The philosophy of 'middle path' in neurosurgery
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.177598
Source of Support: None, Conflict of Interest: None
I was pondering for quite some time for an appropriate topic for the Presidential Oration of Neurological Society of India. I thought that it will be worthwhile to present the crux of my own experience of over 33 years in the field of Neurosurgery. The aims of the oration should be that it is not too ideological; it should not deviate from the ethical and evidence-based scientific principles; it should be capable of providing philosophical guidelines that may actually be applicable to life in general and and to neurosurgical practices in particular; and, most importantly, it should have the ability to reach out to the junior-most residents. The theme of this conference is 'From Controversies to Consensus.' As the 'middle path' is the best way to get consensus, I decided to choose this title as the topic of my talk.
The concept of the 'middle path',,,,,,, was described by Lord Buddha as a 'route to enlightenment.' There are two ways of leading one's life. At one extreme is the material way of life, believing that happiness comes from pleasure and comfort; at another extreme is the belief in a spiritual way of life, where one renounces the material world, relinquishes one's work and responsibilities and becomes a 'sannyasi'.
The 'middle path' is leading a life that exists between these two extremes. The words portrays that one should not give up one's work and responsibilities but rather carry them out with utmost sincerity while using materialistic things in moderation at the same time. However, one should not run after or crave for these materialistic things.
For example, when an attacker places a loaded gun on someone's head, ordinarily, there are two choices: At one extreme is to meekly accept the bullet from the attacker's gun and die. At the other extreme is to defend, overpower and kill the attacker. However, there exists another path, to negotiate with the attacker and convince him that he can do better than to commit a murder. Hence, the 'middle path' is not simply a trail in between two extreme courses of action. It is actually a different path that balances the two extreme view points and avoids errors, imperfections, blind alleys and pitfalls that extremism may lead to. It is similar to the concept of 'false dilemma' in the Western philosophy and the philosophy of the 'golden mean' propounded by Aristotle., It is a path with the greatest clarity and is not even remotely related to a superficial understanding of the concepts or a biased view.
It should not be confused with passivity or a kind of middle-of-the-road compromise. It should also not be ascribed to be synonymous with the words 'mediocre, average, mean, intermediate, median or centre' and is far above and beyond these mundane concepts. It should also not be misunderstood as being equivocal about things in general. The 'middle path' implies applying to the best of one's ability, ongoing efforts in the broadest sense, and maintaining actions and attitudes that create happiness for self as well as for others.
When applied to social life, the 'middle path' is a way to open one's mind and allow oneself to treat others with mutual respect, understanding, tolerance and love. It is based on building a strong foundation. When applied to personal life, it is a path of true freedom and optimal living that keeps one's stresses low and the satisfaction levels high, and is generally ascribed to having a positive attitude towards life. This is the optimum path for which the human body is designed. It is a healthy way to deal with the vicissitudes of daily life and helps to live life fully in the present without being swayed by the past or the future. In other word, it is actually a path to progression and also balances the pressures and complexities of modern life. It is a path to purity, happiness and peace of mind. It is safe and lasts longer. The 'midde path' philosophy is of universal significance and can be used in different contexts.
The neurosurgical training is rigorous and lasts for 6 (3+3) years. It is associated with long working hours and is associated with periods of inadequate sleep. It often forces the trainee to miss a meal, to bear the repeated coercion by mentors to work harder and way beyond one's capacity or inclination. Each trainee is often plagued by repeated thoughts of quitting his/her training at some stage.
I like the tough life and thrive on challenges. I chose neurosurgery because it was challenging and different. The inherent concept of 'hating to lose' makes us neurosurgeons, a breed apart. We all realize that neurosurgery is a stressful sub-speciality and the consequences of small errors may lead to death or disability. Despite the prolonged efforts, and despite the elegant and masterly surgery performed, sometimes our patient may not do well. The patient satisfaction levels are low because of a wide gap in the scientific advances propagated in the media or falsely perceived by the patient and his family, and the actual treatment available. A classical example is that of stem cell technology touted as the holy grail of every form of treatment, especially for incurable diseases., Similarly, there is an undue emphasis on the projected benefits of surgery by the endoscopic or laser technique.
Operating on one's relative/colleague/friend is stressful. Also, there is an acute and additional stress of an intraoperative aneurysmal rupture, brain swelling as well as other introperative mishaps. Too much stress may lead to a poor performance [Figure 1]. A study of the ambulatory pulse and blood pressure recordings performed in our department showed an abnormally elevated stress response in neurosurgeons during surgery that is far greater than that induced by a vigorous exercise.
In this scenario, the concept of 'middle path' is to temporarily detach onself from the situation. This reduces the stress levels and improves perfomance. At the same time, in times of intraoperative stress, requesting your colleague of equal competence to scrub up with you is a great stress-buster. A team effort will bring down the stress levels and will allow a more rational judgement.
The 'middle path' promotes balance, diversity and moderation. It is a path between excess and deficiency. Gladwell described an inverted U-shaped curve that shows that having more stress is not always better. Initially, stress can be utilized to bring about more efficient services, but later it become disadvantageous as one passes the threshold. This Yerkes-Dodson law/inverted U curve/bell-shaped curve denotes that, when levels of stress become too high, performance decreases.,, At a high level of stress, the cost overweighs the benefits. There is a point along the line after which the positive effects turn into negative ones., An example of this is the inverse relationship that often exists between emotional well-being and income, happiness and longevity, class size and academic achievement, alcohol consumption and health, and, crime level and punishment.
The fundamental issues in neurosurgical practice are two. First is developing clinical judgement and decision making; and, second is mastering surgical skills. During decision-making, one should consider the diseased and not the disease. The expectation of benefit must outweigh the risk of surgery, and therapeutic alternatives, for example, radiosurgery, should always be given due consideration. The outcome should be better than that of natural history of the disease, and approaches should be adopted that are best for the patient and not necessarily what is best for the tumor/surgeon. During the surgical planning, due provisions must be made for the many contingencies that may occur. Cognitive bias, overconfidence, fatigue and lack of emotional equanimity may cause errors in decision-making, which may result in morbidity or mortality., Decisions should be based on scientific evidence and recommendations, algorithms, personal experience, intellectual exchange (a team decision) and comes with knowledge, experience and wisdom.
No single personality type or trait describes all neurosurgeons but certain basic personal qualities are required. The neurosurgeon must have commitment, passion, sincerity and dedication. He should also possess professionalism, that is, the ability to work well within a group/system/team. At one extreme, indecisiveness makes one seem as 'spineless,' having no stature or dignity; while at the other extreme is 'arrogance,' with the person not bothering about his colleagues which makes him/her unadjustable in the team. Both of these extremes constitute an abnormal behaviour. Having a flexible/adjustable personality makes one fit as a teammate which is an essential prerequisite for a successful neurosurgeon.,,,,
Another important quality is in knowing when to stop. Do not aim for perfection in trying to remove all fragments of the tumor stuck to vital neurovascular structures. Successful neurosurgeons, when faced with tough intraoperative decisions, consistently do a risk–benefit analysis during surgery that includes the decision to either remove every last bit of the tumor or to leave some behind in order to minimize the risk of neurological deficits. A neurosurgeon should be quick in decision making, should know his limitations, should be efficient while performing under pressure and should know how to get out or stay away from trouble. The neurosurgeon must learn to operate with naked eyes, loupes, a microscope and/or an endoscope. The hallmarks of a neurosurgeon are: Manual dexterity, hand-eye coordination, three-dimensional orientation, spatial perception and tactile memory, that is, the ability to return one's hand exactly to the same place in the operative field where it was, before it was moved.
He also needs to have the ability to maintain longer periods of concentration as neurosurgical operations are often of a long duration. Most importantly, 95% of the intraoperative complications occur in the last five minutes. Hence, the surgeon cannot afford to let his guard down even for a moment.
A neurosurgeon should always be optimistic. Life and death decisions are part of his daily routine and he can either cure, buy time or improve the quality of life. Extra life gained by surgery, and spent in misery in the hospital on chemotherapy and radiotherapy, may be of lesser imortance to the patient whose main focus may be on maximizing his quality of life. Considering the 'middle path' philosophy during resection of tumors like a glioblastoma multiforme (GBM) of a deep/eloquent area, partial resection may be acceptable to preserve the postoperstive quality of life of the patient.,
Great neurosurgeons believe in the 'do no harm' philosophy and have a balance of confidence and empathy for their patients., They always possess critical thinking and are incessantly exploring the possibility that there must be some better way of doing the same thing. They always keeps pace with the technical advancements and newer surgical skills. The judicious adoption of new skills and technology with proper indications is beneficial for the patients. For example, the 'distraction compression extension reduction (DCER)' technique in atlanto-axial dislocation (AAD) and basilar invagination (BI) is quite effective and eliminates the need for a traditional transoral surgery in many patients [Figure 4].
Working for extended hours is unsafe. The concentration and efficiency goes down. Overfatigued residents, who have sleep deprivation and have been working for long hours are unsafe and have the potential to affect patient care. However, working 80 hours per week may not be enough for neurosurgery. Dr Burr requested for an increase in working hours. The Accrediation Council for Graduate Medical Education (ACGME) in USA, approved for a 10% increase in the duration of working hours for residents from 80 to 88 hours a week. Such requests are granted for a handful of the programmes such as neurosurgery owing to the prolonged surgeries, the complex anatomy, the critically ill patients and the lesser number of residents in this field.
Convincing the residents about the importance of becoming more involved in the surgical and patient care by placing a little bit of extra effort can yield dispropotionately better results both for the patient's well-being as well as the resident's learning.
Aging decently is an art. Always train your colleagues. Teaching is learning twice. Inculcate discipline and work culture and develop mutual trust and respect. Always take care of your colleagues' interests and give them credit from time to time. One should develop the right combination of personal and team excellence.
Be a good team leader. A leader is the first among equals. One should continue to learn. The moment you stop learning, you are dead professionally. Learn from failure and successes, learn from mistakes of predecessors and institute a behaviour that prevents repetition of these mistakes. Once in a while, introspect and analyse your own results and learn. Do not compete but seek inspiration from and learn from people who are better than you in that particular skill or surgery.
Encourage and foster younger colleagues to take up areas with lesser conflict as described in the 'blue ocean strategy,' that is moving from the red ocean of fierce competition to a blue ocean area that is unexplored till date.
Developing mentor – disciple relationship is necessary, which is a shared pledge to work together. Each successive person should expand on the vision of his predecessor. The diversity of people should be fostered and encouraged. The mentor–disciple relationship is like a 'needle and thread' relationship, where the mentor (needle) leads the way and the disciple (thread) follows the mentor holding everything together to create a long-lasting impact. It is the deep connection between the mentor and disciple that leads to the development of the organization.
Clinical examples of the 'middle path' philosophy applied to neurosurgery
The 'middle path' is that of controlled agression via an optimal (minimal incision to achieve maximal efficacy) surgical approach and maximum safe resection with the optimal use of endoscopy and radiosurgery. The 'middle path' helps the surgeon to get to the optimal position during surgery in a quicker time. It encourages the surgeon to accept the suggestions of colleagues or to incorporate the advances in surgical techniques in his/her repertoire.
Balance in life
Life is energy flowing in a particular direction that is determined by one's intentions and priorities. Many people direct their energy excessively in one area, ignoring all other aspects of life. This can prove to be unproductive and leads to an imbalance in life. If life is out of balance in one area, it will soon be out of balance in other areas as well (like a domino effect).,
Neurosurgeons face a duanting challenge in balancing their family and professional life. Life is not only about work. There is more to life. When “not on duty”, find some time to socialize, entertain, relax and exercise. This practice recharges and rejuvenates one's inner self and improves efficiency. Always pursue a hobby, for example, playing music, cycling or participating in a game. This acts as a great stress reliever.
In summary, neurosurgery is a delicate, difficult, challenging, and stressful subspecialty. Clinical decision-making, teaching, mentoring, and a continuous updating and learning of new skills are essential components of a neurosurgeon's professional life. Adoption of the 'middle path' philosophy in neurosurgery culminates in a perfect combination of personal and team excellence and safeguards the vital interests of all concerned. It is a genuine philosophical concept and not an analytical one. An analogy would be the 'keyhole' concept in neurosurgery where the approach is optimized to one's needs. It is not a quantitative measure but rather a conscious path that should be determined based on individual circumstances and needs. It investigates and penetrates to the core of the problem and situations with an unbiased attitude; it, therefore, facilitates decision-making and provides practical solutions to moral and professional problems. The 'middle path' of surgical approach for a maximal safe resection with minimal invasiveness is, likewise, quite relevant in neurosurgery.
The 'middle path' is a pathway of moderation and perfect balance. Fine tuning of three areas that includes health, family and profession, creates harmony and a perfect balance in life. Living a balanced life produces a sense of completeness and a deep inner peace.
I extend my gratitude to Professor PS Chandra and Dr. Dattaraj Sawarkar for their help in the preparation of this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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