Presidential Address to the 2025 Annual Meeting of the Congress of Neurological Surgeons

Good morning and welcome to Los Angeles for the 75th Annual Meeting of the Congress of Neurological Surgeons (CNS). In 1951 at the end of World War II, a group of neurosurgeons forged by the adversity of war came together to connect. To share experiences and build a community that was the origin of the CNS. Seventy-five years later, the spirit of connection remains at the heart of who we are today. However, we face different challenges now: administrative burden, barriers to care, cuts to research funding, physician burnout. All demand a renewed connection to our community, our leadership, our peak individual potential, and our pursuit of innovation. This week, we celebrate neurosurgery and the people who make it extraordinary. Today, I reflect on these four enduring themes that define us and the CNS: community, leadership, peak performance, and innovation. First, let us talk about community. Dr Steven Miller was a pediatric emergency room doctor when I was in medical school at Columbia. Sadly, he died later in a tragic plane crash. In his time, he was an early pioneer for an emerging movement: humanism in medicine. Dr Miller said, “we must find ways to permeate each and every aspect of medicine with humanism.” He taught us humanism through the radical, but seemingly simple act of listening. Humanism is asking questions but then to stop and truly listen. Listen for two uninterrupted minutes. It is deceptively simple. A small, marginal yet innovative act of open listening: to build trust, connect, and heal. As neurosurgeons, how deeply are we connecting with our patient community? I was a neurosurgery resident here at Los Angeles General Hospital. Nearly half of this community is non-English speaking preferred. I saw firsthand the importance of meeting patients where they are—language-wise, culturally, emotionally. Doctor–patient connection is a challenge. Studies show that patients remember less than half of the informed consent. Lisa Ling, our Dorothy Nash lecturer, said, “it requires time and energy to get invested in other people's stories, but… you emerge a better and smarter human as a result of taking that time.” This is not simply a communication issue; it is about investing in human connection. Technology such as artificial intelligence (AI) will not replace us—it will help us connect more meaningfully. AI-assisted language translation, transcription, decision support tools, patient education, and counseling. AI will minimize administrative burden such as prior authorization. These tools will free us to connect more humanistically. But community is not just our patients. We are a community that connects through shared learning even and especially through difficult experiences—to uplift us as individuals and elevate our community. This early CNS meeting symposium shows we recognized early on the value of discussing our complications for learning. Today decades later, we are still connecting in the same way through our CNS Complications courses. We learn from each other through listening and sharing experiences from our most challenging cases. The cover of the May 2001 issue of Neurosurgery is a visual representation of the isolation we have all felt after a complication. It looks like what today we call burnout. But the path to improvement is not through isolation. Improvement requires community. As Gandhi said, “Freedom is not worth having if it does not include the freedom to make mistakes.” We must protect that freedom by supporting systems that foster learning. Colleen Fogarty says, “It is the practice of medicine because we must build mechanisms to prompt reflection on our work… seeking and incorporating feedback from others on our team. Effective systems protect time for practice and learning.” Our national organizations, including the CNS, empower us by reinforcing these systems for learning throughout our career. Maya Angelou said, “Do the best you can until you know better. Then when you know better, do better.” Beverly Walters and CNS Past President Mark Hadley taught us this through their pioneering work in guidelines. We build community through efforts like guidelines: asking the right questions, generating science, interpreting data, and sharing knowledge to elevate our practice standards. Advancements in data science—efforts such as the CNS Data Science scholarship—accelerate these processes. Soon, guidelines will be living documents updated in real time. Our community is connecting broader and faster virtually. CNS NEXUS is a digital library of hundreds of peer-reviewed neurosurgical cases—crowd sourced by our members. The CNS+ app has an AI chatbot that generates knowledge from NEXUS cases, CNS webinars, journal articles, and guidelines. Our Editor-in-Chief, Doug Kondziolka, and Eric Oermann are developing technology that will allow us to interact with the neurosurgical literature in innovative ways. Our advocacy work, celebrating 50 years through the CNS/American Association of Neurological Surgeons Washington Committee, is another expression of community. Thank you to past director Katie Orrico, current director Charlotte Pineda, and CNS Past Presidents Russ Lonser and Alex Khalessi for connecting our specialty to national policy. Community is a connection that breaks barriers to care, elevates our clinical practice, and affects lives. Our community is built on neurosurgeons connecting as leaders to shape our future. As a spine neurosurgeon, I am proud to stand on the shoulders of a leader like Sanford Larson. Larson fought for neurosurgeons to perform complex spinal instrumentation. Dr Larson led by training the first generation of spine neurosurgeons through workshops like this one at the 1980 CNS Annual Meeting. Leaders like Albert Rhoton, the 28th CNS President and my institution's first chair. Dr Rhoton, most known for leading microsurgical anatomy of the brain, also recognized the importance of spine surgery as a distinct community. Dr Rhoton had the vision to call upon the first joint spine section in 1978. Leaders who faced resistance and overcame adversity. Volker Sonntag and others who stood firm when orthopedics challenged our role in pedicle screw instrumentation. And those who led the effort with our industry partners to fight against the pedicle screw litigation of the 1990s—as detailed by Rusty Rodts in his 2010 CNS Presidential Address. Leaders opening doors and leveling the field. Dorothy Nash, our first woman neurosurgeon, is memorialized by the CNS Nash Lectureship. And neurosurgeon Frances Conley who championed women's rights with exceptional courage, dignity and resilience. The American Board of Neurological Surgery, the organization that certified Frances Conley as just the fifth woman neurosurgeon, is now led by Marjorie Wang and Judy Huang. A testament to the progress their leadership made possible. Leadership is shared vision. It is the CNS Pathways program which opens doors for under-represented minorities. Essential for our community, where less than 5% of neurosurgery residents are Black. It is groups such as the American Society of Black Neurosurgeons and the Neurosurgical Pride Alliance. They are building community for neurosurgeons to be welcomed and to be the next generation of leaders. It is also building future leaders. The CNS Leadership Institute celebrates its 10th year. A program that has trained nearly 200 neurosurgeons in skills such as team building, negotiation, project and change management. Starting with those in early career to those at the executive level, many alumni of the institute—myself as one of the first participants—are now division chiefs, department chairs, program directors, and health system executives. Neurosurgeons are being called up to leadership positions that we previously witnessed from the sidelines. Leadership is a connection to building community, mentoring, opening doors for the next generation, and shaping our future. I love the sport of cycling. Exercise, being outdoors, mental well-being. I love watching the Tour de France and seeing pro cyclists at the highest level—with their dedication to the science of peak performance. The relentless optimization of peak individual potential: fitness, recovery, nutrition, the psychology of winning. Cycling, such as neurosurgery, demands the absolute individual best. What might optimizing peak performance look like for neurosurgery? Our Walter Dandy Orator, Dan Buettner, studies the Blue Zones—communities around the world with different genetics, geography and culture. But they share one thing in common: human longevity and well-being. As we will hear from him, peak human potential is not about a single factor. It is about purpose, connection, and balance. Yet modern healthcare works against these values. Today's healthcare is like Frederick Taylor and his industrial engineering approach to organizational management—structure work in the simplest way to maximize efficiency at any cost. In healthcare, this is hyperstandardization without meaningful thought. Electronic health record templates that are essentially billing widgets. RVU targets. Operating room block utilization. These quantify output, but do not capture humanism in neurosurgery. Consolidation of large health systems eliminating job competition. Scope creep by non-neurosurgeons. Commoditizing neurosurgery. “The sum total of hundreds and thousands of tiny betrayals of purpose—de-valuing the neurosurgeon” (Richard Gunderman). Organizational psychology teaches us that these efficiencies do not drive performance and individual potential. Psychologists Hackman and Oldham demonstrated that to drive performance, we must find in our work skill complexity, autonomy, meaningfulness, identity, and feedback. We must connect with neurosurgery on a multifaceted deeper level to enhance our individual potential. Vital to our future is to preserve these very characteristics of neurosurgery that drive and sustain performance. We must balance efficiency with humanity. And ensure our systems empower, rather than constrain neurosurgeons. I am grateful for neurosurgeons like these who serve at executive levels: college of medicine deans, enterprise leaders. They have the appreciation for the value of the neurosurgeon in an enterprise—the true value of the neurosurgeon as presented by Council of State Neurosurgical Societies Chair Luis Tumialan at the 2023 CNS Annual Meeting. Our neurosurgeon leaders can affect health systems at an enterprise level to protect that which drives motivation, professional satisfaction, and peak performance. We cannot accept burnout as our defining narrative. Instead, we should approach the study of human performance with the same rigor we apply to neurosurgical training. Let us understand the physical, cognitive, and psychological factors that enhance individual potential. Like CNS Past President Joseph Maroon, who at age 85 years, is a vice chair of neurosurgery, researcher, ironman triathlete, and author. Joe teaches the equal balance of work, family, health, and personal growth. Enhancing peak performance requires a balance of purpose, well-being, continuous learning, mentorship, and community. These are the cornerstones of longevity. Ultimately, it is these connections, community, leadership, and individual potential that naturally propel us toward innovation. At the University of Florida, innovation has long defined our culture from Dr Robert Cade inventing Gatorade, William Friedman and Frank Bova's advances in LINAC-based radiosurgery, Richard Fessler and the first in human stem cell transplant, and Brian Hoh's National Institutes of Health funded multicenter CAPTIVA trial. This CNS meeting is another showcase for innovation: over 5000 submitted abstracts, over 900 oral abstracts, nearly 1000 unique speakers, 185 industry partners, and 3 incredible finalists for our CNS Innovator of the Year competition; we will decide this year's winner on Wednesday. Like last year's winner Alexandra Golby who developed a low cost, open-source navigation system for low-income countries. This scale speaks to our neurosurgical community connecting to innovation. Today, we are at an inflection point with the rapid development of artificial intelligence. AI will process massive data to predict disease and model outcomes. This will undoubtedly drive the pace of innovation at an incredible cadence. I had a recent conversation with Rich Byrne, Society of Neurological Surgeons President, about the potential of AI. We started by talking about chess. Rich has a master rating. We talked about my son Carter, whose chess team won first place at the 2023 national team competition. Rich says he first became interested in AI from his love for chess. Grandmasters like Bobby Fisher dedicated their lives to memorizing thousands of game scenarios. But chess has an estimated 10123 scenarios. A computer, DeepBlue, in 1996, did what humans could not. DeepBlue mastered chess and then beat grandmaster Gary Kasparov. Kasparov described his match with DeepBlue at the 2021 CNS meeting. Go is a 4000-year-old game from Asia with 10170 possible scenarios. Google's DeepMind learned it in days and then beat South Korean grandmaster Lee Sedol. Games such as chess have distinct rules. AI can do what humans cannot—process every potential scenario to generate a win. There is no need for imagination. But could a computer trained on thousands of open aneurysm clippings imagine endovascular coiling? Could AI ask the relevant questions: Who do we treat? What is a better outcome? To paraphrase Fredrik Pohl, AI undoubtedly can predict the traffic jam, but could AI have predicted the automobile? We should embrace AI for what it can do that we cannot. But AI has limitations. Current AI large language models can generate near pitch perfect language that itself does not understand—not in the way we understand, like true listening. Large language models generate text by predicting the most likely next token based on the prior set of tokens. Best fitting to statistical patterns—not actual understanding. Cognitive scientist Gary Marcus says about the limits of AI, “Neural networks of various kinds can generalize within a distribution of data they are exposed to, but their generalizations tend to break down beyond that distribution.” “You can't think we are close to artificial general intelligence once you realize that as yet we have no general solution to the outlier problem.” Often it is in the outliers that we find our greatest discoveries. It is the outliers where true breakthroughs emerge. Could AI have imagined Picasso from Michelangelo? Or innovators like Spike Lee—who we heard from yesterday—who disrupted and redefined cinema? We must listen to patients for the outliers, the nuance beyond their data. Ask better questions. What else is possible? And from there, imagine better solutions. D. Graham Burnett writes, “There is more to humanism than the accumulation of facts. AI only knows, but it has not lived. No dataset can resolve the central questions that confront every human being. How to live? What to do? How to face death?” Consider brain tumor scientist Elias Sayour. At the University of Florida, he is developing an AI approach to analyze tumor mRNA data to design personalized immunotherapy. But AI cannot ask: How do we face disease? How do we give hope? As Burnett suggests, the answers to these questions are not out there waiting to be machine learned. They are not resolved simply by knowledge generation. They are the work of being, of human experience, of humanism. Zo Ghogawala the of human Zo the there a better way to design clinical innovation was a to two This then became the for an innovative way to decision technology to connect a community of to patient and asking the right questions based on human to better clinical outcomes. There is a in of the of human asking the right questions and innovation. In was with leading to an in cycling. 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I am here today because of the of many Thank you to the Annual Meeting and Thank you to our Dan for his to our community, and for being a role and And you to for the my first when he was chair of the But it is for his that I am most Thank you to the CNS and Thank you to the CNS led by Thank you to our partners in the American Association of Neurological American Board of Neurological Surgery, Society of Neurological and the joint Thank you to our Neurological Society of the Congress of Neurological and the Society of Thank you to our many speakers, and And you to my from the Korean Neurosurgery Thank you to my at the University of for for and the many who have to throughout my I not have to serve if not for the exceptional support of the University of neurosurgery residents and Thank you to my who just And you to my have welcomed as of Thank you to my his my and Carter, and love you more than And most you to my who has taught more than about humanism and connection. I am grateful for all of you who have made the of time from practice, and to be to be with all of and to connect with our neurosurgical community. This connection, being here is for It is this connection that and will shape our community for our future. Thank of shared and the we make with one in worth