In Memoriam: Celebrating Juha Hernesniemi, MD, PhD (October 18, 1947-June 26, 2023): An Ode to Passion and Mastery Within Humility and Simplicity

Juha Hernesniemi was so widely beloved and admired that this is unlikely to be the only tribute written about him. I will let others recount his chronology or, even better, read and summarize his recently released autobiography Aivokirurgin muistelmat (Memoirs of a Brain Surgeon)—in Finnish for now and soon in English. If you had never visited the maestro in person in Helsinki, where he was a Chairman from 1997 to 2015, to watch him conduct his microsurgical symphonies, then at least go now online and watch his freely available “1001 surgical videos,” or his multiple recorded presentations, or read his numerous articles. Juha was a man of very few words, hence his eloquence; a surgeon of very few moves, hence his mastery. The man and the surgeon were one and the same, fused most completely, more than anybody else I ever met. The finely tuned surgical machine perfected saving lives, thus leaving little place for idle chatter. But when he spoke, you would better listen, for the words he uttered were packaged with profound forethought, timely delivery, noble intent, and intense meaning…just like every single one of his surgical gestures: measured, rehearsed, effective yet poetic, and deceiving, all at the same time. If you were deceived watching him in the operating room it is because you did not know enough, had not lived enough, and had not struggled enough. To imitate means to replicate; complex surgical actions cannot be replicated; they have to be constructed like a beautiful edifice, 1 stone at a time. Our senses fool us into misinterpreting the “beautiful” or “harmonious” end result as “simple,” and herein lies the tragedy. Juha's mantra of “simple, clean, and fast neurosurgery while preserving normal anatomy” is the product of his relentless drive and passion. I hate to do this to his memory, but his mantra is partially misleading in its first word: “simple.” He should have clarified by stating “simple to me, clean, fast ….” To the rest of the learners, the mantra should have read: “very complex when you start becoming simple over the years if you dedicate your whole soul to it, clean, fast…” Between 1969 and 1973, while in Medical School at the University of Zurich, he mastered the microscope in his research projects. By the time he was completing his neurosurgical residency, 1973–1979 in Helsinki, he was well versed in microsurgery and helping his seniors master it. Between 1978 and 1998, he visited all the greats of the period, eager to learn, hungry for excellence: Arseni, Yasargil, Pasztor, Symond, Crockard, Drake and Peerless (in Ontario), Nyary, Vajda, Bertrand, Yasargil (again), Drake and Peerless (in Miami), Yonekawa, and Perneczky. Travel of course never stopped for the rest of his life. After spending 4 years (1979-1983) between Helsinki, Kuopio, and Uppsala, he settled in Kuopio in 1983–1997, before moving to Helsinki as a Chairman of the Department. By the end of his career, he had operated on more than 16 500 patients, including >6500 aneurysm patients, >800 AVMs, and >5000 brain tumors. I perused his Curriculum Vitae in preparation to writing this tribute. The author of >650 publications had crafted a résumé of … 7 pages. It would have been 6 pages were it not for the inclusion of a picture of his surgical team in Helsinki and a beautiful photograph of him in profile, his face bathed in sunlight, peering in the distance, smiling, with the fingertips of both hands joined together, in a rare moment of satisfied restful contemplation. Why would he bother listing his bibliography in his résumé when you can find it online? Why bother with an “Awards” section, when the real awards awaited him everyday in his operating room as he applied the “perfectly placed clip,” in the smiles of family members in the waiting rooms, in the maturation of his trainees and fellows fortunate enough to witness real mastery, and in the faces of his global audiences who relished his lectures. If a picture is worth a 1000 words, each of his actions was worth a lot more than that. For a man like Juha, a résumé is indeed redundant. “If people knew how hard I worked to get my mastery, it would not seem so wonderful at all,” said Michelangelo. And that is the message that Juha amplified whenever he could. Practice beats talent every time. His surgical technique was indeed the end product of a gradual conscious distillation of the purity of the effective from the redundancy of the unnecessary. Effectiveness, freed from redundancy, yields efficiency. Efficiency, coupled with consistency, yields Mastery. That took work, focus, and intense metacognition. That took humility well more than hubris. That took years of active observation, trials and errors, and an unwavering resolve to get better, to do better, to leave the discipline in a better shape than he found it, to spread the word, and to save lives. To most neurosurgeons watching some of his surgical videos, no matter how experienced and skilled they are, some of his surgical techniques in handling intimidating aneurysms may well seem to be bold at the very least. They confuse lightning speed of determination with hastiness of recklessness. Only he has been there thousands of times, and only he has developed that rarefied sixth sense of what comes next. His courage is not in giving the appearance of recklessness. It is in the relentless and cumulative correction of technical imperfections over a lifetime, in the pursuit of the ideal. “I fear not the man who has mastered 10 000 kicks once; I fear the man who has mastered one kick 10 000 times,” said the martial arts prodigy Bruce Lee. And Juha's “kick” was a sight to behold. “Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason, mastery demands all of a person,” said Albert Einstein. And herein lies the reason why Juha's persona matured into this beautiful synchrony of man and surgeon, soul and purpose, and heart and skill. It is probably also why slowing down and losing autonomy after his retirement from the University of Helsinki in 2015 may have left him with an unquenched hunger for more as well as an understandable melancholy. Disengaging the man from the surgeon after 40 years of perfecting their seamless union is not easy. Not even he could do it. He worked in Nepal and then in Henan Province in China, before returning to live in Helsinki in 2022. Naturally, his 17 years in Helsinki will end up defining his epic career. We may become “masters” of our craft, but we should all remain “at the service” of our patients. Juha always knew that. I will never forget his slide presentations. They stand in stark contrast to those of all the other luminaries. They had simple text on simple backgrounds. Nothing was flashy. The English grammar was often not perfect. Some prepositions were missing. There were no special 3-dimensional effects. He did not waste time on fluff, like most of us do. But who cared! The surgical videos were sublime, the message was always profoundly sincere, and the surgical pearls were priceless, if you understood their subtlety. And then, you always knew where his heart was and what really mattered to him because the last concluding slide was always the same. There was the old black and white photograph of this young boy with a large surgical dressing around his head covering 1 eye, paradoxically smiling, raising his hand with a thumb up, as if to tell us “all is good, I made it, and that is what matters.” And all that mattered to Juha is the perfect outcome indeed, not the perfect show. Juha was extremely kind and caring toward all, but if he did not act warm and fuzzy, it is not because he did not like you; it is rather because liking you is vastly more important to him than showing you that he liked you. What mattered lay within, not on the surface. Call it stoicism, call it cultural, call it what you wish. I call it “I wish the world was made of more people like him.”

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