James I. Ausman
  1. Editor-in-Chief, 69844 Highway 111 Suite C, Rancho Mirage, USA

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James I. Ausman
Editor-in-Chief, 69844 Highway 111 Suite C, Rancho Mirage, USA


Copyright: © 2013 Ausman JI. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

How to cite this article: Ausman JI. What are the three major changes/challenges in your life?. Surg Neurol Int 12-Apr-2013;4:53

How to cite this URL: Ausman JI. What are the three major changes/challenges in your life?. Surg Neurol Int 12-Apr-2013;4:53. Available from:

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I thought that it would be interesting to sample the views of neuroscientists around the world with the question: “What are the three major changes/challenges that are affecting your life as a physician and citizen?” This question was sent to our Editorial Board members; a sampling of their answers is included below, broken up by their country of residence.

For me, the answers are:

The progressive centralization of the control of medicine in the hands of large organizations and the government; the socialization of America with the majority favoring the “entitlement mentality” and, in addition, the loss of individual freedom.

The deterioration of the economy.

The collapse of ethics and morality in the culture.

These are the responses. I have placed the responses from the United States last so that our readers can learn what is happening elsewhere first.


Nobutaka Kawahara

I agree with your opinion. But, the situation seems a little bit different here; I will tell you the current situation in Japan.

The social insurance system has been controlled (at least the medical payment system) by the government. However, recently, a medical professional system (professional board system) is going to be controlled by the extra-departmental organization of the government, to which all the medical board system has to belong. They say that the reason is to offer quality control. Though this has not yet determined, they may also try to control the number and distribution of board-certified professionals.

The deterioration of the economy – this is also true in Japan. The government is going to control payments to medical insurance systems, which is low compared with gross domestic product (GDP) in Organization for Economic Cooperation and Development (OECD) countries. The situation has grown increasingly bitter over the past few years.

The collapse of ethics and morality in the culture. This is related to the economy, I think. Quite a number of young neurosurgeons do not want academic activity; rather, they want to work from the beginning in the local hospital, where academic activities (also ethics and morality) might not be sufficient. The newly organized educational system is going to include these hospitals as affiliated hospitals to provide sufficient academic and educational surveillance.

It may be difficult to conclude since the situation in other countries would be different, but, I wanted to tell the current situation in Japan.

Kazuhiro Hongo

My answers are:

The deterioration of the economy.

The rapidly expanding volume of information – including medical fields – with the advancement of information technology. This might change the relationship between patients and doctors. Doctors need to take longer to explain issues in detail, before starting exams or treating patients, to avoid legal issues.

(Similar to #2) Medical/surgical treatments are, of course, not 100% guaranteed; however, many patients think this should be the case.


T. S. Vesagas

There is a changing perception both among physicians and patients that medicine is a business rather than a vocation or calling. It is the attitude that the bottom line is personal profit rather than patients’ welfare.

Government is attempting to centralize everything, including the practice of medicine. The Philippines have this tendency to follow America's lead in these things.

Poverty and the large gap between the haves and have-nots.


Yuanli Zhao

The progressive centralization of the control of medicine in the hands of large organizations and the government; the socialization of America (the entitlement mentality) and the loss of individual freedoms to government control.

The deterioration of the economy.

The collapse of ethics and morality in the culture.

Mao Ying

People only want to work hard if they are rewarded with social status and money.

Chaos, such as culture revolution.

Diminishing mutual trust and respect, which is the baseline.


Asif Bashir

Worsening antagonism and hatred toward Americans in the Eastern world (Middle East/Southeast Asia), due to U.S. military policy.

U.S. economic decline as world economy, which is moving East to Asia, including medical tourism to India/China/Singapore (and hopefully to Pakistan). Greater than 60% of world's GDP could come from Asia by 2050, according the Sir James Wolfensohn, former head of the World Bank

Due to changing declining U.S. healthcare dynamics, the medical profession is becoming less attractive to the brightest minds of the next generation.


Atul Goel

My leading challenge is to face the change overtaking medical care. Progressive monetization of every activity breeds a profit-oriented ethos spanning a 5-star culture suited to the fancies of a few who can overspend to make the institutions over-earn, to the detriment of the man on the street.

As an end result of the above, compassion and science are given a short shrift whereby most of what is done is questionable, sub-judice and yet is flagrantly and widely done to convert patient into profit and disease into dollars. Treating patients as a commodity, hunting for indications for investigations and treatment, fixating ideas on the basis of market driven clinical research, excessive use of expensive and avoidable drugs, and falling trap to industry-driven treatment has made the spiritual art and philosophy of neurosurgery into a commercial juggernaut.

My existential worry is fouled up water, air, and food. I quench my thirst from a plastic bottle in a few minutes, and the earth will bear the indigestible bottle for 500 years. Like the Red-Indian chief prophesized: It is the end of living, and the beginning of survival.


Ibrahim Sbeih

The Arab spring that is sweeping the Middle East, including Jordan. The economic and security burden of hosting 350,000 refugees from Syria and a similar number from Iraq is felt in Jordan at every corner. Street demonstrations and riots are daily events in our lives.

We can no longer hold major international conferences in the Arab World, because speakers refuse to attend for security reasons. Extremists are on the rise and many good citizens are thinking of immigration. Medical services are affected adversely. In the name of Arab brethren, we, in Jordan, have treated 50,000 citizens from Libya and Palestinian Authority. Both the government of Libya and Palestinian authority refuse to pay doctors and hospital for services rendered to their patients, in the past few years. Many major health projects are cancelled or postponed, including the International Neuroscience Institute of Jordan (which was, to be, the first of its kind in the Middle East).

Degradation of medical ethics among doctors and surgeons. General Medical Councils in the Arab World are political bodies, not concerned with their main objective – namely, the well being of doctors and patients. Lots of unindicted and unnecessary surgeries are performed in all specialties, especially so in lucrative spinal surgery where the industry pays doctors for every screw and plate inserted in their patients. No doctor is held accountable for his/her deeds. Certification exams are conducted by doctors who are corrupt and who themselves need to be put through exams. This system produces young graduate doctors and surgeons who are, literally, given license to kill.

The inflammatory political situation in the Middle East: Arab–Israeli conflict, Palestinian cause, Iran nuclear bomb, Israel nuclear bomb, Al-Qaida, Shiites versus Sunnis, democracy versus dictatorship, princes and princesses of the Arab World, human rights, woman rights and empowerment… to mention just a few of the hot issues on the mind of every citizen in the Middle East.

I hope with this, your readers will have a fair view of what is happening in this part of the world.


Shlomi Constantini

Ensuring physical safety for my family, my country, and the entire free world.

Attempting to keep our moral standards high.

Striving toward economic freedom for a good life, medical care, and the ability to fight poverty.


Yucel Kanpolat

We live in a special time period in the world, in which social activities of companies influence all human beings. The neurosystem distinguishes humans in nature, but we are failing to use this system properly. I do not agree with the generality of mankind that this is a knowledge society; we are not a member of this society. We live in the age of the company and of dogma.

We are living in a unique geographic location in the world. It is not easy to survive our independence. All nations are interested in the economy and unemployment. The social security system forces people and government to be good consumers and the social system supports government, but people are not working and producing efficiently. All social funds are used for the treatment of patients and education without payment. In Turkey's society, we are not aware of science and democracy. All these things are necessary throughout the world, as well as in Turkey.

In this consumption society, maintaining sustainable development is impossible. Humanity must change their lifestyles and habits in the context of social living, consumption, and production. Otherwise, even our elderly generation may witness the end of this world.


Pieter Kubben

The increasing bureaucracy and logistical efforts.

The constant pressure of medico-legal consequences for any action.

The public's opinion that medical doctors are only interested in money.


Jens Hasse

To me as an emeritus, the major problems for the future, viewed from my Scandinavian platform are:

Education. We need experts/super specialists to deal with the complicated cases. Our medical education must be focused on this fact and tailored to educate both “basic M.D.s” who can treat the majority of simple diseases, and experts for the complicated cases. Basic M.D.s have to learn to accept that some of the more “interesting” cases have to be transferred to the specialized experts for the benefit of the patient. This leads to some sort of centralization of the MD-experts, for example, in large hospitals. (Haase J, Boisen E: Neurosurgical training: More hours needed or a new learning culture. Surgical Neurology 2009: 72; 89-95.)

Centralization. Reducing the number of overall hospitals to fewer large hospitals carries the risk that the medical profession will work in a “factory of disease treatment,” unless we change our M.D. education and define what we want to do with these large hospitals. We are seeing an increasingly older population that needs medical treatment, and we must assure that they can achieve the necessary care in their local areas, for example, not in the large hospitals that are meant for the complicated patient cases.

Bureaucracy. If we think back just 100 years, the development of medicine has been based on dedicated medical doctors who loved what they were doing and therefore worked for and with patients despite official “working hours.” The growing number of hospital bureaucrats is extremely costly, and so far, they have not scientifically demonstrated any benefit for the majority of our patients. The bureaucrats tend to measure efficacy by numbers, documentation, and working hours, instead of by “quality” of patient care. Therefore, M.D.s spend more and more of their working time doing secretarial work instead of spending time with their patients.


Eduardo Fernandez

In Italy, medicine has been always socialized. In the past two decades, physicians’ salaries have dropped to ridiculous levels, and every day become more and more subaltern to bureaucrats and administrators, who receive large salaries. The work of physicians in Italy serves to mainly pay for all of the apparatus around the industry of health. Although physicians do the core of the work, they have the less input in the business, and have become the workmen of the managers-masters.

From the previous point derives a loss of prestige of the medical profession in the society.

More and more frequently, people refuse to accept the failure of a therapy and sue for millions in damages against physicians with poor salaries.

Aldo Spallone

To find an almost impossible compromise between the goal of “socialized” medicine (to provide the best quality care, with the best technological options, to everybody) and the restraint of resources due to the economic crisis affecting Europe, possibly as the main result of globalization. In particular, how to balance the necessary presence of bureaucracy controlling care quality and results and consequently providing resources, and the need for quick adaptation to new treatment protocols and requirements suggested by the continuous development of medical science.

The economic crisis affecting the Old Continent and the apparent inability of the Italian leading class to provide effective solutions, and also to appear adequate and strong enough in the International arena in order to claim the legitimate role of my country (a co-founder of the European community) in the construction of a properly functioning European Union. We Italians are paying a very high price for the improper mechanism of selection of the leading class, in almost all the fields of the society, but these recent elections are delineating a scenario that will oblige our leaders to hurry up (and the rest of Europe will face similar problems in the very near future).

New models generated by the collapse of the communist world and the consequent globalization are confusing the new generation, coupled with the role of the Catholic Church – a fundamental liaison for my country and for the majority of European Countries – which is also in crisis. The concept of ethics and morals is being reassessed. We will have to rely on our historical values in order to help the new generations find the needed compromise between tradition and modernity.


Juha Hernesniemi

Increased hospital administration living their own life, causing increased costs and even preventing patient treatment. The past 15 years have been an ongoing fight with different organizational changes, and I have lost numerous hours in fighting for the independence of our operating rooms, intensive care, and bed wards – a compact unit of Helsinki Neurosurgery that has been a model for 2000 neurosurgeons around the world, a pilgrim place to be visited. Unfortunately, our effective and dedicated work has not been understood by our own local administrative people. They live their own lives, far away from the realities of the patient's treatment.

Low retirement age limiting and causing restrictions in neurosurgical careers; as life spans have increased, so should the required retirement ago. No society can pay the costs of equal working years and retirement years.

Increasing needs for free time in the society is preventing effective training of young neurosurgeons.

Mika Niemela

The progressive centralization of the control of medicine in the hands of large organizations and the government. Finland has been ranked the number one place to live, according to Newsweek in 2010, when taking into account “soft values” affecting everyday life – and we have socialized healthcare and schools/universities (

The deterioration of the economy. People have exceeded their expenses and taken too many loans, essentially living on credit. Banks have been too loose in their loan-giving policies, and we are now paying the price of the greed of individual people and banks.

The collapse of ethics and morality in the culture. In many countries there is a lot of corruption (sorry to name a few: Greece, Russia, most of the Latin America, and China) and greed; moral values should be sacrificed for the sake of money and individual perks. What happens in one country is not necessarily applicable elsewhere, and small, homogeneous populations differ from larger, multicultural ones in many ways, not to talk about differences in climate and natural resources.


Ulrich Sure

Here my four major concerns:

Economic pressure to increase surgical numbers given by hospital administration.

Increase of unbelievable surgical complications from mainly spinal surgeons, mainly in private practice.

Increase of bureaucracy (documentation coding, quality management, etc.).

Decrease of national research funding rates.


Antonio Cerejo

In my opinion, in Portugal in present times, the main problems are:

The huge cuts in salary for Neurosurgeons in particular and Doctors in general. This is a problem not only for the fact itself, but also, most of all, because it leads to a need for multiple jobs and, ultimately, to deterioration in the organization of Neurosurgery departments.

The failure in raising cultural standards. If the work of basic education was completed in our country many years ago, the cultural level seems to be lower than it should be, thereby creating an environment conducive to demagogy and low critical thinking.

The devaluation of the role of the government and laws that may lead to a destruction of the society.


Name not disclosed

In Europe, there is a big difference between the south and the north, regarding how things are done that affect the economy. There is tremendous corruption in the south and sloppiness on how things are run with no feeling of responsibility. People behave like children waiting to be helped (i.e., Greece, Spain, Italy.). In that sense, perhaps government-based healthcare and social security are seen as threats in the U.S., potentially making people more passive.


Amos Adeleye

For me, the number one, two, and three challenges affecting my practice as a physician and a citizen are all encapsulated in your number three: The collapse of ethics and morality in the culture.

And that, even in my otherwise supposedly traditionally cultural African society!

There has been such a collapse of ethics and morality all around me; it just takes the wind out of my sails now and then. I’m always scratching my head to figure out how all these highly untoward changes were able to take place within less than a generation – all within my lifespan, short as it yet has been. Nothing is ever the same again. Nothing that is godly, nothing that is moral, true, honest, pure, noble, or of good report. Nothing. Some evil force is abroad, stealthily but surely eating away at our souls and we are each of us his willing, even gleeful, accomplices.


Mahmood Qureshi

Greetings from Nairobi, Kenya, East Africa. You raise very pertinent questions on matters that have been troubling the minds of many of our colleagues over the recent past. The three that you mention are indeed central issues that trouble us as well.

In Eastern Africa, in the capital cities, the government has begun taking control of the way clinicians practice, what they charge, and where they refer patients to. The areas outside the main cities, however, have a more clinician-driven system of care. This, in contrast, suffers from the domineering attitude of clinicians who sometimes play demigods – making it necessary to find an authority that can rein them in.

It would therefore seem that clinicians have themselves to blame. By not developing a strong self-regulatory mechanism within their profession, clinicians have exposed themselves to intervention and control by nonprofessionals who have government clout to control the way in which clinicians should behave and practice.

The deterioration of the economy – an issue that is of special concern in Africa.

The global economy is universally linked. African countries are by and large totally reliant on Western economies for their own progress. Drugs, equipment, materials, innovations, and technological advances are all manufactured and imported from the Western world. Budget for aid to developing third-world countries has steadily reduced. Limited budgets are now only offered through very stringent agreements. Governments in the third-world are seen (often rightly) to be inept and corrupt. Mechanisms to channel support through Nongovernmental Organizations (NGO) has become a long bureaucratic affair. This has slowed down efforts aimed at helping the less privileged. The burden of bureaucracy leads to a huge chunk of the budget being ploughed back to the donor agencies through the costs of maintaining an “accountable” expatriate staff, their families, and their highly expensive needs (4-wheel drive vehicles, expensive schooling of their children, up-market housing in secure areas, etc.).

The downturn in the global economy therefore equates to a dwindling budget to help those on this planet that are desperately in need of help.

Altruism and philanthropy have begun to be seen as the domain of the naive. Growing up in an ethos, which said “Never make money the criteria for making a decision,” such views are now frowned upon. You now hear “If one can use someone to get something, then why not use the opportunity?” No proviso is added to state that “use such an opportunity in a moral way and ensure it benefits both parties.”

This has led to greed and immorality in the way we see clinical decision making being used to benefit clinicians, drug companies, labs, and radiology service providers. It is no longer frowned upon to be a shareholder in such “enterprises.” But it is not just bio-ethics that needs re-visiting; the basic ethics of how to behave – what and how to bill ones patients, ordering investigations and imaging studies, offering the most appropriate line of management (even if this means referring the patient to someone else in a different hospital) – without allowing ego and selfish interest blur ones judgment, all need to be revisited.

Patients are increasingly becoming wary and suspicious of opinions they are offered. Armed with Internet information, they seek out second and third opinions, often confusing the patient even more. Honesty, decency, and selflessness have eroded and are in urgent need of being resurrected!!


Marco Gonzalles Portillo

In Perú, especially in Lima, our major challenges are:

As a physician:

The centralization of the control of medicine in the hands of large organizations (especially insurance companies) and the government (social security hospitals).

The high hospital costs, especially for new medical equipments that are very expensive.

Hospital administrators who treat doctors as if they were simple employees.

As a citizen:

Improve the educational level of the people.

Improve the salaries of teachers, police, army, and physicians.


Marcelo Platas

Here my feelings, from Buenos Aires, Argentina:

Ethical and moral problems among physicians and patients.

The “over-role” of diagnostic methods and lack of correlation between them and the clinical findings.

Preeminence of industry in indication of treatments, especially in spine and vascular surgery.


Saul Kirov

The three major changes/challenges that are affecting my life as a physician and citizen are:

The healthcare system does not ensure proper assistance to the population. Public hospitals are hurt by lack of investment, bad management, corruption, political interference, and foreign physicians lacking proper training fill positions while Venezuelan physicians emigrate. The virtual collapse of public hospitals drives growing numbers of people to private clinics, which in turn lack the capacity to service them. Private investment has been hurt by uncertainty, over-regulation of fees for services, and rising costs. Despite high oil prices, the healthcare system lacks the foreign exchange needed to import medicines and equipment.

Insurance coverage is limited. Patients are not adequately covered and are often unable to get proper and timely treatment. Physicians are not properly rewarded.

Physicians face increasing personal risks - patients looking for scapegoats make physicians their targets. The court system doesn’t provide proper protection to physicians.


Julio Sotelo

I totally agree with your three proposed answers, I would add another challenge, which for me is rather important in the developing world: The ever-rising costs of medical care.


Benjamin Lo

Too much reliance on and belief in the welfare state, leading to over-borrowing by many governments throughout the world.

The domination and greed of big and powerful financial institutions, which can wreck havoc on the world economy if not properly controlled and regulated.

The easy access to information has opened up the horizon of people throughout the world.


Fernando G. Diaz

I would add to that the socialization of the American culture under a paternalistic all-controlling government that is spending the future capital of our children, and creating a dependent population.

Harold Portnoy

Now that I’m retired, I’m sort of a maverick. You will not agree with me, I am sure.

The multitude of insurance companies, each with their own forms that add to the cost of medicine without improving medicine. There should be a universal medical/payment form and electronic medical record (EMR) established by the government. This will significantly reduce medical costs and strengthen the EMR so that patient information obtained in California can be used in any state the patient visits. May this lead to a single payer (government) system? Maybe? It is probably not that bad. Just ask my Canadian neighbors who make sure they return to Canada to retain residency. They love it!!!

Stop griping about the economy. This country has had a major or minor downturn about every 15 years. It always returns. The only real problem we have is Congress. It does not function for the best of the nation. When you are sent to Washington, you have got to put insane ideas (both right and left) aside and compromise. If you do not know how to compromise, resign!

“Do unto others as you would have them do unto you.” Very good advice. Stop trying to legislate ethics and morality. What is ethical and moral to you may not be to somebody else. If a person does not harm you, stop telling him/her how to live their life. If a political party keeps trying to tell people how to live, they will never gain the presidency. If you tell somebody you do not like them (African-Americans, gays, women, Hispanics, etc.) why would they vote for you?

Daniel L. Silbergeld

The continued inappropriate belief by Americans that we are the best and are entitled to force our governmental system and religious beliefs on others.

Overcrowding of the planet, leading to over-utilization of natural resources (land, water, oil, animals for food, etc.) and subsequent global warming and armed conflicts.

De-personalization of the global culture secondary to digitalization and distrust of those in power.

Harry Vinters

With regard to your point number one, I would add that medicine must be one of the few (only?) professions in the universe that has so willingly, gladly, and swiftly ceded control and regulation of its own members and priorities to other (sometimes “alien”) organizations with overtly antimedical agendas – the ACGME (Accreditation Council for Graduate Medical Education) being (in my view) a prime example. It is staggering and shocking.

One other thing I might add in the “medical area”: The shift of research priorities from trying to understand disease mechanisms that would allow for logical disease treatments, to “touchy feely” areas (including many in the health services research field) that are driven almost entirely by a political agenda and a “feel-good” approach (as in, “evil McDonald's is making our children obese, and evil soda-makers are killing us; if we didn’t have them, we’d all be healthy”). This relates of course to an abrogation of individual responsibility for one's health and well being, very close to your point number one.

William Yong

Overpopulation, aging, and increased health care needs. The aging and inexorably expanding world population has growing medical needs, and the diagnostic and therapeutic options have increased; together, this leads to a rapid increase in costs that the current funding mechanisms paid into by the shrinking younger population (percentage-wise) in the Western world cannot sustain. These cost pressures force M.D.s to be more businessmen than we want to be or should be. Wasteful bureaucracy related to a plethora of for-profit insurance companies and confusing, conflicting governmental regulations further drain our ability to provide enough good care.

Find a cure regardless of cost. Our goal in research is cure without any thought of cost, and this is flawed. Our goal in research needs to shift to affordable prevention and affordable cures. Who would have thought a $100 laptop was feasible until that goal was set? (One mutation costs $400 to analyze/sequence by standard polymerase chain reaction [PCR], but one can now also sequence for 750 mutations for $1000-$2000, so some technologies can lower our costs and give greater bang for the buck.) We must be realistic; there is not enough money to give everyone a “private jet” in terms of health care, nor should it be needed. So let us get everyone to health in a way we can all afford, and our children can afford.

Growing legal barriers – that is, insufficient and too many regulations. Gene patents are problematic, inhibiting research and testing – there are insufficient laws limiting such patents. Over-done privacy laws (while well-meaning) create substantial drag (time and cost-wise) on research and patient care. Federal and state regulations vary across our country. Cooperation across multiple countries is even more problematic, as laws from each vary. Global agreement on appropriate patient consenting, sharing of materials, etc., are crucial for us to cost-effectively work together to do the large-scale, statistically-meaningful studies, while accounting for genetic variation.

Isaac Yang

The decline of moral and ethics, as the culture of life and family deteriorates and we stop caring for our fellow man.

Concern for deficit and overall debt burden and whether or not we will never pay back our debts, which will be a permanent drag on economy.

Too much bureaucracy developing and getting in the way of doctors from doing their jobs - which is taking care of patients.

Bernard Bendock

A shift toward healthcare systems shifts the focus from excellence to standardization. Finding a balance will be a challenge.

A growing corporate culture and shrinking research funds will make research more challenging and mentorship difficult.

Innovation is being hampered by harsh intellectual property (IP) policies, legal concerns, and hyper regulation.

Despite lip service, infrastructure is shrinking rather than growing. Systems are not evolving sufficiently to meet modern needs. Electronic health record (EHR) systems are at least a decade behind what could be. Why do we still use pagers? Why does a patient with a stroke still go to any hospital?

Jonathan Sherman

The impact of insurance companies and how they impact my ability to treat patients. This includes insurance companies acting like physicians, rejecting pre-authorization claims, and attempting to dictate how I practice medicine. This also includes insurance companies that generate ridiculous negotiation demands making it impossible for my group to accept patients with that insurance and provide treatment.

The heavy influence that hospitals put on administrators and their goal to increase hospital billing. This generates an unrealistic expectation that even small community hospitals can perform even the most complex of cases, as opposed to referring those patients to tertiary care facilities.

The expectation from referring doctors that as a surgeon I will always operate on their referred patient. I am very conservative with a variety of neurosurgical conditions, and am surprised that not operating can actually hurt future referrals.

Russell Blaylock

The rapid movement and solidification of the United States toward a tyrannical system of federalism with a loss of states’ rights and individual rights - that is, the institutionalization of collectivism. One sees the implementation of a police state appearing under the guise of protecting the nation from “terrorism,” which is now defined by the nebulous term “domestic terrorists.” We are repeating a pattern used to destroy a number of nations in the recent past.

Solidification of the executive powers of the president so as to allow dictatorial command of all aspects of the nation, which also entails attempts to abrogate the Constitution and Bill of Rights, and the establishment of arbitrary law.

Destruction of the culture, especially its moral and religious foundations, and a resulting loss of civility, with a rapidly evolving barbarity. This also entails the use of extensive collectivist propaganda in our schools and the major media.

Chaim Colen

National socialization of healthcare.

Rising healthcare costs coupled with decreasing physician reimbursement.

Lack of tort reform.

Dade Lunsford

For the world at large:

Increasing intolerance and the belief that our way is the only way.

The inability of leadership to develop a consensus of benefit for as many as possible rather than partisan attempts to benefit the selected few.

For physicians:

A compensation methodology that rewards competence, innovation, and outcomes as opposed to volume. The WRVU model is the single worst way to reward physicians and surgeons, and leads to decision making based on revenue generation. This approach is the antithesis of what we thought was the physician creed.

Miguel Faria

For me the three major changes are:

The negative impact on my sense of well-being and liberty because of the growth of collectivism, socialism, forced egalitarianism, authoritarianism (accepted by the masses because of the prevailing entitlement mentality as well as politics of envy), and the concomitant loss of individual freedom. This has also impaired individual innovation and the entrepreneurial spirit that made this country great!

The negative impact on my medical care and freedom of choice because of the growth of corporate socialized medicine and the unholy partnership of government and the medical insurance corporations. Rationing of resources by the state is on the horizon with better health care and unlimited resources only for those who are connected and are more equal than others. This negative consequence will then be used to reinforce number one, above.

The catastrophic changes and eventual collapse of America and the West that benefited the entire world with their legacy of freedom and prosperity. This is happening because of economic deterioration (because too many people are riding the wagon and too few are pulling), strangulation of free enterprise by government controls and loss of economic freedom, deterioration in ethics in individuals and institutions (i.e., moral relativism and situational ethics), as well as the prevailing attitude that successful people are bad and greedy, while the sloth and lazy deserve what they are getting as a human right. Number three is a result of number one, so they are interconnected, with numbers one and two reinforcing number three.

Andrew Fishman

The harsh regulatory environment in the United States (Food and Drug Administration [FDA], etc.), though protective in principal, has begun to act as a barrier to the timely introduction of new technology and materials. Given that Europe and other parts of the world are encumbered to a far lesser extent, America is slowly losing its status as the region for new innovation.

The medico-legal climate promotes low-risk interventions over innovation, resulting in a culture of mediocrity.

The overtraining of sub-specialists has had a detrimental effect on the resulting skill level of newer physicians due to low case numbers, which is not likely to catch up over time, as more and more individuals are put into the market from a growing number of fellowships. While in principle the numbers trained is guided by need, most highly trained surgeons tend to settle in large cities and do not seek positions in underserved areas. Foreign centers, in contrast, tend to under-train residents in order to keep tighter control on their market share into the future. Neither system is ideal.

Tarun Arora

Here are my thoughts:

Our healthcare system has been constructed around reactive rule-making to a series of bad events, rather than a root cause analysis with a good, hard look at our societal expectations and values. We should build a system around what we, as physicians would want if our loved one needed care. Use that premise to design EVERY component of the system including choice in physician, choice in hospital, an EMR that is built around your patient/physician relationship and interaction rather than an EMR that forces you to change the way we interact with patients; efficient utilization of INTELLECTUAL and SKILLED resources – have the doctors give the best care they can to the most patients they can, rather than doing paperwork to make someone else's life easier or other laborious tasks that can realistically be done by lower paid (but still appropriately trained) care givers. (It is easy to put the work on the physician because we are obligated to stay until the job is done, whereas shift workers are compensated for their time, which pushes the system to optimize use of the shift workers time, not that of the professional physician.) If you build the system around the ideal patient/physician relationship and extend that principle to EVERY patient/physician relationship, then everything else falls into place, including efficiencies, patient and provider satisfaction, quality, and innovation. Unfortunately, our day-to-day work is like that of a puppet where we get penalized if we did not ask enough of the review or systems questions, even though this would just distract the patient and us from the major issue at hand. The problem is that our reaction to this situation is to find a way around the rules so we still get paid rather than fighting against the inherent stupidity of the rules. We should not be letting the system turn doctors against other doctors – financially, legally, ethically, professionally, or otherwise.

I could go on, but I think you get what I am saying.

Mel Cheatham

Three major changes/challenges affecting life as a physician and as a citizen today are the following:

The greatest changes/challenges to our lives as physicians, and as citizens of the world, are changes and challenges that have accompanied the rapid growth and development that have taken place during the electronic age. There can be no question but that the incredible electronic, computer and telecommunication discoveries and developments of our time have brought about great advances in medical research, education and in patient care. Unfortunately, these great advances have not yet reached patients in much of the developing world.

In spite of all of these changes that have so positively impacted the practice of medicine, during the electronic age, the closeness, caring, and compassion that have historically characterized the doctor/patient relationship has largely been lost. In this electronic age, the practice of medicine can be likened perhaps to “a spinning top” as we see so much time consumed by record keeping and adherence to government and corporate controls, and so little time being left for maintaining the closeness of the historic doctor-patient relationship.

The “Golden Years” in the practice of medicine, and perhaps life as some of us once knew it, appear to be over. Ever-increasing rules, regulations and government controls, along with the problem of rapidly escalating costs for health care, further complicated by worldwide economic difficulties, personal and national debt, terrorism, and violence make these years less golden.

In countries around the world, the long-established standards of conduct, behavior, ethics, principles, and time-honored religious beliefs, guidelines, and practices have been replaced. These are the things that create a stable, forward-moving, world society, and restore them to the all-important prominence they once had. This we must do. The time is now. It can and must be done.

Ron Pawl

Since I am completely retired now, I cannot respond to your inquiry regarding issues in practice. However, one thing that has bothered me recently is the lack of response by the medical community to the rash of shootings going on and leading to significant loss of life, including, unfortunately, young children. You did publish, recently, a great article by Miguel Faria on this very important problem. It is clear from his article that a change in handling mentally ill patients is in order and also that the mental health community and some ancillary services are remiss in not dealing appropriately with mentally ill people, even when red flags are flying high that they might be dangerous. I did a quick search of the American Psychiatric Association but did not find any evidence that this group is doing anything. Do you think it is in order that SNI take some action on this issue, since brain function and mental illness often go hand in hand? I would like your thoughts on the matter and if I can be of any help, I stand ready.

Phil Dickey

Decreases in reimbursement for physicians in favor of hospitals, which has led to bizarre incentives to provide more complex care.

The federal government's power over hospitals via Medicare reimbursement, which leads the hospitals to agree to unrealistic targets for cost-of-care for Medicare patients (they now tell me 2 level fusion on a Medicare patient is a 23-hour stay!).

Increased corporate versus other funding for clinical research (especially for drugs and devices), which affects direction of innovation of medicine (I was told by a biotech executive that a biomedical company has to give at least $100 million to get its products into one of our premier academic institutions in order to get them studied and - presumably favorably reviewed).

Ben Roitberg

For me, three (there are more) challenges are:

The increased government control of medicine. This includes control by government-sanctioned monopolies. Insurance companies are protected from competition because they cannot sell medical insurance across state lines. I thought limits on interstate trade were against the constitution. Now insurance companies can hire people to deny reasonable care and have us spend a lot of time to try and appeal the denials.

Increased control of medical education and resident training by unelected organizations with dictatorial powers.

Computer interfaces taking so much time away from nurses, residents, and increasingly attending physicians that they decrease direct interaction with the patient.

Kal Post

Interesting question requiring some thought. My initial reactions are the following:

I believe our schools are headed, and have been for some time, toward the lowest common denominator rather than toward the highest. Schools should be more competitive for entry in high school, and trade schools should be more available for those less interested in study.

Government has collapsed. Democracy as we knew it no longer works. The two-party system is so partisan that it is basically defunct. There is little to no respect within our own country for our leaders. They represent only their party and money sources.

The media look for sensationalism rather than important news. Headlines are for drama, not necessarily for accurate information. How do we now keep trash and dirt out of everyone's main focus?

Barbara Nelson

In my respect for an agreement with Dr Ausman's three major challenges in American medicine, I would like to add the following:

With a failing economy abetted by centralization and large organization control, I find a loss of spirituality, hope, imagination, optimism and the breakup of family values and, over the preceding generations in public school education and in many private American schools, psychobabble substituting for classical knowledge, ignorance of U.S. history, inability to use logical reasoning and psychological arrogant secularism, which contributes nothing to compassion and which translates in medical practice to rigidity and a false conformity. If there is a growing lack of respect for the aged, restriction and rationing of care for them, and a lack of curiosity to learn from their beliefs, experience, and values, such ignorance translates into medical care or restricted medical care for those older patients, and, in the end, perhaps without self-recognition, a lack of hope within the treating physician.

The collapse of ethics and morality in the culture, again with the imposition of psychobabble's “do your own thing, which you are entitled to, without self-sacrifice,” and the growing prohibition of government and education under God, the prohibition of the Pledge of Allegiance, all contribute to minimization of medical care to the individual patient, to the lack of medical curiosity on the part of the physician to curiosity about the patient's family and, again, the injection of hope and the offer of alternative, positive treatments to insure life and continuing life to that patient and to that patient's family. I cannot tell you the suffering I have seen in many hospice situations and in many nursing homes. And the lack of educational principles of Honor, Dignity, and Love of Country, principles which used to translate into individual physician self discipline and generosity, I now no longer see in young doctors in training: I see the desire to meet rules and follow regulations, abandonment of imagination and creativity, failure to give hope to the patient and lack of love and compassion for the individual patient. Aside from Dr Ausman's three questions and answers for the challenges in today's medicine, it should be remembered that this president's first executive order in his first term, was to ban all prayer in the White House. Of the political leaders and of the medical leaders I admire, prayer enters into their medical philosophy (and here I think of Dr Blaylock and Dr C. Crandell, IV).

Mahmood Mafee

I agree with all of your answers. The following are some of my ideas:

The expanding population in conjunction with the shortage of doctors in the future. How that would affect my job itself, but also how it would affect my care as a patient.

Lack of opportunity for foreign medical graduates to train in developed countries, and therefore lack of well-trained physicians in those countries.

How the new health legislation will affect patient care, physician salary, and physician quality of life.

Eric Nussbaum

Thank you for your thought-provoking question. I cannot separate easily those issues that concern me as a physician from those that concern me as a “citizen” since the very same issues apply to both areas of life.

The growing abdication of personal accountability and responsibility in every aspect of life in America, including medical care.

A progressive decline in the basic work ethic compounded by a growing sense of entitlement within society; the pervasive belief that “I deserve something” whether or not I can afford it or society can afford it, and no matter the cost to future generations!

The loss of religion within society as evidenced by the substitution of a true “moral” compass with one of political convenience.

Vincent Traynelis

Your three concerns mirror mine. With regard to number 3, I am more concerned with the lack of ethics and morality in our specialty. Where is the concern for the patient? We are creating a class of shift workers who do not suffer through complications with their patients but rather look at these adverse events as just to be expected.

Ekkehard Kasper

Just as you said – centralization of control over medical care in the hands of nonmedical personnel; this limits the care provided as directed by noncare providers. It directly correlates to the fact that access to the best available medicine is limited to people with a certain insurance coverage only.

The fact that reimbursement incentives do not favor better medical care (e.g., spinal over-instrumentation without definite indication) and that there is a profound lack of evidence-based practice.

The fact that hospital politics often prevent the elimination of incompetent physicians.

Robert C. Rostomily

The decline of interest in basic science among young neurosurgeons.

The lack of governmental funding mechanisms that specifically support surgeon-scientists who strive to maintain active clinical and research efforts.

The demise of the importance paid to the “old-fashioned” notions of commitment, accountability, and striving for excellence.

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