Another Day in the Frontal Lobe (5 page)

(In some ways, my experience in residency was actually easier than most because my husband is also a surgeon, so he understood the erratic schedule and the commitment required. We often had dinners together in the cafeteria, sometimes took call on the same nights, and even operated together, on occasion.)

Aside from being a woman, something else about my application apparently stood out: I did not use up the entire space allotted for my personal statement. Many neurosurgery applicants, obsessive by nature, tend to fill the entire page in the smallest possible font. I filled the majority of it, but stopped when my point had been made, which wasn’t at the very bottom. I left a wide margin. One interviewer told me I had one of the best statements he had read. I’m convinced that was because it was shorter than most. That’s one piece of advice I can give with confidence: on an application, more words are not necessarily better. In fact, when an interviewer is faced with the task of reading through dozens of applications in one sitting, brevity coupled with clarity is much appreciated.

The black box of choosing candidates for neurosurgery programs was finally revealed to me when I was given the opportunity to participate in this hallowed selection process as a chief resident, coming around full circle after seven years of training. Our program was more progressive than most in that the faculty actually considered our opinions in their decision-making.

What struck me was our conversation regarding an applicant with a preternaturally strong science background. His résumé fanned out as the most impressive peacock tail of the group. He had done everything right: joined the best lab and first-authored a paper slated for publication in a well-regarded journal. He had big research plans for the future. The most senior and academic-minded faculty members marveled at his résumé and put him at the top of the list. Given the early and hearty endorsement by our leaders, a few other faculty members piped up in support as well (even if they didn’t fully understand his research projects). It seemed like a done deal. A cool, seasoned voice from the back, though, dissented: “Listen. Is this a guy you really want in your foxhole?”

The foxhole analogy was an obvious nod to the long-standing comparison between surgical training and military duty. The neurosurgeon I quoted, now retired, was widely renowned for his winning personality, surgical skill, and calm demeanor. The residents revered and respected him. They thought he was cool. So did his patients. He did not have the lengthiest list of publications, but that never seemed to matter. His résumé was not his focus.

With this interjection of dissent, I and the two other chief residents felt licensed to speak up. We were impressed, but not blinded, by the applicant’s résumé. Although he was certainly smart, we thought he was kind of a nerd, to put it bluntly, and a bit too arrogant for comfort—a worrisome combination, especially in the trenches. We knew he would be a star in the lab, but how would he be in the OR, the ER, and joking around on rounds?

The faculty heeded our concerns and changed their minds. They sided with us and the foxhole commentator. The science star was moved lower down on our rank list and ultimately ended up at a different competitive program. Was he our loss? It depends on how you balance the priorities: scientist versus teammate.

Overall, I would say that our foxhole mentor was more typical of the average neurosurgeon doing most of the neurosurgery out there, outside of academia: generally smart, skilled, and hardworking, well aware of the standards of care in treating patients, but likely to gloss over half of what is published in the neurosurgery journals. I have to admit that I, too, often give little notice to the same half.

Our journals are roughly divided into two major sections: clinical papers, based on real patients, and laboratory research papers, which are often laced with super-specialized jargon. The latter is the less popular section. I had an interesting conversation with the editor of one of these esteemed neurosurgery journals several years ago. He admitted that even he didn’t understand many of the laboratory research papers, but they certainly looked impressive in the journal, and that was important.

This is not to say that the laboratory science is unimportant, of course. Some of the work will certainly save, lengthen, or improve lives in the future. My point is simply that such work is not widely read by the average neurosurgeon whose sole focus is taking care of patients, right now. If a basic science concept comes to fruition and is shown to be of practical benefit to humans,
then
a surgeon’s interest is piqued. By that time, of course, the same important research conclusions can also be found in
Time
or
Newsweek
and will make perfect sense to both the average neurosurgeon and his next-door neighbor.

I wonder, then, if my gerbil work had made it into one of the top journals, how many people would have actually read it? Consider that there are about four thousand neurosurgeons in the United States. Most probably subscribe to the major journals but not all will actually crack open every journal. Of those who do, a large portion would gloss over the laboratory section, probably skipping my article altogether, especially as their eyes hit the words “gerbil” and “amiloride.”

Then, of the subset of neurosurgeon-readers who would actually focus on the laboratory articles, only the ones interested in stroke would pay attention to mine. Of those specifically interested in laboratory stroke work, only some would actually read the whole article. Most would probably just skim the abstract. How many human beings, then, would have actually read my paper? I’d rather not know the answer, but at least I had the title of my project on my CV in time for the interviews.

FIVE

Culture

Before I became a neurosurgeon, I thought I knew what a neurosurgeon was supposed to be like. The ideal neurosurgeon was a James Bond type of character: calm, cool under pressure, precise in his actions, and culturally refined. I’m not sure where “culturally refined” came from, but as soon as I became a neurosurgery resident myself, I dropped it from my list of expectations. The social isolation can put a strain on refinement.

By chance, though, I have come across a few surgeons who reflected my preconceived notions quite nicely. The one who fit the bill most accurately was a general surgeon I worked with once, early on in my general surgery internship. A patient arrived in the ER late one evening with serious bleeding into the abdomen. The chief resident and I called the attending surgeon in for emergency surgery. The man who arrived just happened to be British, with a true James Bond accent and the accompanying air of refinement.

He arrived quickly—but calmly—from a formal party wearing a well-tailored suit, and wasted no time in changing into his scrubs. In surgery, he was slick, efficient, and no-nonsense. He was in the guy’s belly in no time. In rapid sequence, he isolated the bleeding vessel, repaired the injury, and left me and the chief resident to close the case. (I imagined a quick getaway, back to the party, in his Bond car.) Everything was effortless, including the politeness he maintained throughout, even toward the scrub nurse who had struggled to keep up the pace.

Upon leaving the OR table, he looked down at his shoes. They were speckled with blood. “Damn. I just brought these back from Italy.” He walked out of the room, shaking his head. Saving the guy’s life was no big deal for him: all in a day’s work. The blood-speckled Italian leather was relatively more distressing. As a young intern—my first month on the job—I found that intriguing.

I should say a word here to clarify the stages of the training process. Residency is the period of time when a newly minted M.D. is in training to become a certain type of physician, such as a pediatrician, surgeon, or radiologist. Depending on the specialty, this can last from three to seven years, immediately following the four years of medical school. The very first year of residency is referred to as the internship. In surgical specialties, this intern year involves rotating through a variety of different surgical specialties.

The terms “junior” and “senior” resident are somewhat variable. In my residency program, a resident was a “junior” in years two and three, a “senior” in years four, five and six, and a “chief” in the seventh and final year. In some fields, in which further subspecialization is desired—pediatric neurosurgery, neuroradiology, transplant surgery, for example—additional training is required
after
residency in the form of a fellowship. A physician is then finally “in practice” after the completion of all this training.

As a junior resident, it became obvious to me that different neurosurgeons respond to stress in different ways. Many do remain quite calm, but not all are James Bond. I have witnessed temper tantrums, high-decibel yelling, and even the type of foot stomping you might expect from unruly children. I have observed instruments being flung to the floor. I have watched nurses flee from the room, scared to return. These behaviors certainly aren’t refined or worthy of imitation, but they can at least offer amusement, as long as you remain a detached observer.

Unfortunately, a hot temper does tend to get the OR staff to spring into action, albeit begrudgingly and bitterly, and the fact that it works can further reinforce the bad behavior. Problems can arise, though, when a hot-tempered surgeon exhibits such behavior outside of the OR, like in a bank or a supermarket. He may be regarded as unstable. Although he may feel like a king in the OR and the hospital hallways, nobody outside of this isolated world recognizes or acknowledges his royalty. (His office staff may treat him royally, too, but this is an even smaller world.)

These days, in this era of political correctness, the worst offenders can actually be threatened with forced time off and sensitivity training. This fate befell one foreign-born surgeon who yelled at a nurse, in awkward English: “I cut your face!”

Neurosurgeons tend to be competitive in nature. This is a double-edged sword. As I mentioned before, neurosurgeons were the kids who always got a chair in musical chairs. I remember attending a residents’ luncheon sponsored by the company that supplied us with our surgical drills. In order to lure us into the conference room so they could show off their latest drill bits, the company representatives (the “reps”) had a nice buffet set up on one side of the room and a series of sheep heads lined up on the other side. We did not consider this strange. Food was necessary to get our attention, and the sheep heads were necessary to allow us to try out the drill bits.

To further pique our interest, they organized a clever competition for us. The resident who could create a standardized bone flap the fastest using their new drill bit would win a PDA device, or personal digital assistant. These devices were still new at the time, not yet mainstream, and were expensive, especially for a resident. (We all knew that the young well-groomed reps serving us lunch earned a lot more than we did, but we preferred not to dwell on such inequities.) Everyone lined up after finishing lunch and the reps presented the heads, one by one, and stood by with a timer. I won. My win did not sit well with one of my colleagues, though, who demanded an extra head. He drilled two additional bone flaps and was able to beat my time. Onlookers cited the well-known “practice effect” and discounted his time. He sulked. I took my PDA device home and used it for a few days before storing it in my closet. My white coat was already weighted down enough. Plus, my index cards worked just fine.

Although the culture of neurosurgery breeds certain collective traits, like confidence and a competitive nature, other traits are more variable. Take, for example, neatness. Here is a question to ponder: If you’re trying to decide between two neurosurgeons with equally good reputations, do you go with the guy with a neat and organized office or the one with papers and charts strewn everywhere? Maybe the neat one has too much time on his hands and the messy one is in greater demand—no time for neatness. Or, maybe the neat guy appreciates form and the messy guy cares only for function. Although a sloppy desk (or manner of dress, for that matter) does not necessarily translate into messy surgery, the question would certainly enter my mind, if I were the patient.

My mother is quick to report her dismay at the clothing of various physicians she has seen. She was startled to notice dirty sneakers on one, and a simple polo shirt (“No white coat! No jacket!”) on another. I was a bit embarrassed to learn that she did not reserve her comments for me, but was up front with her doctors as well. Although professional attire at work is still the norm among physicians, the trend toward more casual wear seems to have come about with the wide acceptance of the term “service provider” in medicine, lumping us together with the providers of all other sorts of services out there. (Fries with your craniotomy?)

There is no correct answer as to whether or not neatness counts for much, but, all other things being equal, I would prefer the neat surgeon if I were the patient. Neurosurgery is not plastic surgery, but I would prefer a surgeon with a concern for aesthetics. Take, for example, the issue of the hair shave. From the surgeon’s standpoint, shaving a patient’s hair prior to brain surgery is the most minor of concerns, understandably. The hair is just in the way of the scalp, which is in the way of the skull, which is in the way of the brain. Years ago, neurosurgeons would routinely shave the entire head, thinking that this was necessary to control infection. Over time, the extent of the shave lessened to include only a large patch around the incision, which is more efficient. Many patients, though, have told me that as long as a large patch is coming off, their whole head might as well be shaved. They have a point here.

More recently, restricting the shave to only a minimal strip of hair along the incision line has become popular among neurosurgeons who care about the hair issue (more commonly, I have found, the ones with hair themselves). This approach is especially gratifying for patients with longer hair, as the incision can be hidden entirely. These patients can go out in public without wearing a hat or broadcasting to the world that they just had brain surgery. I remember seeing a photo of Elizabeth Taylor in a magazine after she underwent surgery for a benign brain tumor. All I could think was: Why did they shave her entire head? That’s so old school.

I met a girl who was a high school senior and who developed seizures due to a benign brain tumor. In order to control her seizures, the tumor needed to come out. I was to assist the senior surgeon on the case. The girl was looking forward to starting college and confided in me that she had just begun dating a guy “with the greatest muscles.” She was equally concerned about the fate of her long hair as she was about the risks of surgery. The senior (bald) surgeon, however, was in the habit of shaving a large patch and his routine was set. Her hair was doomed and she knew it.

As the patient was being put under anesthesia, I pleaded with the senior surgeon. “Just let me do the hair shave. Don’t worry about it. She won’t get infected. You can blame me if she does.” He didn’t like the sound of it but he gave in to my desperate tone. He had to leave the room, though. He didn’t want to watch. I shaved a thin strip of hair along the exact path of the proposed incision (a curved “reverse question mark” incision that we often use on the side of the head, just above the ear). I scrubbed her scalp and hair with an antibiotic solution and stapled the sterile drapes along the shaved edges to keep the hair out of the operative field.

The case went smoothly. In the ICU, after the patient was fully awake, she wanted the full report. She asked about her hair. I surprised her with the news and she was ecstatic. In fact, I have never seen a patient happier after waking up from brain surgery. She couldn’t wait for her well-built boyfriend to see her. (Her delight made me wonder—but only for a moment, before I considered the ethical implications—if we should play a similar trick on other patients, setting up the expectation of a bald patch, but then surprising them with a full head of hair.) Not only that, but her seizures remained under control, too, which was something we all cared about, hair or no hair.

Neurosurgery requires a delicate balance between fearlessness and caution. As residents, we have to be willing to push ourselves to take the next step, even if our confidence level is not one hundred percent. Otherwise, we won’t go very far. On the other hand, I fear the resident who forges ahead with brazen overconfidence. Some are tempted to do this in an effort to impress the “attending” (attending surgeon) when he walks into the OR, hoping to provoke a comment like “Wow. You’re under the ’scope (microscope) already. I’d better get in there before you finish the case!”

This leads me to an awkward admission: in the training of a neurosurgeon, the level of supervision can be variable. Keeping a patient safe depends on the judgment of both the attending and the resident: the attending on knowing how much to trust the resident’s skills and the resident on knowing the limits of those skills. Believe it or not, this very human system is much safer than it sounds. Neurosurgeons are generally intelligent individuals who exercise good judgment (in the OR, at least). As a result, the norm is good patient care and the turning out of a steady stream of well-trained neurosurgeons.

When I was a junior resident, after I had performed a history and physical on a patient scheduled to undergo surgery, the woman turned to me with the sweetest voice she could muster and said: “Oh, and by the way, dear, I don’t want any residents involved in my operation.” Although this may seem like a simple request, akin to asking for a private room, such requests were very rarely heeded at our institution. Our chairman, who was to perform the operation, explained to her that the numbers we quote regarding risk and outcomes are based on our tried-and-true routine perfected over the years at our teaching institution. This routine involved a team, and the team included residents. He did not like to deviate from routine. In general, it is wise to avoid deviating from the routine in surgery. Every surgeon can tell you about a mishap that occurred when a VIP was treated differently from everyone else.

If avoiding residents is critical to you, a private, nonteaching hospital is always an option. At these hospitals, surgeons usually operate with a variety of non-M.D. surgical assistants rather than residents. In addition, the surgeons in those hospitals are more likely to have surgery as their sole focus. Many academic neurosurgeons have multiple roles: surgeon, teacher, researcher, committee member. They often don’t have time to spend the entirety of each case in the OR, from start to finish. The residents will do a portion of the work while they parallel-process on other tasks. Some neurosurgeons are very hands-on and will stay in the room for nearly the entire case. Others will flit from room to room or between room and office, attending to the case when needed.

At the extreme of laissez-faire supervision is the government-run VA system (the Veterans Administration hospitals). Although supervision is always around the corner, and decent quality health care is the rule, the residents tend to run the show. At my training program, the affectionate term for our VA hospital was the “Va Spa,” a sarcastic reference to the humble and somewhat depressing standard-issue municipal edifice. The expansive, oversized room that housed dozens of patients in long rows was nicknamed “the ballroom.” On the door of our small single-room neurosurgery office at the VA, one of the residents scrawled, “Resistance is Futile.” Common knowledge dictated that it was no use trying to change the system at the VA; better just to live with the quirks and inefficiencies. Physicians with Republican leanings are quick to point out that this is what a broader government-run health care system would be like. We’d get the care we needed, but we’d all have to lower our expectations a bit, and take a number.