Spring 2004 Volume 16, Number 3	AS I SEE IT: Rafael Tamargo Insights from a Hopkins Neurosurgeon
	It's difficult to describe the 12 years and more it takes to become a neurosurgeon without using hyperbole: Most rank the time as the hardest, scariest, most gripping, most fulfilling and fascinating of their lives. And then, pfft, it can be blown over.

"I personally know of three neurosurgeons -- outstanding at their art, good people -- who have quit the profession," says Rafael Tamargo, head of cerebrovascular neurosurgery at Hopkins. Just short of his second decade in neurosurgery, Tamargo's specialty includes the aneurysms, arteriovenous malformations and skull-base tumors that place him in the thick of highest-risk surgery. A champion of outcomes research, Tamargo has worked assiduously to whittle the hazards. His records stand with the country's best. But Tamargo sees trouble. Medical liability issues threaten the reasonable practice of neurosurgery, he says, as nothing before. The two specialities hardest hit by medical liability excesses are obstetrics and neurosurgery. Why? Because, by their nature, they provide automatic targets. If you're doing, say, thyroid surgery, which is very difficult and detailed, you can have complications-any surgery can. But it's extremely rare to have someone paralyzed or die from it. Not so with certain neurosurgeries. Complications from, say, intraoperative rupture of a giant brain aneurysm are almost certain to be serious no matter how good the surgeon. They're unavoidable. But in our courts, the worse the outcome, the easier it is to convince a jury someone was at fault. And that's just devastating. Say you're a fine neurosurgeon-you are knowledgeable, do good work, have a good record and a rapport with your patients-you can expect a lawsuit, on average, every five years. And if you're with an institution that absorbs the awards, then teaching and research will likely suffer. Likewise, insurance becomes prohibitive. I know of a neurosurgeon in Philadelphia who got a premium notice for $333,000 for six months' coverage. It's unbelievable! No neurosurgeon makes that kind of money. I have a sense that in the last few years, we've lost between 5 percent and 10 percent of our neurosurgeons nationwide. To turn this around, I believe three things need to happen. First, each state needs an arbitration board made of specialists to review cases, to decide which have merit and which should be dropped. That's difficult to do well internally, so choose out-of-state people for the board. Next, cap the pain and suffering awards juries give out at $250,000. [Maryland's present cap is $635,000.] And finally, people who testify as experts, who give witness to whether there's malpractice or not, shouldn't spend more than 10 percent of their time at this. Otherwise, witnessing becomes their profession, not surgery. We need to do these things now.