James I' Ausman, M'D', Ph'D' Editor

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James I. Ausman, M.D., Ph.D.Editor SURGICAL
NEUROLOGYProfessor of Neurosurgery UCLA
University of Illinois at ChicagoClinical
Healthcare Consultant Navigant Consultants, Inc
Strategic Planning and Market Research for the
Healthcare Industry Medical Expert KMIR 6 TV
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What your Future will be Like And How to Plan
for It
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What is the likelihood that what we are doing
today in Medicine and Neurosurgery will be the
same at the end of the 21st century? NONE
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The World We Live In Present and Future
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The Future of Healthcare

• We are in a wartime economy- will last for years
• Our GNP will grow at 3 / year not 7
• Healthcare is 16 of the GNP in the USA-2006
• Health insurance premiums went up gt7 this year
• In 2015 it will be 20 of the GNP
• 2 trillion dollars will be spent on healthcare
  this year
• The Government controls 45 of healthcare
  expenditures this will rise to 49
• Others bill at Medicare or of Medicare rates
• There will be no more money available for doctors
  or hospitals

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The Future of Healthcare

• How will you make money in this environment?
• Cut costs
• Larger group
• Efficient operation
• Volume with good payers
• Find other ways to generate revenue

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The Economy in the Future

• We are in a global economy
• What is happening in Industry?
• Mergers and acquisitions
• Large corporations
• Multinational corporations
• Competition on the basis of price companies need
  to survive have become larger, global
• Healthcare costs increasing to industry
• Employees have larger copays
• Healthcare costs are going up no one likes it
• Companies are cutting retirement benefits

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The Economy in the Future

• Healthcare
• Has large players Government, Insurance Co,
  Hospitals
• Physicians
• 50 solo or small group (3 or less)
• Disunited
• How can you play effectively in this market?
• Failing business strategy

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The Economy in the Future

• How do you survive in this market?
• Become larger for greater market power
• Greater market share
• More political power
• What are you doing to help the community in this
  time of limited funds?

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Neurosurgery The national picture

• 3000 neurosurgeons in the USA
• Few specialized
• Most selling the same products
• Most in major cities
• Competition
• Interventional neuroradiology- advancing
  technology
• Ortho, plastic, vascular surgery spine,
  peripheral nerve, vascular
• Because less pay from payers
• Increased volume
• No time for RD
• No chance to advance
• Where are you going to be in 10 years with this
  strategy?

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Neurosurgery The national picture

• This is a formula for certain business failure
• No RD
• No new products
• No differentiation from competitors
• Solution
• Merge with others
• RD
• New strategy larger group

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Neurosurgery The case market

• 17,000 new primary brain tumors ( 5/
  neurosurgeon/ year)
• 100,000 metastases (33/ neurosurgeon/ year)
• 700,000 new strokes per year
• 25,000 SAH , aneurysms AVMS
• 200,000 carotid endarterectomies
• Epilepsy 2,000,000 people
• 1-2 have Parkinsonss
• Back pain most common cause of loss of work
• only 10 need surgery
• Pain is the most common symptom of patients

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Neurosurgery The case market

• Solutions
• Concentrate on large volumes in market
• Expand market share Provide full service
• Need to have a larger group to do this
• Need time for RD
• Subspecialize
• What neurosurgeons are doing with the figures
  above
• If you choose a niche, be a Focused Factory

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Physicians A psychological analysis

• Intelligent, Individualistic
• Ego driven
• Know it all
• Do what I tell you
• Cannot work together
• Unwilling to change
• Politically naïve
• Poor negotiators and business mentality
• Used to arguing
• Risk Averse

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Your business adversary A psychological analysis

• Goal Directed
• Intelligent
• Ego driven
• One leader speaks, the rest follow
• Have a strategy
• Organized, work as a team
• Will change to gain market share and succeed
• Politically savvy
• Good negotiators and business mentality
• Work as a team (I pay your salary do what I say)
  
• Risk Takers

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Which of these two opponents will win at the
negotiating table?
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Your business adversary A psychological analysis

• The world you compete in is a business world not
  the OR
• Learn the RULES

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Physicians A psychological analysis

• Solutions
• Hire people who believe as you do
• Those who do not fit dont hire or fire
• Change your way of dealing with people
• Get a Strategic Plan

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How to negotiate to get what you want

• Physicians say, Do what I say now
• (no negotiation)

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• Be happy with half-victories and come back for
  the rest later-

Lyle French, M.D. As he went from Chairman of
Neurosurgery to VP of Health Sciences
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What your patients think of your service

• Hard to get an appointment Automated answering
  service
• Waits to see doctor patients time is not
  valuable
• Fragmented care specialized care go to multiple
  doctors lost time
• 96,000 patient deaths per year caused by
  doctors
• Doctors make too much money (look at the cars
  they drive)
• Expectations are unlimited
• Press doctors self-centered generation
  (boomers)
• Patients do not want to pay co-pays
• But rather spend on VCR, golf or etc
• They understand some of the system problems
  affecting you

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What your patients think of your service

• Solutions
• You must deal with patients perceptions, not
  reality! The customer is right!
• Change your way of doing business
• Better PR locally, nationally
• Academic Centers are the worst at service
• can only leverage their unique treatments
• You must work like you never have enough business
  (Avis)
• Do you have an unlisted phone number?
• Is your office phone automated?
• YOU ARE IN THE SERVICE INDUSTRY PROVIDE SERVICE!

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The Future Nursing and other paramedical
professions

• Nursing
• Shortage now
• Worse in the Future
• Nurses seeking other careers with better respect,
  pay and independence
• Climbing pay
• Paramedical Professions
• Growth industry
• Climbing pay

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• What did you learn from analyzing your business
  from the available information today?

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Solutions so far

• Healthcare environment
• Cut costs larger group efficient operation
  volume- payer
• Global Economy
• Larger group for market and political power
• Neurosurgery national market place
• Present formula is a business failure
  Differentiate yourself from your competition
• Merge RD larger group
• Neurosurgery case market
• Concentrate on large volume Tumors mets and
  others pain and spine Movement disorders
  epilepsy vascular disease need larger group

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Solutions so far

• Physician personality
• Hire people who believe as you do
• change your behavior
• Get advice and strategic plan
• Opponents personality
• You are playing in a business marketplace not the
  OR Learn the rules
• How to negotiate
• Be happy with 1/2 victories and come back for the
  rest later Change learn to negotiate
• What do your patients (customers) think of your
  business?
• Change PR Customer focus You are in the
  Service Business

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What about your own Personal Future?Do you
have enough money to retire?If you retire at 65
and live to 90sHow much money will you need to
allow you to live the way you want for 30
years?At least 10 million dollars in the bank
at retirement or more
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The Future Trends in Neuroscience Research

• Where research is leading us

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Where Neuroscience Research Is Taking Us

• Neurosurgery
• Less invasive approaches to neurosurgical
  diseases
• Aneurysms, AVMs, pituitary tumors, some spine
• Successful molecular treatments for neoplastic
  diseases
• CML, medulloblastoma, meningioma, ALL
• Will eliminate skull base surgery for tumors, and
  other grossly invasive approaches for neoplasms
• Imaging indicating functional significance of
  every part of brain.
• damage to cognitive brain functions by standard
  neurosurgical procedures
• Will change neurosurgery to a minimally invasive
  technical specialty

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Where Neuroscience Research Is Taking Us

• Neurosurgery
• Understanding molecular level dynamic genetic and
  biochemical processes
• Will need constant evaluation and changes in
  treatment
• Trauma, ischemia, spinal cord injury, spinal cord
  repair
• Care of the Recovering and Injured Brain
• Neurointensive Care.
• Will overlap interests of neurologists who will
  be treating different diseases similarly
• Neurosurgeon will become less surgical. Will
  there be a neurosurgeon?

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Where Neuroscience Research Is Taking Us

• Neurology chronic and progressive diseases
• Will have genetic and molecular bases
• Imaging will reveal causes of these
• Neurology and Neurosurgery will overlap
• Pain Genetic differences Fiber tract
  differences
• Will require knowledge of psychiatrist,
  neurologist, neurosurgeon and rehabilitationist
  to treat patient successfully

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Where Neuroscience Research Is Taking Us

• Psychiatry
• Cognitive Functional Diseases will have a
  genetic basis.
• These disorders will be understood in molecular
  terms.
• Imaging will reveal basis for cognitive and
  functional disorders
• Psychiatry and Neurology will merge with
  Neurosurgery

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Where Neuroscience Research Is Taking Us

• Neurosurgery, Neurology and Psychiatry
• We are all looking at the same brain
• INTERDISCIPLINARY RELATIONSHIP
• In academic centers, Basic Neuroscientists will
  join clinical neuroscientists
• Grants will be awarded to teams of
  neuroscientists
• Examples at present
• Stroke
• Pain
• Epilepsy (MINCEP)
• Movement Disorders

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The Future The Neurosciences Market
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The Neurosciences Market Is Large But Diffuse
Estimated Prevalence in U.S. (in thousands)
Total 15 million 90 million(with cognitive,
functional and behavioral disorders contributing
75 million 1 /3 of the population)
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Value of a Neurosurgeon
Average Hospital Inpatient and Outpatient
Revenue Generated Annually (millions)
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Inpatient Care Is More Concentrated at Teaching
Hospitals
Percent of U.S. Discharges at Teaching Hospitals
All Discharges 22
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Market Realities Emerging Physician
Shortages

• Supply and Demand

• Shortages Continue for Other Specialists
• Spurred by declines in specialty residencies,
  demand for select specialists are expected to
  rise (1994 vs. 1999)
• Orthopedic residents declined 9
• Radiology residents declined 13
• Oncology residents declined 63

Source AANS Bulletin Winter, 2003 Too Many?
Too Few?
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Market RealitiesA Sellers Market

• How Competitive Is Your Market/Organization?

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ED Coverage Forcing the Issue
Hospitals Naming Specialty Among Hardest to
Secure ED Coverage (n1,501)
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For facilities with resident coverage, this
situation has been particularly problematic due
to new residency work week limits
Source Tiber Group analysis AHA and The Lewin
Group TrendWatch (March, 2001) Governance
Institute
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Less Hospital-Physician Competition
Distribution of Physicians by Group Size (2001)
Capital Cost of Neuroscience Equipment
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Aging Populace Requires More Hospitalization
Rate Per 1,000 Population
50 of Todays Population
Source National Hospital Discharge Survey,
Center for Disease Control and Prevention, 1998
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Expect Long-Term Rise in U.S. Hospital Admissions
U.S. Hospital Admissions
(Millions)
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The Neuroscience Market-Summary

• There is a large volume of people with
  neurological and functional disorders- 90 million
• The number of neurosurgeons and neurologists is
  decreasing
• Many in solo or small group (lt3) group practice
• Neuroscience is expensive-equipment intensive
• Complex neurological conditions seen more at
  academic or major centers
• Neurosurgery is big IDP revenue generator, second
  to cardiac hospitals need to find other sources
  of revenue
• Baby boomers will increase demand for services in
  the next 20 years neurosciences will benefit
• People are living longer with chronic diseases
• Research dollars are increasing
• Neuroscience is next big area for hospital
  program growth

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The Neuroscience Market-Summary

• How should you take advantage of these changes
  and opportunities?
• Should you do what you are doing or change?
• Academic Medical Centers? What strategy?

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Future-Neurosciences Healthcare Delivery

• Scientific knowledge doubles every 7 years
• Impossible for one physician to know everything
• HOW ARE YOU GOING TO KEEP UP IN THIS RAPIDLY
  CHANGING WORLD?

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Future-Neurosciences Healthcare Delivery

• YOU WILL HAVE NO CHOICE BUT TO SPECIALIZE
• THUS, YOU MUST WORK IN GROUPS
• THE LARGER, THE BETTER
• You will be more satisfied professionally
• Have more time to be good
• To be with your family
• To learn
• BUT
• What will you give up to get there?
• Some independence
• New methods of compensation in a group. Who is
  most important?

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Future-Neurosciences Healthcare Delivery

• What if you decide not to Change?
• Where will you be?
• Alone
• With less satisfaction, less knowledge than your
  peers, no power,
• And less money

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Future-Neurosciences Healthcare Delivery

• What happened to the Mom and Pop Store around the
  corner?
• WALMART
• What happened to Chrysler, the Steel Companies
• What happened to the community hospital?
• What Happened to the University of Minnesota
  Medical Center?
• Does the Mayo Clinic have it right?

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Given all the things you have learned About
The world we live inYour Personal Family
NeedsThe Neurosceinces marketThe Progress of
NeuroscienceWhat is you Plan to Succeed in this
World?Will your present Strategy Work?NOT A
CHANCE
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The Minneapolis-St.Paul Neurosurgical
MarketGood NeurosurgeonsKnow respect each
otherFragmented CompetingHospitals have the
PowerNeurosurgeons dont Is there a better
solution?
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Some Solutions
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Solutions What can we do?

• Do your market research
• Assess your strengths and weaknesses
• Get a strategic plan

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Solutions General Principles

• Implementing your strategic plan
• Add neuroclinicians
• Select programs

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Solutions General Principles

• Form a larger group to gain power in the
  marketplace
• Start with (?size) group (How are you going to
  build this corporation?)
• Recruit
• Costly
• need financing
• Get loan partners at risk
• Advantages
• Build with people who have your interest
• No arguments
• New knowledge with young people

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Solutions General Principles

• Form a larger group to gain power in the
  marketplace
• Merge
• Shortens time to build
• Already tested people experience
• Disadvantages
• Independent
• Set in ways
• Philosophy differences
• Become Employed
• Work with hospital for win-win

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Physician Compensation (continued)

• Neurosurgery

Source MGMA - Physician Compensation and
Production Survey 2004 Report Based on 2003 Data
(n169)
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Physician Productivity (continued)

• Neurosurgery
• How productive are your physicians?

Source MGMA - Physician Compensation and
Production Survey 2004 Report Based on 2003 Data
(n169)
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Solutions General Principles

• Select Programs for Development
• Super-specialize (Can everyone do everything in
  your corporation?)
• Concentrate cases
• Vascular, spine, peds, tumor
• Expand (How can you get the best products for
  your customers?)
• Neurologists
• Screen patients
• Psychiatry
• Pain evaluation other
• Rehab
• Imaging
• interventional
• Plastics
• Ortho
• Psychologists
• Other ideas

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Solutions General Principles

• Other ideas How are you going to make this
  corporation successful?
• Serve community needs
• Get community on your side
• PR
• RD
• Education
• Industry
• Schools
• Compensation
• May need new compensation schemes

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Solutions General Principles

• Satellites
• Allows expansion and produces income for growth
  direct to bottom line
• Win Win for community and AMC
• Do not drain from satellite to AMC
• Do what can be done there transfer rest
• Close beats far
• Develop neurosurgery there
• They want to make money too!

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Solutions General Principles

• Other businesses
• Franchise care to others
• TV monitoring
• Sell services to other hospital - ER
• Politics-get involved
• Local, state,
• Focus cases at one hospital complex cases
• You are running a multimillion dollar corporation
• Large group has power to do this
• Disease Management Interdisciplinary care

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Solutions General Principles

• Other ideas
• Finances
• Loan
• Need BUSINESS MANAGER
• Compensation Schemes
• Eat what you kill
• Redistribute
• Combined economy- value point system
• Socialism wont work

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Solutions General Principles

• NEUROSURGEONS DONT GET IT!
• How do you subspecialize? I want to be a
  generalist. I am as good as X. I just want to
  practice medicine. Those d--n administrators!
• GET ADVICE, GET ADVICE, GET ADVICE
• What do you do if you have a clinical problem?
• You have to spend money to make money
• PR, Consultants, Business advice
• Retired CEO
• Think like the head of a multimillion dollar
  corporation, not like a neurosurgeon

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Solutions Academic Medical Centers

• Academic Medical Centers (AMC) are failing in the
  market place
• Because of need for money, forced clinical
  enterprises to support center
• Less time devoted to research
• Competition with referral sources
• Cannot compete on amenities and convenience
• Lose leverage that distinguishes AMC from
  community
• Failing strategy
• Doctors do not understand economics, market
  principles, or business strategy
• Teaching, Research and Practice is the fall back
  position

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Solutions Academic Medical Centers

• AMC
• Need to leverage strength
• huge resources and research base
• For future that is interdisciplinary and disease
  management,
• AMCs can do this easier than anyone in the market
  
• Need to leverage research, basic science,
  engineering, other disciplines
• Be in forefront of medicine and science
• Compliment community physicians
• Doctors need to change! ( So does the
  administration)
• Pursue strategies outside the administration You
  will not make money with their plans
• AMCs are suffering from ACADEMENTIA

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Spine Program
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250,000 instrumented fusions done in 2004, 3X as
many as in 1994 750,000,000 in 2004 by Govt on
fusions National bill for hardware is 2.5
billion a year Little scientific evidence fusion
works better than laminectomy.. Up to 4X more
money for a fusion( for the doctor) 2-4X as
much for the hospital Fewer than 50 necessary-
Ed Benzel
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NEJM 350 2003
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• A Molecular Cure for Arthritis

NEJM 355 522-523, 2005
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James I. Ausman, M.D., Ph.D. Surg. Neurol.
60469, 2003 61313, 2004
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Solutions Special Centers

• Spine Centers Is this the way to go?
• Pays
• Instrumentation costly for hospital
• No proof treatments work
• Government will interfere NY is already
  interfering
• Death of Spine Surgery
• Surgery is only 10 of the market What about the
  other 90

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Solutions Special Centers

• What to do Set up a SPINE AND PAIN CENTER
• Captures rest of Spine Pain market (other 90)
• Interdisciplinary
• Psychologists
• OT, PT
• Physiatry
• Accupuncture, blocks
• Other
• Surgery
• Strategy is to keep the patient whatever happens
  to the politics or reimbursement

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Pearls of Wisdom from the Business Community

• The Secret of Innovation
• Find our what everyone else is doing, and dont
  do it!
• The Ultimate Market Control
• You physicians are the only ones who can do what
  you do. You can control the market totally, and
  no one can do anything about it. I do not
  understand why physicians have given up their
  power in the market place!

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Future fields of opportunity
Pain and Spine Centers Comprehensive Stroke
Centers Neurointensive Care Functional
Neurosurgery Depression, Obsessive Complusive
disorders, Functional disorders Rehabilitation Rad
iosurgery Cancer Teams Epilepsy Psycho-neuro-end
o-immunology Nano medicine Trauma neurosurgery
care Peripheral Nerve Treatment
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Hospitals vs Doctors
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Hospitals, Doctors and the Healthcare System of
the Future

• Silo Mentality from the 20th Century
• Hospitals, doctors and suppliers compete with
  each other for the healthcare dollar
• New relationships required
• Hospitals and doctors will have to cooperate and
  share risk and reward to compete
• Joint ventures
• Hospital administrators will also have to change
• Those who get it will win in the market place

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Doctors Secret Weapon
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The Secret Weapon of Doctors in the Future

• There will be a shortage of physicians in 10
  years
• There is and will be a shortage of neurosurgeons
• The population will be increasing
• Baby boomers will want more care
• Supply Demand equation for physicians
• Will physicians drop Medicare?
• Will the government make medicine a right?
• People will pay for quality or
• Only if physicians utilize this power properly
  will they succeed
• You can decide to work for the hospital and
  forget all of this aggravation!

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What a Futurist says about our Future
Ray Kurzweil The Futurist. January February
2006
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The Future by Ray Kurzweil

• The Past 200 years (1800s)
• Women lived to 35 years old today to 85
• 1/2 day to prepare a meal
• Physical labor for most things
• No social safety nets
• Still Billions live in this manner-2000

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The Future by Ray Kurzweil

• Human scientific progress in Exponential
• All of the discoveries of the 1900s are equal to
  20 years of discoveries at the rate of progress
  in 2000
• By 2100 1000X more progress than today
• 20 years of progress will be made by 2020
• 20 years more in 2027

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The Future by Ray Kurzweil

• Overlapping Revolutions
• Genetic
• Nanotechnology
• Robotic

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The Future by Ray Kurzweil

• Genetic Revolution
• Genomics
• Proteomics
• Gene therapy
• Targeted drug therapy
• Cloning of cells, tissues , and organs

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The Future by Ray Kurzweil

• Nanotechnology Revolution 2030
• Microchips under the skin
• 100s of medicines from wells responding to
  metabolic changes
• Telepathic communication
• Expansion of memories
• Nanorobots in our bodies destroying disease

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The Future by Ray Kurzweil

• Robotic Revolution 2030
• Artificial Intelligence (AI)
• By 2100 will be trillions of times faster than
  the human brain
• Will exceed biological intelligence by 2040
• AI can handle more complex data than the human
  brain
• Computers will have lifelike intelligence

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The Future by Ray Kurzweil

• The Next 100 years
• Eliminating 50 of preventable diseases will
  extend life expectancy to 150 years
• Eliminating 90 to 1000 years
• Technology will eliminate poverty, disease,
  pollution and other problems

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The Language of Failure

• It cant be done
• I cant do it
• I am too busy
• That will never work
• I cant work with that guy-hes..
• Its the system
• What can one person do?
• You cant fight the government
• But medicine is not a business!
• Its the government its the HMO or
  insurer..
• This guy is out of touch
• These changes will take years
• Have you become accustomed to losing? Are you a
  loser?

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The Language of Success

• I know all the reasons why it can be done,
• now find a way to do it!

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I dont take NO for an answer!

• I am not interested in popularity
• I am interested in results

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Final Question

• Will I be successful and make money with these
  ideas?
• What choice do you have?
• The strategies being used by your colleagues are
  failing. (Practice and academia)
• You have no choice but to change

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A few last notes
Do you think you are going to RETIRE? If you
live into your 90s, do you have enough money put
away to support your idea of retirement? Are
you Happy?
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What about this idea of Retirement?Can you or
the country afford it?Can you stand it?Does
the Brain Grow with Age?What are you going to
do with the rest of your life?
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Nature 420 788-794 2002
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There is only one RULE

• THE PATIENT COMES FIRST
• If your put the patient first, you will never
  have to worry about money,
• If you put money first, you will lose both

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What is the likelihood that what we are doing
today in Medicine and Neurosurgery will be the
same at the end of the 21st century? NONE
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Thank You
THINK DIFFERENT Apple Computer
jamesausman_at_mac.com
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Future Trends and Predictions
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Whom do people trust?
AMA News 2/9/06
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Future Trends and Predictions

• World Population is 6.5 Billion 9.0 billion by
  2050
• 1 billion are connected to each other by the
  Internet
• In 15 years , majority of world will be connected
• Increasing numbers of people are poor, unhealthy
  and lack access to education
• 60 of our life support systems are gone or in
  danger of collapse
• Forests and oceans absorb 3 -3.5 billion tons of
  carbon/year
• We generate 7 billion Rest goes into atmosphere
• With 2.5 billion more people by 2050 14 billion
  will be generated

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Future Trends and Predictions

• 1.1 billion people do not have access to safe
  water
• 2.6 billion lack adequate sanitation
• Only 17 of worlds people live in countries with
  free press
• Conventional military force has little effect on
  civil war, terrorism and crime
• WMD will be available to many
• Oil reserves have peaked and will decline

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Future Trends and Predictions

• US traffic jams alone waste 2.3 billion gallons
  of gas
• Military Spending is 1 billion dollars
• Income from crime is 2 billion dollars
• 3-4 billion have access to good health and living
  conditions
• The Futurist Jan-Feb 2006, Glenn, J and Gordon,
  T Update on the State of the Future

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How we are delivering healthcare now

• SPECIALTY CARE
• Patient must see a series of specialists to
  obtain solution for medical problem
• Inefficient
• Delays diagnosis
• Patient loses time and money by waiting
• Industry loses time and money of employee

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How will we deliver healthcare in the future?

• DISEASE MANAGEMENT
• Back Pain is the Disease Management Category
• vs.
• The fragmented specialty care of Neurosurgical/
  Orthopedic treatment, Rehabilitation, Epidural
  injections from Anesthesiologists, Psychological
  care, or Rehabilitation
• With DISEASE MANAGEMENT the patient sees all the
  specialists in one setting and the disease
  problem is solved in that setting. This is One
  Stop Shopping or The Focused Factory Concept
• HOW WILL YOU BE DIFFERENT THAN YOUR COMPETITION?

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Where Neuroscience Research Is Taking Us

• INTERDISCIPLINARY CARE and DISEASE MANAGEMENT
  will Distinguish you in the marketplace from
  others
• The INTERDISCIPLINARY relationship of
  neurologists, neurosurgeons and psychiatrists
  with the basic neuroscientists will
• give the neuroscience group power in the academic
  center and the ability to obtain research grants.
  
• This relationship will also promote the
  pre-eminence of the neuroscience group in the
  community.

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Relationship between Genetics and Behavior

• Experiment
• Two groups of subjects 1/2 with long form, 1/2
  with short form
• Each presented fear image
• fMRI scanned brain and found R amygdyla activity
• R amygdala activity was significantly increased
  in those with short form who also had more
  fearful response
• Study links genetic variation to differences in
  brain activity
• Did not verify serotonin activity in brains
• Reason for differences in behavior of
  individuals?
• Criminal activity, suicide, affective illness,
  abnormal levels of anxiety

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Bio-psychosocial aspects of pain

• Pain can become a learned behavior
• imaging shows more activation of primary motor
  sensory cortex and
• patient has more sensitivity
• H. Flor ( Lancet 3571763, 2001)believes that
  structural changes occur in pain pathways with
  chronicity
• leading to heightened excitibility in pain
• Feeling pain may be generated without stimulus
• Phantom limb
• Stimulation of limb can reduce somatosensory
  field of pain (Adv Neurol 93 195-204, 2003)
• A New form of treatment based on Plasticity of
  Neurons

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Bio-psychosocial aspects of pain

• Chronic back pain- Flor, H.(Arthritis Rheum.
  53343-350, 2005)
• With solicitous spouse present
• exacerbated response
• Imaging shows increased activity in Anterior
  Cingulate Cortex
• Anticipation of pain can produce pain ( Brain
  1272339-2347, 2004)

129
Physician Compensation

• 2004 Neuro Physician Compensation
• National Comparison

Source MGMA-Physician Compensation and
Production Survey 2004 Report based on 2003 data
130
Physician Productivity

• Median RVUs

Source MGMA-Physician Compensation and
Production Survey 2004 Report based on 2003 data