Not Everything Goes According to Plan

Neurosurgery is hard. Not only in clinical practice, but sometimes even in scientific publishing. I say this all the time, as reminder to myself, my colleagues, and my trainees and students. Of course, we all encounter challenges in many different forms from challenging diseases and disorders, patients, people, payors, and those in the medicolegal community. When I think of the inconveniencies that all people face, the missed events, the schedule changes, we all could make a long list. Everyone, whatever their lines of work, or what they do, suffer from the unexpected outcome. Our understanding of the nervous system and how it is kept healthy is incomplete—what is the blood supply to things? Is there ischemia or just compression? What might be the tolerability to dissection planes? Is this patient radiation sensitive? Is that a genetic predisposition? This is when we and our patients are surprised or disappointed with the care outcome. In retrospect, did we actually learn anything? Nicholas Nassim Taleb1 from New York University writes about “antifragility,” and how most languages do not have a word for the opposite of “fragile”. Something that breaks and falls apart under stress is fragile. Something that can manage stress and not be changed by it is “robust” or “resilient,” but what about something that is improved by stress? What is our word for that? Indeed, in English, there really is no such word. Does that concept pertain to us as neurosurgeons? Indeed, that feature may be part of our human condition and part of Mother Nature. Perhaps it is just part of evolution. As I write this, my flight was canceled, and I had yet another stay in an airport hotel. My tremendous nurse practitioner had to rearrange the schedule. There were inconveniences, but nobody got hurt. Most neurosurgeons know the name of neurosurgeon Henry Marsh because he wrote about his own experiences when someone got hurt. His reflections and his humility are compelling and relatable because they relate to his own actions and decisions. We sometimes struggle with our decisions, and the effects can be agonizing and even detrimental to our own health. One of my partners, a vascular neurosurgeon, shared his current inpatient with a large fusiform vertebral artery aneurysm and a thrombosed outpouching that caused significant brainstem distortion and compression. The patient progressively deteriorated to the point of requiring intubation and tube feeding. He was essentially locked in. Endovascular solutions were not suitable, and one vertebral artery had been closed to try and reduce flow. He was considering open aneurysm direct decompression of thrombus and attempted clip reconstruction. Bypasses did not seem feasible. Perhaps surgery with cardiac arrest? There was no doubt that the potential mortality of such surgery was high, but what were the alternatives? What did our teachers do? What would Charles Drake do, from the University of Western Ontario, perhaps the most well-known early surgeon investigator on posterior fossa aneurysms? Drake2 was known not only as a master surgeon but also for being incredibly honest when things did not go so well. Why is this problem not easier to resolve than 40 years ago? Perhaps only a physician deals with such human dilemmas in such a direct and personal way. When neurosurgery does not seem to go according to plan, the ramifications are different. This is why the bar is high in our specialty. It has been this way since inception and fortunately attracts a certain personality that usually can deal with it. The public, the patients, and their families who entrust us with their care have long held neurosurgeons to a high standard because we care not only for disease but for function, and often that function defines the person—what they can do and how they interact with others. Most people who are drawn to neurosurgery come because of these elements. For many, it is a calling, a vocation, and not just a career. This is why I reject the term “provider” and do not respond to that moniker. I am a physician and a surgeon. Those terms have special meaning. I did not tell my parents years ago that I wanted to study to become a “provider.” This term and other elements are part of the gentrification of medicine, toward the creation of a service industry. We take care of one person at a time, and for each, the effects are appreciated by a network of others interconnected to that patient. As individual surgeons, we are not an industry. This societal change is also something that is not according to plan. We can either live with it or lead. Scientific publication relies on high-quality peer review, and yet, mistakes are made. There can be investigator misconduct, research improprieties, and even fraud. Much has been written about this and sometimes can affect not just one patient but large groups of people. From time to time, whistle blowers contact us with evidence of dual publication of text or figures, and, periodically, we need to issue corrections or even article withdrawals. Fortunately, those are rare and also not according to plan. Clinical care, research and investigation, and learning to work and practice in an increasingly challenging administrative environment are hard. To continue to have the specialty we want, we must prove it through our clinical studies with ethics and integrity, on education and healthcare access, on topics of public health relevance, and with technical innovation. Some progress is rapid, and some is frustratingly slow. Fortunately, a core principle of our specialty as surgeon scientists is always about getting better. We have always attracted the “best and the brightest,” but resilience is a different personality trait and so is personal evolution in response to stress, and it is never easy. Douglas Kondziolka, MD, MSc Editor-in-Chief, Neurosurgery Publications New York, New York, USA

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