Gender Differences in the Pediatric Neurosurgical Workforce: Professional Practice, Work-Life Balance, and Beyond.

BACKGROUND AND OBJECTIVES: Evidence suggests that female neurosurgeons experience unique challenges in the workplace including lack of academic advancement, challenges with work-life balance, harassment, and discrimination. How these factors influence the gender gap in neurosurgery remains unclear. This analysis investigated gender differences in pediatric neurosurgeons in professional and nonprofessional activities and responsibilities. METHODS: A survey examining professional activities, work-life balance, family dynamics, career satisfaction, and workplace discrimination and harassment was administered to 495 pediatric neurosurgeons. Response rate was 49% (n = 241). RESULTS: One-third of the pediatric neurosurgical workforce is female. There were no gender differences in race/ethnicity, American Board of Neurological Surgery/American Board of Pediatric Neurological Surgery certification rates, or pediatric neurosurgery fellowship completion. No gender differences were found in operative caseload, weekly hours worked, or working after 8 pm or weekends. Women took call more frequently than men (P = .044). Men were more likely to work in academia (P = .004) and have salary subsidization from external sources (P = .026). Women were more likely to anticipate retirement by age 65 years (P = .044), were less happy with call commitments (P = .012), and worked more hours at home while off (P = .050). Women more frequently reported witnessing and experiencing racial discrimination (P = .008; P < .001), sexual harassment (P = .002, P < .001), and feeling less safe at work (P < .001). Men were more likely married (P = .042) with 1 (P = .004) or more children (P = .034). Women reported significantly greater responsibility for child and domestic care (P < .001). There were no gender differences in work-life balance, feeling supported at work, or having enough time to do things outside of work. CONCLUSION: Despite little difference in workload and professional responsibilities, women held more domestic responsibilities and experienced and witnessed more racial and sexual discrimination in the workplace. Surprisingly, there were no reported differences in work-life balance or feeling supported at work between genders. These findings suggest that factors unique to female neurosurgeons may contribute to continued gender disparity in the field.

Comparison of sleep improvement in patients undergoing lumbar spine decompression.

OBJECTIVE: Degenerative spine conditions affect many people each year. These conditions have been shown to negatively impact pain, function, and patient quality of life (QOL), which often require surgical intervention. It is understood that sleep plays an important role in all of these factors. However, the relationship between sleep disruption and lumbar surgery is not well understood. The objective of this study was to use a large database to understand the relationship between sleep quality and lumbar spine surgery outcomes. METHODS: The surgical database of the authors' institute was used to identify all patients undergoing lumbar spine surgery for degenerative spine disease from January 1, 2012, through December 31, 2021. Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were collected, and only patients with both pre- and postoperative scores were included. Additional measures related to disability, pain, and depression were also obtained. Chart review was performed to collect patient demographics, health risk factors, and information related to sleep disturbances such as sleep medication usage and prior sleep condition diagnosis. RESULTS: The study had 674 patients who met the criteria. At 3, 6, and 12 months postoperatively, there was a significant decrease in sleep disruption scores (i.e., sleep improvement), although these decreases were not greater than the minimal clinically important difference (MCID). When stratified based on preoperative sleep quality, patients with poor preoperative scores (PROMIS sleep disruption > 63.04) showed a significant decrease in sleep disruption by 8.17 at 3 months, 7.99 at 6 months, and 7.21 at 12 months. All of these decreases were greater than the sleep disruption MCID of 6.5. Multivariate analysis showed high preoperative sleep disruption and improvement in PROMIS physical health were most associated with decreased postoperative sleep disruption at all postoperative time points. CONCLUSIONS: In patients with degenerative spine conditions, lumbar spine surgery offers improvement in sleep disruption for all patients. Those with poor preoperative sleep quality are more likely to see clinical improvement in their sleep disruption.

Ergonomics, musculoskeletal disorders, and surgeon gender in spine surgery: a survey of practicing spine surgeons.

OBJECTIVE: The objective of this study was to gain a greater understanding of the burden of musculoskeletal disorders (MSDs) in spine surgeons, their impact on practice, and risk factors contributing to MSDs, including surgical instrument design and surgical ergonomics. METHODS: An anonymous REDCap survey was distributed via email to the departments of several academic and private centers across the United States, as well as to the AANS/CNS Women in Neurosurgery Section email list. Chi-square tests and Wilcoxon rank-sum tests were used to compare responses by gender. Multivariable linear regression analysis was performed to identify predictors of discomfort in instrument utilization. RESULTS: Survey responses were received from 120 spine surgeons (29.1% response rate), of which 73 were included in the analysis. A very high number of respondents had experienced an MSD (70.4%), 38.2% had undergone treatment for at least one MSD, and 13.4% had lost time at work for at least one MSD. Women were more likely than men to have lost time at work due to an MSD (22.6% vs 5.6%, p = 0.04). Women were more likely than men to report difficulty in instrument grip, comfort, and use on a 20-point Likert scale (mean 10.7 vs 15.2 points, p < 0.0001). This effect persisted when adjusting for glove size and days per week spent operating (p = 0.002). Specifically, women were less likely to agree that the handles of surgical instruments were an appropriate grip (p < 0.0001), that they rarely experienced difficulty when using them (p < 0.0001), and that they rarely needed to use two hands with instruments meant to be used with one hand (p = 0.0002). CONCLUSIONS: The MSD burden in spine surgeons is substantial. While there was no evidence of gender differences in MSD rates and severity, female surgeons report significantly more discomfort with the use of surgical instruments. There is a need for more investigation of MSD risk factors in spine surgeons and mitigation strategies. Gender differences in comfort in instrument use should be further explored and addressed by spine surgeons and device manufacturers.

An assessment of the long-term impacts of the coronavirus disease 2019 pandemic on academic neurosurgery.

OBJECTIVE: The goal of this study was to survey residents, fellows, and residency program leadership to assess the long-term impacts of the coronavirus disease 2019 (COVID-19) on residency training by using a structured survey methodology. METHODS: A survey was distributed to US neurosurgical residents and fellows (n = 2085) as well as program directors (PDs) and chairs (n = 216) in early 2022. Bivariate analysis was performed to identify factors associated with a decreased likelihood of pursuing a career in academic neurosurgery because of the pandemic, a perception that surgical skills preparation was negatively impacted, personal financial concerns, and a preference for remote education. Significant differences in the bivariate analysis underwent further multivariate logistic regression analysis to evaluate for predictors of these outcomes. RESULTS: An analysis of complete surveys from 264 residents and fellows (12.7%) and 38 PDs and chairs (17.6%) was performed. Over half of the residents and fellows (50.8%) believed that their surgical skills preparation was negatively impacted by the pandemic, and a notable proportion believed that they were less likely to go into academics because of the pandemic's impact on their professional (20.8%) and personal (28.8%) life. Those less likely to pursue academics were more likely to report that work-life balance did not improve (p = 0.049), personal financial concerns increased (p = 0.01), and comradery among residents (p = 0.002) and with faculty (p = 0.001) did not improve. Residents who indicated they were less likely to go into academics were also more likely to have been redeployed (p = 0.038). A large majority of PDs and chairs indicated that the pandemic resulted in financial setbacks for their departments (71.1%) and institutions (84.2%), with 52.6% reporting reduced faculty compensation. Financial setbacks at the institutional level were associated with a worsened opinion of hospital leadership (p = 0.019) and reports of a reduced quality of care for non-COVID-19 patients (p = 0.005) but not from faculty member losses (p = 0.515). A plurality of trainees (45.5%) reported a preference for a remote format for educational conferences compared to 37.1% who disagreed. CONCLUSIONS: This study provides a cross-section of the pandemic's impact on academic neurosurgery, highlighting the importance of continued efforts to assess and address the long-term consequences of the COVID-19 pandemic for US academic neurosurgery.

Standardized Interview Scoring Methodology for Neurosurgical Residency Applicant Selection.

Interviews are critical to the neurosurgery resident application process. The COVID-19 pandemic forced residency interview activities are conducted virtually. To maintain a degree of control during a period of uncertainty, our department implemented a standardized survey for interviewers to evaluate the noncognitive attributes and program compatibility of applicants. Our objective was to assess the reliability and biases associated with our standardized interviewer survey implemented in neurosurgical residency interviews. A 5-question interviewer survey to assess applicant interview performance and program compatibility was implemented during the 2020 to 2021 interview season. After the application cycle, survey metrics were retrospectively reviewed. Multiple cohort analyses were performed by dividing interviewers into cohorts based on status (faculty or resident) and sex. Applicant scores were assessed within sex subgroups for each aforementioned interviewer cohort. Intraclass correlation coefficients (ICCs) were calculated to assess survey reliability. Fifteen interviewers (8 faculty and 7 residents) and 35 applicants were included. Female applicants (17%) and interviewers (20%) comprised the minority. There were no differences between resident and faculty reviewer scores; however, female reviewers gave higher overall scores than male reviewers ( P = .003). There was no difference in total scores between female and male applicants when evaluating all reviewers or subgroups of faculty, residents, females, or males. ICC analysis demonstrated good (ICC 0.75-0.90) or excellent (ICC > 0.90) reliability for all questions and overall score. The standardized interviewer survey was a feasible and reliable method for evaluating noncognitive attributes during neurosurgery residency interviews. There was no perceptible evidence of sex bias in our single-program experience.

Price Transparency in Neurosurgery: Challenges and Opportunities in the Online Publishing of Treatment Prices to Enable Cost-Conscious and Value-Based Practice.

OBJECTIVE: There is a paucity of evidence describing the price information that is publicly available to patients wishing to undergo neurosurgical procedures. We sought to investigate the public availability and usefulness of price estimates for non-emergent, elective neurosurgical interventions. METHODS: Google was used to search for price information related to 15 procedures in 8 major U.S. health care markets. We recorded price information that was published for each procedure and took note of whether itemized prices, potential discounts, and cross-provider price comparisons were available. RESULTS: Online searches yielded 2356 websites, of which 228 (9.7%) offered geographically relevant price information for neurosurgical procedures. Although accounting for only 16.4% of total search results, price transparency websites provided most treatment price estimates (74.1% of all estimates), followed by clinical sites (19.3%), and other related sites (5.3%). The number of websites providing price information varied significantly by city and procedure. websites rarely divulged data sources, specified how prices were estimated, indicated how frequently price estimates were updated, offered itemized breakdowns of prices, or indicated whether price estimates encompassed the full spectrum of possible health care charges. CONCLUSIONS: Under 10% of websites queried yield geographically relevant price information for non-emergent neurosurgical imaging and operative procedures. Even when this information is publicly available, its usefulness to patients may be limited by various factors, including obscure data sources and methods, as well as sparse information on discounts and bundled price estimates. Inconsistent availability and clarity of price information likely impede patients' ability to discern expected costs of treatment and engage in cost-conscious, value-based neurosurgical decision-making.

Neurosurgeons Relate Heterogeneous Practices Regarding Activity and Return to Work After Spine Surgery.

OBJECTIVE: Given the paucity of relevant data, the Council of State Neurosurgical Societies Workforce Committee launched a survey of neurosurgeons to assess patterns in activity restriction recommendations following spine surgery; the ultimate goal was to optimize and potentially standardize these recommendations. The aim of this initial study was to determine current practices in activity restrictions and return to work guidelines following common spinal procedures. METHODS: The survey included questions regarding general demographics and practice data, postoperative bracing/orthosis utilization, and guidelines for postoperative return to different levels of activity/types of work following specific spine surgery interventions. A spectrum of typical spine surgeries was assessed, including microdiscectomy, anterior cervical discectomy and fusion (ACDF), and lumbar fusion, both open and minimal invasive surgery (MIS) approaches. RESULTS: There was significant interprocedure and intraprocedure variation in the neurosurgeons' recommendations for postoperative activity and return to work recommendations after various spinal surgery procedures. Comparisons of the different surgical procedures evaluated revealed significant differences in cervical collar use (more often used following ≥2-level ACDF than single-level ACDF; P < 0.001), return to both sedentary and light physical work (greater restriction with ≥2-level ACDF than with single-level ACDF; P < 0.001), and return to a light exercise regimen (sooner following MIS versus open lumbar fusion; P < 0.001). CONCLUSIONS: This survey demonstrated little consistency regarding return to work recommendations, general activity restrictions, and orthosis utilization following common spinal surgical procedures. Addressing this issue also has significant implications for the societal and personal costs of spine surgery.

Evaluating diversity in neurosurgery through the use of a multidimensional statistical model: a pilot study.

OBJECTIVE: There is a growing body of evidence demonstrating the benefits of diversity across many domains. However, neurosurgery consistently lags most of medicine in many aspects of diversity. Any inability to make progress in this arena is likely due to the multifactorial and complex nature of the issue, which makes it difficult to meaningfully measure and track diversity within the workforce. The goal of this pilot study was to assess the utilization of a multidimensional statistical model to quantify and assess diversity within neurosurgery. The authors sought to 1) assess the diversity of neurosurgery residents using Simpson's Diversity Index and Sullivan's Composite Diversity Index (CDI) and 2) determine if a medical school's intrinsic academic opportunities and resources, indicated by US News & World Report's (USNWR's) best research medical schools ranking, are related to the number of neurosurgery residents produced per medical school. METHODS: A cross-sectional study of all neurosurgery residents (projected graduation years 2020-2026) and 1st-year medical students (matriculating years 2016-2019) was undertaken. Biographical diversity data (gender and matriculation data) were collected from institutional websites between December 2019 and June 2020. The CDI expresses the diversity of a given population by representing the effective proportion of categories present across all diversity attributes and was calculated for neurosurgery residents and medical students. Statistical results are reported as the median and interquartile range. RESULTS: Neurosurgery residency program CDI (0.21, IQR 0.16-0.25) was significantly less (p < 0.001) than medical school CDI (0.42, 0.37-0.48). There was no significant difference in CDI between top-40 and non-top 40 Doximity ranked research output neurosurgery residency programs (p = 0.35) or between top-40 and non-top 40 USNWR ranked research medical schools (p = 0.11). Over a 7-year period, top-40 ranked research medical schools produced significantly more (p < 0.001) neurosurgery residents (11.9, IQR 7.1-18.9) than the non-top 40 ranked research medical schools (5.6, IQR 2.6-8.5). CONCLUSIONS: The authors demonstrated the feasibility of using a multidimensional statistical model as a measure to understand the complex issues of diversity. Their preliminary data suggested that neurosurgery's challenge in achieving the desired diversity relates to uneven attraction and/or recruitment across an increasingly diverse medical student body. In recent years, neurosurgery has made great progress in the arena of diversity and has shown a strong desire to do more. Utilization of these diversity measures will help the neurosurgery field to monitor progress along this valuable journey.

The Utility of Remote Video Technology in Continuing Neurosurgical Care in the COVID-19 Era: Reflections from the Past Year.

OBJECTIVE: In 2020, the coronavirus disease 2019 (COVID-19) pandemic exposed existing stressors in the neurosurgical care infrastructure in the United States. We aimed to detail innovative technologic solutions inspired by the pandemic-related restrictions that augmented neurosurgical education and care delivery. METHODS: Several digital health and audiovisual innovations were implemented, including use of remote video technology to facilitate inpatient consultations and outpatient ambulatory virtual visits, optimize regional hospital neurosurgical coverage, expand interdisciplinary patient management conferences (i.e., tumor board), and further enhance the neurosurgical resident education program. Enterprise patient experience data were queried to evaluate patient satisfaction following the switch to virtual visits. RESULTS: Between January 2020 and April 2021, use of virtual visits more than doubled in the Department of Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visits were equal if not better in providing satisfactory patient care than in-person visits. After switching our interdisciplinary spine tumor board to a virtual meeting, we increased surgeon participation and attendance by 49.29%. Integration of remote audiovisual technology in resident didactics and clinical training improved our ability to provide comprehensive and personalized educational experiences our trainees. CONCLUSIONS: Digital health technology has improved neurosurgical care and comprehensive training at our institution. Investment in the technologic infrastructure required for these remote audiovisual services during the COVID-19 pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States in the future. Governing bodies within organized neurosurgery should advocate for the continued financial and licensing support of these service on a national fiscal and policy level.

Developing a Professionalism and Harassment Policy for Organized Neurosurgery.

Annual conferences, educational courses, and other meetings draw a diverse community of individuals, yet also create a unique environment without the traditional guard rails. Unlike events held at one's home institution, clear rules and jurisdiction have not been universally established. To promote the open exchange of ideas, as well as an environment conducive to professional growth of all participants, the leading neurosurgical professional organizations joined forces to delineate the expectations for anyone who participates in sponsored events. The One Neurosurgery Summit Taskforce on Professionalism and Harassment developed a foundational policy that establishes common expectations for behavior and a unified roadmap for the prompt response to untoward events. We hope that publishing this policy will inspire other medical organizations to establish their own meeting and conference policies. More importantly, we wish to bring greater attention to everyone's responsibility for ensuring a safe and respectful space for education, scientific debate, and networking during organized events.

Developing a professionalism and harassment policy for organized neurosurgery.

Annual conferences, educational courses, and other meetings draw a diverse community of individuals, yet also create a unique environment without the traditional guard rails. Unlike events held at one's home institution, clear rules and jurisdiction have not been universally established. To promote the open exchange of ideas, as well as an environment conducive to professional growth of all participants, the leading neurosurgical professional organizations joined to delineate the expectations for anyone who participates in sponsored events. The One Neurosurgery Summit Taskforce on Professionalism and Harassment developed a foundational policy that establishes common expectations for behavior and a unified roadmap for the prompt response to untoward events. We hope that publishing this policy will inspire other medical organizations to establish their own meeting and conference policies. More importantly, we wish to bring greater attention to everyone's responsibility for ensuring a safe and respectful space for education, scientific debate, and networking during organized events.

Neurosurgery Resident Interviews: The Prevalence and Impact of Inappropriate and Potentially Illegal Questions.

BACKGROUND: The impact of workplace discrimination has gained recognition. Nearly two-thirds of all medical residency applicants reported being asked inappropriate or potentially illegal interview questions. The use of such questions during neurosurgery residency interviews has not yet been studied. OBJECTIVE: To evaluate the prevalence of inappropriate or potentially illegal questions in residency interviews and the impact on applicants' rank lists. METHODS: All 2018 to 2019 United States neurosurgery resident applicants were anonymously surveyed. The survey included 46 questions focused on demographics; if they were asked questions regarding rank list, age, gender, marital status, family planning, religion, sexual orientation, or disability and whether such questions affected their rank list formation. RESULTS: Of 265 surveyed United States applicants, 133 (50%) responded. Most respondents were male (78%), 24% were married, and 10% had children. During the formal interview, 94% were asked at least 1 inappropriate or potentially illegal question. About 78% reported being asked about marital status, 29% were asked about intent to have children. About 46% reported being counseled on their personal life, 30% were asked about their ethnic background, and 15% were asked about their religion. A total of 2 candidates reported questions about mental illness/disability, and 2 candidates reported being asked about sexual orientation. About 45% of applicants that were asked at least 1 of these questions ranked those programs lower. CONCLUSION: Nearly all (94%) neurosurgical residency applicants reported being asked at least 1 inappropriate or potentially illegal question during interviews. Our results indicate that inappropriate questions negatively affected program rankings.

Slow progress in the visibility of women in neurosurgery in the United States: opportunity for improvement.

OBJECTIVE: The goal of this study was to analyze the visibility of women within organized neurosurgery, including leadership positions, lectureships, and honored guest/award recipients at neurosurgical conferences. METHODS: A cross-sectional study was used to analyze the gender demographics within the five major national neurosurgical societies (Congress of Neurological Surgeons [CNS], American Association of Neurological Surgeons [AANS], Society of Neurological Surgeons [SNS], American Board of Neurological Surgery [ABNS], and Council of State Neurosurgical Societies [CSNS]) from 2000 to 2020. Data for top leadership positions, keynote speakers, honored guests, and invited lectureships at these neurosurgical societies were reviewed. Additionally, national neurosurgical residency match data from 2018 to 2020 were collected. For each aforementioned data point, gender was determined and confirmed via publicly available data. Data from the US News and World Report best hospitals publication for 2020 were applied for analyzing gender trends within neurosurgical residencies specifically. RESULTS: In the past 2 decades (2000-2020), top leadership positions across the neurosurgical organizations were held by 45 individuals, of whom 5 (11.1%) were women. Spanning from 2000 to 2018, just 8.1% (50 of 618) of guests/honored speakers on the national neurosurgical stage of the CNS, AANS, SNS, and CSNS meetings have been female. Excluding the Louise Eisenhardt Lecture (honoring women), the percentage of female guests/honored speakers at the AANS meeting was just 5% (17 of 367). For the CNS annual meetings, 13.4% (20 of 149) of the speakers were women from 2000 to 2018, whereas the CSNS annual meeting data from 2001 to 2018 found that 11.9% (7 of 59) of speakers were women. From 1952 to the present, there have been no female honored guests at the CNS annual meeting. Across the residency match cycles from 2018 to 2020, the percentages of matched applicants identifying as female have been 22.7%, 28.1%, and, most recently, 25.3%. The percentage of female residents is 28.5% (top 20 program) versus 24.3% (non-top 20 program) (p = 0.267). CONCLUSIONS: This study found that for all the data points surveyed, including leadership positions, invited lectureships at national neurosurgical meetings, and successful neurosurgical residency applicants, disproportionate female underrepresentation was evident. Consistent lack of visibility leads to a negative impact on progress in the recruitment and retention of women in neurosurgery. Visibility, mentorship, role models, and sponsorship are highly interrelated processes and are essential for meaningful progress.

History of Women in Neurosurgery (WINS).

In 2020, the Women in Neurosurgery (WINS) organization, a joint section of the AANS and Congress of Neurological Surgeons, celebrated 30 years since its inception. In this paper, the authors explore the history of WINS from its beginnings through its evolution over the past three decades. The achievements of the group are highlighted, as well as the broader achievements of the women in the neurosurgical community over this time period.

Does double-blind peer review impact gender authorship trends? An evaluation of two leading neurosurgical journals from 2010 to 2019.

OBJECTIVE: Publications are key for advancement within academia. Although women are underrepresented in academic neurosurgery, the rates of women entering residency, achieving board certification, and publishing papers are increasing. The goal of this study was to assess the current status of women in academic neurosurgery publications. Specifically, this study sought to 1) survey female authorship rates in the Journal of Neurosurgery (JNS [not including JNS: Spine or JNS: Pediatrics]) and Neurosurgery from 2010 to 2019; 2) analyze whether double-blind peer review (started in Neurosurgery in 2011) altered female authorship rates relative to single-blind review (JNS); and 3) evaluate how female authorship rates compared with the number of women entering neurosurgery residency and obtaining neurosurgery board certification. METHODS: Genders of the first and last authors for JNS and Neurosurgery articles from 2010 to 2019 were obtained. Data were also gathered on the number and percentage of women entering neurosurgery residency and women obtaining American Board of Neurological Surgeons (ABNS) certification between 2010 and 2019. RESULTS: Women accounted for 13.4% (n = 570) of first authors and 6.8% (n = 240) of last authors in JNS and Neurosurgery publications. No difference in rates of women publishing existed between the two journals (first authors: 13.0% JNS vs 13.9% Neurosurgery, p = 0.29; last authors: 7.3% JNS vs 6.0% Neurosurgery, p = 0.25). No difference existed between women first or last authors in Neurosurgery before and after initiation of double-blind review (p = 0.066). Significant concordance existed between the gender of first and last authors: in publications with a woman last author, the odds of the first author being a woman was increased by twofold (OR 2.14 [95% CI 1.43-3.13], p = 0.0001). Women represented a lower proportion of authors of invited papers (8.6% of first authors and 3.1% of last authors were women) compared with noninvited papers (14.1% of first authors and 7.4% of last authors were women) (first authors: OR 0.576 [95% CI 0.410-0.794], p = 0.0004; last authors: OR 0.407 [95% CI 0.198-0.751], p = 0.001). The proportion of women US last authors (7.4%) mirrors the percentage of board-certified women neurosurgeons (5.4% in 2010 and 6.8% in 2019), while the percentage of women US first authors (14.3%) is less than that for women entering neurosurgical residency (11.2% in 2009 and 23.6% in 2018). CONCLUSIONS: This is the first report of female authorship in the neurosurgical literature. The authors found that single- versus double-blind peer review did not impact female authorship rates at two top neurosurgical journals.

Neuro-Oncology Practice resources for optimizing care and practice in spinal oncology.

As the diagnosis and treatment of systemic cancers continues to improve, increased patient survival has resulted in a rise in the number of patients who develop spinal metastases (SM). Within many areas of oncology, utilization of multidisciplinary care models in the management and decision making of SM patients has proven effective for optimizing care and improving patient safety. Three main goals of an effective clinical pathway include improving outcomes and quality, improving the patient experience, and lowering cost. This paper outlines the strategies employed to optimally establish such a collaborative program for the management of patients with SM, as well as direct providers in and out of the field, patients and caregivers, and practice managers to the appropriate resources.

Toward an understanding of sexual harassment in neurosurgery.

OBJECTIVE: The goal of this study was the creation and administration of a survey to assess the depth and breadth of sexual harassment across neurosurgery. METHODS: A survey was created to 1) assess perceived attitudes toward systemic issues that might be permissive of sexual harassment; 2) measure the reported prevalence and severity of sexual harassment; and 3) determine the populations at highest risk and those most likely to perpetrate sexual harassment. Demographic information was also included to facilitate further analysis. The SurveyMonkey platform was used, and a request to complete the survey was sent to all Society of Neurological Surgeons and Congress of Neurological Surgeons (CNS) active and resident members as well as CNS transitional, emeritus, and inactive members. Data were analyzed using RStudio version 1.2.5019. RESULTS: Nearly two-thirds of responders indicated having witnessed sexual harassment in some form (62%, n = 382). Males were overwhelmingly identified as the offenders in allegations of sexual harassment (72%), with individuals in a "superior position" identified as offenders in 86%. Less than one-third of responders addressed the incidents of sexual harassment when they happened (yes 31%, no 62%, unsure 7%). Of those who did report, most felt there was either no impact or a negative one (negative: 34%, no impact: 38%). Almost all (85%) cited barriers to taking action about sexual harassment, including retaliation/retribution (87%), impact on future career (85%), reputation concerns (72%), and associated stress (50%). Female neurosurgeons were statistically more likely than male neurosurgeons to report witnessing or experiencing sexual harassment, as well as assessing it as a problem. CONCLUSIONS: This study demonstrates that neurosurgeons report significant sexual harassment across all ages and practice settings. Sexual harassment impacts both men and women, with more than half personally subjected to this behavior and two-thirds having witnessed it. Male dominance, a hierarchical environment, and a permissive environment remain prevalent within the neurosurgical community. This is not just a historical problem, but it continues today. A change of culture will be required for neurosurgery to shed this mantle, which must include zero tolerance of this behavior, new policies, awareness of unconscious bias, and commitment to best practices to enhance diversity. Above all, it will require that all neurosurgeons and neurosurgical leaders develop an awareness of sexual harassment in the workplace and establish consistent mechanisms to mitigate against its highly deleterious effects in the specialty.

Spinal cord injury in the United States Army Special Forces.

OBJECTIVE: Spinal cord injury (SCI) is an area of key interest in military medicine but has not been studied among the US Army Special Forces (SF), the most elite group of US soldiers. SF soldiers make up a disproportionate 60% of all Special Operations casualties. The objective of this study was to better understand SCI incidence in the SF, its mechanisms of acquisition, and potential areas for intervention by addressing key issues pertaining to protective equipment and body armor use. METHODS: An electronic survey questionnaire was formulated with the close collaboration of US board-certified neurosurgeons from the Mount Sinai Hospital and Cleveland Clinic Departments of Neurosurgery, retired military personnel of the SF, and operational staff of the Green Beret Foundation. The survey was sent to approximately 6000 SF soldiers to understand SCI diagnosis and its associations with various health and military variables. RESULTS: The response rate was 8.2%. Among the 492 respondents, 94 (19.1%) self-reported an SCI diagnosis. An airborne operation was the most commonly attributed cause (54.8%). Moreover, 87.1% of SF soldiers reported wearing headgear at the time of injury, but only 36.6% reported wearing body armor, even though body armor use has significantly increased in post-9/11 SF soldiers compared with that in their pre-9/11 counterparts. SCI was significantly associated with traumatic brain injury, arthritis, low sperm count, low testosterone, erectile dysfunction, tinnitus, hyperacusis, sleep apnea, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Only 16.5% of SF soldiers diagnosed with SCI had been rescued via medical evacuation (medevac) for treatment. CONCLUSIONS: A high number of SF soldiers self-reported an SCI diagnosis. Airborne operations landings were the leading cause of SCI, which coincided with warfare tactics employed during the Persian Gulf War, Operation Iraqi Freedom, and other conflicts. A majority of SCIs occurred while wearing headgear and no body armor, suggesting the need for improvements in protective equipment use and design. The low rate of medevac rescue for these injuries may suggest that medical rescue was not attainable at the time or that certain SCIs were deemed minor at the time of injury.

Pregnancy and parental leave among neurosurgeons and neurosurgical trainees.

OBJECTIVE: Despite recently heightened advocacy efforts relating to pregnancy and family leave policies in multiple surgical specialties, no studies to date have described female neurosurgeons' experiences with childbearing. The AANS/CNS Section of Women in Neurosurgery created the Women and Pregnancy Task Force to ascertain female neurosurgeons' experiences with and attitudes toward pregnancy and the role of family leave policies. METHODS: A voluntary online 28-question survey examined the pregnancy experiences of female neurosurgeons and perceived barriers to childbearing. The survey was developed and electronically distributed to all members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons who self-identified as female in February 2016. Responses from female resident physicians, fellows, and current or retired practicing neurosurgeons were analyzed. RESULTS: A total of 126 women (20.3%) responded to the survey; 57 participants (49%) already had children, and 39 (33%) planned to do so. Participants overwhelmingly had or planned to have children during the early practice and senior residency years. The most frequent obstacles experienced or anticipated included insufficient time to care for newborns (47% of women with children, 92% of women planning to have children), discrimination by coworkers (31% and 77%, respectively), and inadequate time for completion of board requirements (18% and 51%, respectively). There was substantial variability in family leave policies, and a minority of participants (35%) endorsed the presence of any formal policy at their institution. Respondents described myriad unique challenges associated with pregnancy and family leave. CONCLUSIONS: Pregnancy and family leave pose significant challenges to the recruitment, retention, and advancement of women in neurosurgery. It is thus imperative to promote clear family leave policies for trainees and practitioners, address discrimination surrounding these topics, and encourage forethought and flexibility to tackle obstacles inherent in pregnancy and the early stages of child rearing.