What Neurosurgeons Should Do To Succeed in Tomorrow's Scientific and Socioeconomic Environment

There will be major scientific advances and socioeconomic changes in the 21st century that will influence the development of medicine and neurosurgery. These changes will affect those in academic medical centers and the private practitioners of medicine and neurosurgery. Neurosurgeons' philosophy and practice methods must adapt to these trends. Because of the continuing growth in scientific knowledge and the rapid spread of communications of all types, physicians will best work in groups and teams. These group forces will require the physicians to surrender some independence to gain the power of the integrated knowledge and political and social force of a group. Graduate and postgraduate education programs will also change to adapt to these new realities. Those who understand these new shifts will be the most successful in establishing and conducting practices in academic centers and private practice.

Physicians worldwide have been selected from among the most capable and intelligent people to enter their profession. Their education takes years, and most not only look forward to the personal satisfaction of caring for patients but also to financial security. The globalization of economics, however, has placed industry worldwide in competition to produce the lowest-cost products. Driven by expanding populations, health care expenses have risen beyond the ability of industry and government to afford them. In the US we are conditioned to desire the latest medical treatments in the hope of prolonging life, which are regarded as valuable in this and other industrialized cultures. New restrictions on government-sponsored health care expenditures or reduced payments by third parties hired by industry, have limited the reimbursement for physicians, threatening their long-planned careers in terms of financial security and satisfaction. Physicians are reluctant to revise long-set career goals and behavior, and they are frustrated by the socioeconomic changes influencing medicine. Some retire early; others become frustrated in practice, and seek security as salaried employees of large health care systems or insurance plans; but few adapt and change with the new environment.

The purpose of this paper is to outline for neurosurgeons and other physicians the influences leading to changes in the practice of medicine in this century and to propose solutions to allow future success in this new environment.

There are two major areas of scientific growth: biology and technology. In biological science, the extensive research into the molecular events of the cell and the sequencing of the genome will lead to major changes in the practice of medicine. These discoveries will change how we treat cancers of the central nervous system and other diseases. Surgical debulking of brain tumors, which has been performed for the last 100 years, aided by radio- and chemotherapy, has failed to control intracranial neoplasms and often results in serious morbidity. Targeted molecular therapies will become more successful and will prevail in treating cancer and other diseases. Furthermore, these molecular advances will allow us to understand the biochemical sequence of events leading to ischemia-induced cell death. This information will influence the way we treat cerebral ischemia, edema, and trauma. Neurosurgeons will have to be knowledgeable about the metabolic changes occurring in each of these conditions. Specific biochemical treatments will exist for different phases of the metabolic chain reaction that occur with cell injury underlying all of these diseases. We have seen evidence of this in the recent discoveries of the multiple posttrauma phases through which the brain cells pass.

No less important an advance will be cell transplantation, which will restore functions that are lost due to trauma-related cell death, infarction, and degenerative diseases.  Neurosurgeons must be participants in this research and must understand all of the genetic, behavioral, and immunological phenomena involved to achieve success, as did transplant surgeons 25 years ago. If not, the neurosurgeon will cling to a few technical procedures, becoming marginalized while new advances allow other practitioners to take over their patients and treatments. The rise of those performing interventional treatments for aneurysms is an example.

In technology, major advances in neuroimaging will continue to enhance insights into the function of the brain. We will be able to visualize fiber tracts and determine their function noninvasively in each individual. There will be metabolic maps of the brain indicating differences between ill and healthy people. For example, the differences in each patient's reaction to pain will be understood because neuroimaging (positron emission tomography and magnetic resonance imaging) reveals the biochemical, fiber tract, and synaptic diversities among patients. This information will be used to guide computerized surgical approaches to lesions, which will minimize morbidity. Differences among individuals in transmitter concentrations, determined by neuroimaging, will become the basis for selective drug modeling and therapy that will be individually tailored.  The development of nanoscience will allow the creation of implantable prostheses for hearing, vision, and perhaps other functions.

It is and will be impossible for one person to know and understand all the available information. Because of the increasing rate of scientific discovery, the amount of medical-related data doubles every 8 years. This increase of scientific information will continue at an asymptotic rate, requiring even greater specialization among professionals. The flood of new information will necessitate that physicians become interdependent to remain informed about treatments. Specialization in specific domains of neurosurgery will be essential for the neurosurgeon to remain current in the specialty and to provide the best and latest care to his/her patients. Our meetings have already become divided into superspecialty sections; most of these sections also hold independent meetings.

In the academic center, basic scientists, engineers, and magnetic resonance imaging physicists, to name a few, will need to work together with clinicians to develop the advances. Outside the academic center in private practice, neurosurgeons, neurologists, psychiatrists, neuroradiologists, and others will have to share their knowledge to provide the latest and best treatment for their patients.