Neurosurgery: A legacy of excellence
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.161966
Source of Support: None, Conflict of Interest: None
Neurosurgeons are often identified with traits such as arrogance and hubris. However, the true legacy of neurosurgeons is excellence. Harvey Cushing, the pioneering neurosurgeon of the United States, is largely responsible for this legacy of excellence. Eminent personalities have agreed that sincere and hard work is necessary to achieve excellence. Excellence in neurosurgery in the domains of surgical work and research will be discussed in the article. Excellence in surgical work should be measured comprehensively and over long follow-up periods using tools such as functional outcomes and quality of life instruments besides morbidity and mortality. For excellence in neurosurgical research, one can use the help of indices such as the h-index and i10 index. No single measure, whether for surgical excellence or excellence in research, however, incorporates a measure of qualities such as empathy, integrity and mentorship. These intangible qualities should be an integral part of the assessment of a neurosurgeon and his/her work. Cushing's attributes of meticulous record keeping, attention to detail, and maximal utilization of opportunities should guide us in our pursuit of excellence. In recent years, it has been suggested that excellence is not the result of an innate talent but can be aspired to by anyone willing to adopt a work ethic that involves several hours of "deliberate practice," feedback and passion. Neurosurgeons should continue to pursue the legacy of Cushing especially in present times when medical professionals are frequently depicted as being driven more by avarice than by Hippocratic principles.
Keywords: Bibliometrics; excellence; Harvey Cushing; neurosurgery; outcomes; research
In common lore, brain surgery and rocket science are considered to be the acme of human intellectual achievement, reserved for the smartest of the smart. While that may make us neurosurgeons smug, we have to contend with another common perception of our personality. We are considered to be rude, unfriendly, bossy, arrogant, and in love with ourselves, not to talk of our hubris. Fortunately, neurosurgeons do have a desirable stereotype, that of having a handsome, brilliant personality, which most others aspire to.
But should brilliance, good personality or hubris provide a neurosurgeon's identity?
I want to put it to you that, in fact, the defining trait of a neurosurgeon should be excellence because that is our legacy. The Oxford English Dictionary defines excellence as "the quality of being outstanding or extremely good." However, excellence is a much bandied about word, and I am sure that it has many interpretations. In this article, I will give my perspective on it. First of all, let me remind you that excellence is a quality that is different from brilliance or being successful. Joe Paterno,  the American college football coach says, "excellence is largely within a person's control, and if you try to be excellent, the chances are that you will be successful." However, it does not necessarily work the other way round.
Let us go beyond the dictionary meaning of excellence: "Quality of being extremely good or outstanding," to delve into what excellence really represents.
Common to the definition of excellence by several eminent personalities , are qualities of earnestness, dedication, sincerity, hard work, and persistence and as Abraham Lincoln put it to achieve excellence "I do the very best I know how, the very best I can, and I mean to keep on doing so until the end."  In other words, excellence is not a destination, it is a journey. It is also clear, from studying the definitions of excellence attributed to these personalities, that excellence is not something we are born with. Everyone can aspire to excellence and no one is excluded. All it requires is giving the task at hand all you have, approaching it with the utmost devotion and dedication. We must also recognize that human excellence is not measured on an absolute scale, but is relative to the achievements of other humans.
Who created this fortunate legacy for us? Although several neurosurgical giants exemplify excellence, to my mind, Harvey Cushing epitomizes it. Arguably, therefore, it is Harvey Cushing who deserves most of the credit for this legacy. Since he was portrayed by the press of his time as the prototypical brain surgeon, it accounts for the enduring layperson's image of a neurosurgeon.
There are many other neurosurgeons, both pioneers and contemporary (from India and other countries), who have kept this legacy alive for us. But for the purpose of this article, I have used Cushing as the exemplar of excellence.
Cushing was much more than an accomplished neurosurgeon. His legacy lives on with us in the form of the several eponymous conditions that we refer to almost on a daily basis. One of the more remarkable achievements for a busy neurosurgeon was his Pulitzer Prize for the two-volume biography of his mentor, Sir William Osler published in 1925 [Table 1]. For a detailed insight into the life of this medical and neurosurgical giant, I recommend the unbiased biography of Harvey Cushing by Michael Bliss.  He tells it warts and all. In fact, I would consider it essential reading for all neurosurgeons. I have taken the liberty of quoting extensively from this book.
We will come back to Cushing on and off throughout this article but let us now get back to analyzing what constitutes excellence. We have defined excellence, but how do we measure excellence in our field of work. All of us sit on the famous three-legged stool of patient care, teaching and research. Hence, I will try to discuss the issue of metrics of excellence in the domains of clinical care and research, but not in teaching, due to limitations of space.
Imaging display of surgical excellence
Let us begin by discussing excellence in our clinical work. Excellence in clinical neurosurgery in an era where visual imagery reigns supreme, frequently involves display of images, which show complete removal of difficult tumors with presumably an intact patient. [Figure 1] shows preoperative and follow-up image of some of my patients with intracranial tumors in difficult locations , which have been excised completely. [Figure 2] shows similar preoperative and follow-up images but the setting is that of central corpectomy for cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament (OPLL).
However, images demonstrating total excision of difficult tumors do not represent consistent surgical excellence. For that, a surgeon is required to provide hard data from a cohort of surgical patients. That is what Cushing did. Cushing kept a careful record of mortality rates in his series of brain tumors. With every succeeding year of practice, his mortality rates improved, so that by the end of his career in 1931, his operative mortality rate for brain tumor patients had declined from 16.9% in 1923 to 6.8%.  The mortality rates from Cushing's series of brain tumors show his remarkable success in an era when other neurosurgeons reported dismal figures. While we may consider his mortality rates to be too high, we must not lose perspective. Remember this was nearly a 100 years ago and he achieved this level of success with surgical tools and other paraphernalia far less sophisticated than available to us. Around the same time, Ernest Sachs from the United States had reported a mortality of 35.5% (85 cases), Olivecrona (Sweden) 30%, and Eiselberg (Germany) 46% in 333 cases. Hence, Cushing's results were excellent for that era.  This underscores the point that excellence is relative and not absolute.
For an example of surgical excellence from the modern era, I have chosen the article which provides a benchmark for the surgical management of vestibular schwannomas.  It reports the results of the master surgeon Majid Samii. The focus of the results reported in this article is on the high rates of total excision, preservation of facial and cochlear nerves, and the low morbidity and mortality. By all measures, this is true excellence but do these results convey the full picture? What happened in the long-term and how did the patients perceive their outcomes?
Long term studies
A long-term follow-up of one's patients is necessary to understand the true impact of a therapeutic protocol, surgical or medical. In a study of 114 patients with tuberculous meningitis and hydrocephalus undergoing shunt surgery followed up for up to 13 years (mean of nearly 4 years), we showed that while most mortality occurred within a few years after surgery, mortality continued to occur for several years in the Vellore grade 2 and 3 patients, finally plateauing at around 10 years after discharge.  Short term follow-up figures would have given deceptively good outcome results in these patients. In another long-term study involving patients with solitary cysticercus granulomas (SCG), we followed up 185 patients for 2-10 years (mean of 65.8 months) after the withdrawal of antiepileptic drugs (AEDs).  The SCG had resolved in all these patients prior to the withdrawal of AEDs. Recurrence of seizures occurred in only 15% of patients for up to 3 years after the withdrawal of AEDs. Calcification was seen to be a major risk factor for the recurrence of seizures. Again, a short-term follow-up of 1 or 2 years would have given a falsely optimistic seizure outcome in these patients. Several neurological disease processes including degenerative and neoplastic pathologies require long-term follow-up studies.
Cushing realized that once the hurdle of reducing mortality from brain surgery was crossed, the focus had to shift to the surviving patients' functioning. He remarked in his monograph on brain tumors that more important than mere enumeration of patients alive and dead after the surgery was their long-term outcome with respect to their daily activities and ability to work. Hence, towards the end of his career, he let three of his fellows investigate precisely that. Van Wagenen looked at the long-term outcome in patients with gliomas,  Cairns did the same for all brain tumors  while Henderson focused on pituitary adenomas. 
Longevity alone does not constitute a good surgical outcome. Assessing patients' functioning status whether it be ambulation or with respect to their activities of daily living brings us closer to understanding the true surgical outcomes in our patients. There is some debate about the utility of surgical decompression in poor grade patients (Nurick grades 4 and 5) with CSM or OPLL. We assessed ambulatory function in these patients following central corpectomy.  At a mean follow-up of 36.3 months we found that up to 75% of patients in poor Nurick grades (4 and 5) have improvement of one Nurick grade or more, and more importantly, nearly 25% of them improve to Nurick grade of 0 or 1. This justifies decompressive surgery in this group of patients.
Quality of life outcomes
It is well-recognized that there is a discrepancy between the surgeon and patient-assessed outcomes. Hence, we assessed patients' perception of outcome prospectively in a group of 208 patients undergoing central corpectomy for CSM/OPLL.  We found that there was a good correlation between the patient perceived outcome score (PPOS) rated from 0 to 100 and the Nurick grade recovery rate. However, the PPOS did differ from the Nurick grade outcome in about 15% of patients and provided additional information.
For a more comprehensive assessment of the impact of surgery, the patients' overall quality of life (QoL) studies are necessary. In a prospective study on 70 patients undergoing central corpectomy for CSM or OPLL, we used two generic health related QoL instruments, namely the Short Form 36 and the WHO QoL - Bref.  We showed that both instruments were useful in demonstrating the beneficial effects of surgery on the patients' QoL. 70% of patients reported improvement in different domains of these instruments.
In another prospective QoL study, we studied QoL in 100 patients with large and giant vestibular schwannomas at 1-year or more after surgery.  We found that the QoL does improve in nearly 85% of patients after surgery, in contrast to what is reported following surgery for small tumors. Nearly 70-80% of our patients achieved what is termed as the minimal clinically important difference (MCID) in their domain scores. MCID improvement rates are important as they reflect a true change in the patients' QoL, and not just a statistical change.
Finally, do only these patient outcome measures count toward judging of the excellence of a surgeon? How does one quantify empathy, compassion, ethical care, and courteous behavior in dealing with one's patients, as a measure of excellence in clinical care? Numbers do tell a tale but not the full story.
Excellence in research
We move on to the second domain of our work, namely research. In recent years, the application of bibliometrics or scientometrics has made the metrics in the domain of research more objective and quantitative. While the number of grants, articles, and citations as a measure of one's research output has existed for some time, in recent years, different indices have been suggested as better alternatives. The number of citations of an individual article is an important measure of the utility of an article; any article that has more than 400 citations is labeled a citation classic. However, the number of citations does not measure the consistency of a researcher.
A scientometric analysis of Indian neuroscience research was published a few years ago. 
To go beyond a mere count of citations, the h index was introduced by Jorge Hirsch in 2005.  It reflects the productivity and the impact of a researcher or an organization using a single number. It is defined as the number of papers of a scientist which have the same number of citations or more. For example, h index of 20 indicates that at least 20 papers have 20 citations or more. The h index of academic neurosurgeons working in the top 10 highly ranked institutions in the US correlated well with the seniority of the surgeon and his/her academic rank. On an average, assistant professors had an h index of around 5, associate professors around 10, and professors over 18. , Google introduced i10 as another index which provides a number to measure the effectiveness of one's research. It gives the number of articles that have received 10 or more citations. More recently introduced indices such as the hc index overcome some of the weaknesses of the h and i10 indices. However, these are more complicated to calculate and have yet to gain popularity.
Like all measures, no one index is perfect. Hence, probably excellence in research like in patient care should be evaluated using different tools and indices and even then qualities such as mentorship and integrity of a researcher cannot be captured by any number.
We have recognized what excellence is, we have some measures of excellence for our work but how do we achieve it?
Learning from Cushing
We have a lot to learn from Cushing on how to achieve excellence. I shall touch upon three of his defining traits which enabled him to achieve excellence.
The first and the most important trait was record keeping. I believe that it forms the foundation on which the edifice of clinical excellence is built. Cushing was obsessed with keeping track of everything he saw or did, right from his medical student days. He was a keen observer and recorded his observations in words and pictures. The second trait was attention to detail. He personified attention to detail. His articles about brain surgery give an insight into his attitude toward neurosurgery; no detail was too small for him. He deservedly earned the reputation of being a "crotchety perfectionist."  The third trait was his uncanny ability to use opportunities that came his way. One would not imagine that a battlefront could be an appropriate place for careful documentation and record keeping. However, this is what Cushing did. He used his time serving in World War I to evolve protocols to treat patients with penetrating head injuries and improve their outcomes. His meticulously documented experiences led to the publication of a monograph on the treatment of these patients which remained the standard reference for several decades. , There is a lesson in this for all of us on how to spot opportunities even in the most unlikely circumstances.
Is talent important?
I am sure that most of us will attribute Cushing's success to some innate skills. It is a common perception that one needs to be immensely talented or be born with some God given gifts to be excellent in any field of human endeavor. Gladwell  and Colvin,  among many others, have debunked the myth that innate talent is a major determinant of excellence. Gladwell showed that most "outliers," that is those whom we consider to have achieved excellence, had to work very hard and practice for at least 10,000 h before they reached the summit of excellence. Colvin also supports this theory and has worked out that it takes at least 10 years of "deliberate practice" to be a master in any field. Gladwell also documents how successful people leveraged available opportunities while those less successful ignored the same.
I would like to briefly elaborate on the concept of "deliberate practice," which was first enunciated by Ericsson et al.  It differs from routine practice in that it is targeted at fixing deficiencies in one's performance in any field. Once the deficiency is identified, then a practice routine which can address it, is initiated. Deliberate practice needs a coach or mentor, is more mentally demanding than physically demanding and is not fun. One of the other major components of the deliberate practice is feedback, feedback from patients, peers, and mentors [Table 2]. As deliberate practice is not fun, what comforts high achievers during their 10,000 h or 10 years of practice? An inner desire to excel, passion and the expectation of fulfillment are factors that mitigate the misery associated with the tedium of hard work and practice needed to achieve excellence.
Thus, it appears that practice, focus, maximal utilization of opportunities, and feedback, are the four mantras that anyone of us can adopt to achieve excellence.
Achieving surgical excellence
It is evident that the tenets of deliberate practice would work very well in our attempts to achieve surgical excellence. I would like to emphasize the need to incorporate feedback into our practice through clinical audits and outcomes research to improve our competence. Feedback gives us insight into where and why we went wrong and this in turn allows us to recognize and seek the skills required to overcome those deficiencies. These skills are then acquired through deliberate practice.
We are all probably convinced that practice makes perfect in the surgical field. However, only recently has there been hard data to substantiate this common belief. There are several studies reporting the benefits of surgical volume on patient outcomes. , Hence, repetition and focus improve patient outcomes and achieve excellence in a particular field of surgery.
Our experience with the learning curve involved avoiding acute graft extrusion following un-instrumented central corpectomy in a series of 410 patients undergoing decompressive surgery for CSM or OPLL.  We had the maximal acute graft extrusions in the first 100 patients, in fact, all 6 of these were in the first 50 patients. Subsequently, acute graft extrusion was almost completely eliminated. This demonstrates the impact of practice on surgical outcomes.
Surgical skills can also be acquired through practice on cadavers and specially created models. However, computer simulation has come of age and this makes it a great tool to practice surgery.
Preventing errors is essential to achieving good surgical results. The efficacy of the Surgical Safety Checklist in reducing surgical errors and improving mortality and morbidity in surgical patients in 8 different centers all over the world was published in a landmark article a few years ago.  Gawande, the senior author of the article, has published an excellent book on how checklists reduce errors in different walks of life.  Checklists originated in the airline industry and then spread to other trades such as the building trade. Anesthetists were among the first in the medical field to adopt checklists, and now we surgeons have realized their utility. I am a strong proponent of checklists in surgery and clinical care.
Well-reasoned protocols with evidence either from literature or from personal experience are another great way to reduce errors and ensure uniformity of care especially when there is a constant stream of doctors at different levels working in a unit or group. It is useful to have a protocol book for residents. The protocol book should be constantly reviewed and updated as and when necessary. [Figure 3] illustrates our protocol for steroid therapy following surgery for pituitary adenomas.
Another measure to reduce errors is by documenting them prospectively as shown in a recent article from Bernstein's group.  While all of us may not be able to meticulously record minor errors, major errors should be recorded in a prospective manner in audit statements similar to those used in our hospital [Figure 4]. Regular monthly audit meetings should have the benefit of a peer interaction or feedback. Graphs such as these tracking surgical site infections and mortality over several years, show the trend and capture any upswing, which should prompt corrective actions [Figure 5]. All these activities provide feedback, an essential component of deliberate practice.
Audit reports can result in a scientific publication that can benefit others. The results of a prospective infection audit maintained by us over 9 years were published recently.  Using chloramphenicol as the prophylactic antibiotic for craniotomies, we were able to maintain a relatively low rate of postoperative meningitis of 0.8%, and more importantly, keep the multidrug-resistant organisms at bay with only 0.1% of meningitis caused by these organisms.
I would like to use the title of the autobiography of Wilder Penfield - "No man alone" - to emphasize the point that in clinical work, excellence cannot be achieved by an individual but belongs to a team. 
Approach to neurosurgical research
I will now move on to how to approach clinical research and our experience in this domain of our work. It is commonly felt that research belongs to the ivory towers of academic centers. However, clinical research need not be far removed from one's daily clinical work. One of the attractive features of clinical research as opposed to bench research is the immediacy of applicability of results. I will discuss three such studies of ours, two prospective and one retrospective, which changed our clinical practice.
Hyponatremia with natriuresis
This is a common clinical problem in neurosurgical patients. , The common causes include syndrome of inappropriate ADH secretion (SIADH) and cerebral salt wasting (CSW). Determining which of these is the cause is important as the treatment is completely different - SIADH requires fluid restriction, whereas CSW requires administration of fluids and salt. Till these prospective studies were performed, we were treating most patients with fluid restriction in the belief that SIADH was the cause. Our studies in the mid-1990s revealed that in most neurosurgical patients, CSW rather than SIADH was the cause of hyponatremia and patients benefit from the fluid administration. In a follow-up study, we found that central venous pressure (CVP) could be used to guide therapy in these patients. For the last several years, we have followed a CVP based protocol outlined in the second study and successfully managed most patients with hyponatremia and natriuresis.
Duration of antituberculous therapy for brain tuberculomas
In a prospective study, we studied the optimal duration of antituberculous therapy (ATT) in patients with histologically proven brain tuberculomas.  There is no consensus on the duration of therapy in these patients with the recommended duration varying from 6 months to 18 months. We found that brain tuberculomas may need more than 18 months of therapy as residual lesions were seen on imaging in nearly 70% of patients at the end of that period. We suggest that ATT should be continued till the tuberculoma resolves on the imaging with no enhancing lesion and no edema seen.
Significance of histological grade of brain stem astrocytomas
Finally, this retrospective study on the prognostic value of histological grade of a brain stem astrocytoma in children and adults showed that while in children, the grade of the astrocytoma did not correlate with the survival, in adults, there was a significant correlation. , Based on our findings, we changed our approach in children with brain stem masses and do not perform a stereotactic biopsy in children with diffuse pontine non-enhancing masses with typical clinical features of a brain stem glioma.
I want to suggest that clinical research, especially prospective studies involving surgical outcomes, also improve patient outcomes because feedback of any kind associated with better care and outcomes research is all about getting feedback of our work. Focus and perseverance play an important role in achieving excellence in research. Although major discoveries are frequently attributed to serendipity, you must remember that they cannot occur in a vacuum.
I want to cite this oration delivered in 1967 by William Stewart, the Surgeon General of the US.  He reminds us that excellence associated with our specialty comes with a price, the price of responsibility. He mentions four responsibilities, most important of which is that to the society at large. Most of us, in India, have received medical education and neurosurgical training at a fraction of what it costs elsewhere in the world. We owe it to the people of India to provide neurosurgical care of the highest standard at a reasonable cost.
Advice to younger colleagues
As I come to the end of my article, I proffer some advice to the younger colleagues. I leave with you the acronym OPP, the first three letters of the word "opportunity." They stand for opportunity, practice (deliberate), precision (attention to detail), and an additional P for passion. I believe that the first three will put you on the path to excellence in your profession but without passion, your achievements will not be fulfilling, and expectation of fulfillment is essential to overcome the hardships of the journey of excellence.
Finally, trust Harvey Cushing to leave us some sage advice and observations. "I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work."  Ponder on this quotation about a surgeon with no hands and realize that the actual operative part plays the least important role in achieving good patient outcomes. If you remember, I pointed out that deliberate practice is more of a mental effort than physical; so is surgery more of a mental than physical exercise. Cushing argued for a "quiet, patient and undramatic performance" in the operating room. In other words, he recommended "boring" surgery. 
Ladies and gentleman, excellence is not the preserve of a select few; we all can and must pursue it. To counter all the bad press, we as doctors and neurosurgeons are receiving, , we should secure our legacy and ensure that our speciality and its practitioners continue to be beacons of excellence.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]