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NI FEATURE - COMMENTARY: TIMELESS REVERBERATIONS
Year : 2017  |  Volume : 65  |  Issue : 4  |  Page : 694--696

The making of a complete neurosurgeon

K Ganapathy 
 President, Apollo Telemedicine Networking Foundation, Apollo Hospitals; Past President, Telemedicine Society of India, Indian Society for Stereotactic and Functional Neurosurgery, and Neurological Society of India; Formerly Adjunct Professor, IIT Madras and Anna University; Emeritus Professor Tamil Nadu Dr. MGR Medical University, Chennai, Tamil Nadu, India

Correspondence Address:
K Ganapathy
Apollo Telemedicine Networking Foundation, Apollo Hospitals, 21 Greames Lane, Chennai - 600 006, Tamil Nadu
India




How to cite this article:
Ganapathy K. The making of a complete neurosurgeon.Neurol India 2017;65:694-696


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Ganapathy K. The making of a complete neurosurgeon. Neurol India [serial online] 2017 [cited 2017 Nov 23 ];65:694-696
Available from: http://www.neurologyindia.com/text.asp?2017/65/4/694/209498


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To one, who was initially trained in the BC (before computers) era, and who started his neurosurgical residency by injecting air into the lumbar cerebrospinal fluid (CSF) to indirectly diagnose brain tumors, neurosurgery has come a long way. The coming decades, however, will reflect radical and exponential transformations, and not just the earlier incremental changes. Today, the bottom-line is technical excellence. Encomiums and accolades are for those who do the most technically challenging, sophisticated procedures in large numbers. While being trained to become a master craftsman and a superb technician, knowing more and more about less and less, there is now a very real danger that one may miss the wood for the trees. In today's era of personalized medicine, where antibiotics could be customized to suit your genome, where stem cell therapy and surgery of the unborn could be options, where fundamentals are being challenged and obsolescence is the name of the game, should today's neurosurgeon look beyond acquiring skills in surgical expertise? Can one be technologically savvy and also a commiserating doctor? Rudyard Kipling had once remarked “What do they know of England, who only England know?” This could be very true of the neurosurgeon. Understanding that developing traits, quality, character, and sterling values will ultimately make one a better neurosurgeon than the mere access and deployment of sophisticated armamentarium, is the first step.

The empathizing neurosurgeon should learn to communicate, communicate, and communicate with his patient. He/she should be the embodiment of clinical judgement and wisdom. One must remember that there will always be a role forno interventionanddelayed/less aggressive intervention. One must also remember to empathize with the family of the patient, treat the individual with the tumor, not just the tumor, or the image on the magnetic resonance imaging (MRI). There are many ways to skin a cat and one should be humble enough to acknowledge the lack of familiarity with all of them. The surgeon may be bold, but often it is the patient who is bolder in giving consent for the surgical procedure!

An ideal neurosurgeon is perceived to be a specialist among specialists, constantly innovating in a rapidly changing world, with the realization that if one does not continually change, one will be consigned to history. New skills must be acquired-what got you where you are now, will not keep you there! Today, unlearning and relearning is more important than learning. Mid-course corrections and responding, rather than reacting, are crucial. We are what we repeatedly do, and for success, one has to do the job one often hates the most! No man is an island unto himself. In today's world, one has to delegate-true delegation is giving up something to a colleague or a subordinate. One has to be realistic, not bite more than what one can chew, and be able to change one's course whenever and wherever necessary. Changes can never be isolated and reactions to changes will always be different.

 Traits of a Neurosurgeon



The ability to interact with those outside one's immediate job and to trust colleagues is important. Leadership must be participatory not authoritative. Looking far afield helps one see better what is closer to home. The essential traits required include a doer who wants to get things done as early as possible, and a person who is passionate about his/her work and who is highly motivated, focusing on long-term results and goals, acknowledging uncertainty, and using one's support network. A leader willing to listen and look from afar, a frontrunner who has realized that there is no number one in the TEAM (together everyone achieves more), a head who understands strategy, planning, and execution—these are the hallmarks of a neurosurgeon. Raising the bar, not being content with low-hanging fruits and looking at every failure as a learning experience are the qualities that should be in one's DNA (deoxyribonucleic acid). In neurosurgery, asfailure is not an option, one has to learn from other's failures, which is an act of acquiring wisdom, not just factual knowledge. Every experienced neurosurgeon has learnt that it is better to lose the battle and win the war. One can always come back another day. “Ego” has no place in the neurosurgeon's lexicon. Being a perfectionist is not necessarily always the right thing to do. The ability to take a quick, effective decision, drawing on insights from those on the frontlines, retreating if necessary, defines not only a platoon commander but also the neurosurgeon encountering an emergency, like an intraoperative aneurysmal rupture!

 The Multifaceted Neurosurgeon



A clinician par excellence, never ever discounts the history and observations of the patient and his/her family. Remember what William Osler said, “Listen, listen – the patient is telling you the diagnosis.” When managing an eloquent area glioblastoma, the patient's long-term and short-term objectives along with the family's views must be considered. The patient's survival is not the only consideration; what is equally important is also the cost, both in financial and emotional terms, as well as the quality of life. Harvard Business School, citing examples of decisions taken by Fortune 500 chief executive officers, concede that there is a place for emotional intelligence. “Gut feeling” sometimes scores over sophisticated business analytics and this could be so in clinical neurosurgery. Evidence-based medicine is a guideline, not an absolute end. Problems must be reduced to their individual constituents. A neurosurgeon of the third decade of the 21st century will necessarily also have to be a scientist. The all–consuming mantra will be: Measure, Measure, and Measure; Document, Document, and Document; Update, Update, and Update; and, Continually assess what is working and what is not.

Neurosurgery is not mathematics. It is not an absolute black or white science. It has various shades of grey with different options being offered to the patient and the doctor for identical problems. The process of development of a neurosurgeon also encompasses the realization that all men are equal but some are more equal than others. This in the real world applies to neurosurgical management as well. One has to be a patient to truly understand what a disease means. Several doctors use patient-authored websites to get practical advice. An e-patient transcends the white coat. The choice of a treatment option will be influenced by the payer. Health care will be delivered by organizations with an eye on return-on-investment and cost containment. Early diagnosis and prevention, to reduce surgical procedures, will be the daily mantra. Promoting wellness will be a business. Salaried surgeons could be compensated even more for using medical therapy rather than for carrying out a surgical procedure!

Does cutting edge technology always need to be deployed. The questions that should automatically come to mind include: when, where, why, how, and at what cost. This requires an in-depth technical knowledge and the ability to quantitatively measure the expected alterations in outcome while deploying robotics vis a vis other management options, in that particular patient. Many patients want a definitive treatment immediately and look askance when intervention is decided against. Sniggers ensue when a computed tomogram (CT) scan is not advised for an inconsequential head trauma. A specialist's opinion that nothing needs to be done is generally unacceptable. When a patient is told after a thorough clinical history and physical examination that anticonvulsants are not always indicated for one single seizure, he goes, in utter disgust, to a street-smart doctor who gets a contrast magnetic resonance imaging (MRI) done, following which he/she reassures the patient that all is normal!

Variations in the practice of procedures of tonsillectomies, hysterectomies, and prostatectomies are fifteen-fold in the UK and the USA. The Dartmouth Atlas of Health Care 2010 concluded that in medical management, “geography is destiny.” This can be extrapolated to the neurosciences as well. There could be a difference in approach by salaried surgeons and those who get a “fee for service”—unconsciously brought out when different treatment options are discussed. The younger generation of healers now subscribe to the credo that invasive prevention is better than waiting for the clinical problems (which may or may not develop) to emerge. The earlier belief “don't trouble trouble, until trouble troubles you,” is now viewed with superciliousness.

 Information and Communication Technology (ICT) and Neurosurgery



Distance today has become meaningless and geography has become history! Tomorrow's neurosurgeon will be a part of the newly emerging me Health, where the prefix 'me' now used before Health, represents the delivery of more personalized health care. Digital hospitals, electronic medical records (EMR), hospital information systems, mobile personal health record (mPHR), tele-health, tele-education, and tele-mentoring will be an integral part of the neurosurgical health care delivery system.[1],[2] With an inexpensive tablet or a personal computer, the neurosurgeon will be available to anyone, anytime, anywhere. Professor Google and Dr. Facebook will ensure that the patient is truly empowered, having real-time access to almost the same exabyte of information, the neurosurgeon now has access to. “Caveat emptor”—let the buyer beware—the neurosurgeon of the 2020s could very well be at the receiving end! Familiarity with medical social networking sites such as PatientsLikeMe.com, Sermo.com, iMedExchange.com, ICYou.com, CarePages.com, and DailyStrength.com will become mandatory. These will be the channels that the patients and health care providers simultaneously utilise to learn from each other. The availability of multiple opinions for difficult cases, exchanging observations, getting help with patient care, practicing health care management, with the entire set of information condensed and packaged in an electronic medium, transcending regions and even continents, will be commonplace. Patients have already started sharing their challenges, hopes and victories, treatment experiences, and support. How does one face a life-altering health event. More than 500 online support groups with a comprehensive health network of patients now share advice and make available research on the latest drugs, treatments, and alternative therapies. Healthcare video-on-demand from hundreds of certified medical and health care providers are freely available. Neurosurgeons, who do not consider using social networks, risk being run over on the super-highway of health information sharing. 33% of Americans who go online to research their health, use social networks to find fellow patients. Patients with amyotrophic lateral sclerosis have organized their own clinical trial on www.patientslikeme.com.

Neurosurgeons in the yester years did not have to deal with systems, processes, audits, accreditations, review meetings, multiple specialist opinions, third party administrators, and the nuances of insurance and billing. Today, to ensure uniformity and standardization, one has to follow protocols, algorithms, and flow charts. Every clinical problem has to be reduced to a series of “what/if.” Such dispassionate and objective mathematical approach is thought to be necessary for high-quality disease management. Perhaps this six sigma (a measure of quality that strives for near perfection) approach has made a significant difference in health care outcomes. But, somewhere along this journey, have we forgotten that people can still die with a brain tumor not of a brain tumor; that TLC could mean 'tender loving care' not 'telemedicine linked care;' that every deviation from the norm (do we really know what is truly normal?) does not need to be corrected; that MRI or (positron emission tomogram-computed tomogram (PET-CT) images are still shadows; that it is a human being, we need to build a rapport with; and, that the whole is greater than the sum of its parts. Yes, what appears as science fiction today may become the standard operating procedure for fellow senior citizens of tomorrow. I love technology but deep in my heart is a craving and lingering to go back to the bygone era. After all, our grey matter is still the most sophisticated computer and arriving at a diagnosis and a customized and individualized management strategy, taking a truly holistic view, has always been so much more appealing—at least in the twentieth century.

 Conclusions



The only thing that is constant in the universe is change. Many of us are afraid of the future and cling desperately to the present, not realizing that we already represent the past. Arthur Clarke, the eminent science fiction writer, once said, “Advanced technology will eventually be indistinguishable from magic.” To face this magic, what we require, in the coming decades, is a mature head on young shoulders that does not get carried away by gadgets. Science without compassion is blind, compassion without science is lame. In our anxiety to keep up with the Jones, let us never forget that we are healers first and technologists later. A combination of the surgical skills of Sushrutha, the compassion of Mother Teresa, the scientific acumen of Albert Einstein, the pragmatic “karma yoga” philosophy of Lord Krishna, and the innovation, shrewdness and information technology skills exemplified by Steve Jobs will produce a Superman/Superwoman, which is what the neurosurgeons of the 2020s need to be! Primum non nocerum. Neurosurgery is much more than neurosurgery!

References

1Ganapathy K. Distribution of neurologists and neurosurgeons in India and its relevance to the adoption of telemedicine. Neurol India 2015;63:142-54
2Sharma S, Padma M V, Bhardwaj A, Sharma A, Sawal N, Thakur S. Telestroke in resource-poor developing country model. Neurol India 2016;64:934-40