The deterioration of the economy.

The collapse of ethics and morality in the culture.

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.

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.

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.

The deterioration of the economy.

The collapse of ethics and morality in the culture.

Chaos, such as culture revolution.

Diminishing mutual trust and respect, which is the baseline.

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 http://asiasociety.org/policy/strategic-challenges/intra-asia/wolfensohn-reform-required-prepare-future-asia).

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

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.

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.

Attempting to keep our moral standards high.

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

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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!!

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

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

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

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.

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.

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.

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?

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.

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.

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.

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?

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.

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.

Rising healthcare costs coupled with decreasing physician reimbursement.

Lack of tort reform.

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.

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.

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.

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.

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).

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.

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?

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).

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.

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.

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.

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.