in starting a program and taking it to this level?

- Top three things I think one would be to have a vision. Two, to make sure that your vision is based on real data, not your imagination. Because you might, if you just dreamed up something, you might overshoot in one area. Like I know, I've heard of a neurosurgery academic department that hired a new chairman came in and hired a number of neurosurgeons and unfortunately too many. And the last thing you want is highly trained technical individuals sitting around with nothing to do. And then I think third thing is don't come into a place as a new person and start by firing a bunch of people. You're not going to, you don't need to win every battle in order to win the war. And that was one of the things that, the comments that I got when I self commissioned my own internal review from the department, and I asked the Director of Professionalism to help me with the interview, and he interviewed all the faculty anonymously. And things I got back, this was 2021, it said, "He doesn't wear his mask around the office as much as he should." I'm like, "Okay." "A bit authoritarian." I said, "Perfect." Just a bit of the big stick. And then the one I really took to heart was that quote, which I think is from Stalin, "You don't have to win every battle in order to win the war." But then what that means is, you don't need to have control over every single thing. You have to be able to give up a little bit of this in order to get things that you might consider more important. Neurology wants to hire neural hospitalist, let them work one week on, one week off, 'cause everybody else does, even though it seems like a weird model for an academic department. Can't fight it, got to let it go, let 'em do it. And tends to keep everybody happy. One of the things I was just talking about today with somebody was, I think as an executive, I guess it doesn't really matter what business you're in, but I think you have to keep some humility in order to be successful. When you walk into an office or into a patient exam room to see a patient, you don't need to introduce yourself as Dr. McDermott. They know why they're there. They're seeing a doctor, you're a neurosurgeon. And, you know, "Hi Mr. Cohen. I'm Mike McDermott." That's how I introduce myself. And so I like to keep it, level the playing field and we're all human, and I think that's an important thing to keep some humility.

- No, understood. It's a big difference for you going from a large academic institution.

- Yeah.

- To building a new program. It's really a significant change of sort of career. New challenges, good challenges, bad challenges. Every job position has its own good and bad. What would you say is the part that you have enjoyed the most doing what you're doing now?

- Well, the part I've enjoyed the most is bringing on new people and into programs, developing sub-specialization within neurosurgery and physiatry. I have a very good leader in physical medicine rehab. Get along great. We have the same idea. We work together, we do field trips together to go look at the physical plant at other sites. And I have a very good, we have the leanest administrative group amongst all the centers of clinical excellence. So we have, I don't know how many employees we have now, but we have one Assistant Vice President, a young woman who was trained MBA at Cornell. And then we have a Director of the Clinical Services, and that's it. And me and my division directors, Ron Tolson in physiatry, Diego Torres in neurology. And because we're lean, it creates a small team, so decision making can be quick and can be done easily. And I've enjoyed seeing the success of programs that we've built so far, and importantly, I think we haven't overshot, meaning, like some years I've not hired a neurosurgeon I was hoping to attract because they went to an academic program. But I didn't hire anybody that year because I didn't want to settle for the person I didn't really want. So I just passed, and I didn't hire anybody that year. So in the hiring plan it gave me some flexibility because they're all forward approved. And so if I didn't hire one this year, I could hire two next year, et cetera. But it's been good. I think it's- As you said at the beginning, there are different challenges in academic versus non-academic and established programs versus new startups. But I haven't found it, it's not been that hard and it's not been stressful or anything like, you know, you have days, but it's usually HR problems, and thankfully I have few of those.

- Do you take call there or?

- No.

- Okay.

- So when I was at UCSF, I ran the call schedule for 14 years after, even before Nick Barbara left. And one of the rules I put in was, after the age of 60, no more weekend or holiday call. And after the age of 65, I mean, weekday call was optional if you wanted to do it, but after 65 you were off. When I first came, I tried to take call here, and it's very busy at night here there's 18 to 22 consults per night. A lot of those are non-surgical, but, and hence the hiring of inpatient physiatrist to consult for back pain and stuff like that. And then we do have a, not a written rule, but a lot of the faculty were used to, if they were up late at night, they would just cancel the next morning, the whole clinic and everything. So that didn't work out well. So I got a call room so they can sleep. And the rule is if you got less than three hours of sleep, then you get a four-hour window before you have to come back, and you can just sleep. And if you got less than four hours, you get another two-hour window so you can sleep. So you get at least six hours, and most neurosurgeons can function properly with six hours of rest. That avoids canceling whole clinics for four hours and 12 patients, which is really annoying for the patients.

- I agree, I agree. Okay. Well, you know, this is exciting. It's definitely a new chapter in life.

- Yeah.

- And sometimes you need that.

- Yeah.

- Sometimes being operating all the time in the OR and incredible work that you did with skull base meningiomas, and you become a master of it, you really sort of almost reached to the level of expertise that very few people have reached, and at some point you may look for other challenges.

- Yeah.

- That drives you to be better. You know what I mean? I always tell people just being in the OR and operating more is not what makes a neurosurgeon a great neurosurgeon. It really isn't. I mean I know people who spend 10 hours doing surgery that you and I can probably do in two or three hours, and when they leave the OR they feel so empowered, they feel, "Oh yeah, I was in the OR for 10 hours." That's not what makes us great. It's about us being a great technical surgeon, doing good surgery, being efficient, and a great leader, entrepreneur, innovator. You cannot just be a surgeon who is in the OR most of the time and try to spend time dragging procedures and feeling that you're empowered. It's not the number of hours in the operating room that makes you a better surgeon. It's about how efficient you are, how well-rounded you are, and how great results you have.

- Yeah.

- None of these are a function of operating time. Do you agree?

- Yeah, I think I still focus a lot on listening to the patient, the history and physical is very important. I could tell you stories for another hour about misdiagnoses at UCSF because nobody examined the patient. Nobody used a stethoscope to listen for a BRUE. I mean, you know, crazy stuff. But yeah, I think it's important to maintain expertise in the art of medicine and the art of the neurologic exam, rather than just be somebody can interpret a scanner, do some technical operation because you have to be both a physician and a surgeon.

- No, I agree with you a hundred percent. As Harvey Cushing once said is, and you may correct me, said, "I wish for a day to see a chief of surgery without arms, as surgery is the least part of the work."

- Yeah, I mean... I still like operating. I'm still pretty efficient. I don't want to go too long. You want to end on top, not end when somebody tells you you need to stop kind of thing. So it's fine. I've had a great career as far as I'm concerned, and it's been fun.

- I agree. Pleasure having you, Michael.

- Thank, Aaron.

- We enjoyed as always listening to you and perspectives you have that very much I agree with and align with you, and look forward to having you with us in the future.

- Yeah, thank you Aaron. Thank you very much.

- Thank you.

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