THE MASTER NEUROSURGEON

Friends,
This is the first Blog that I am posting and it is but natural that it is about a legend which is born once in many thousand years. 
He is very close to my heart, and indeed, the guiding path to thousands of neurosurgeons, even after a century of insanely rapid evolution in medical knowledge and technology.
 
Discussion about the art, science, philosophy and ethics of brain and spine surgery cannot begin or end without mentioning Harvey Cushing, who undisputedly is the father of neurosurgery.
I am normally not given to hero-worshiping, but there have been people out there …..you know…..who did justice to the word “legendary”.
If we could create a category a step ahead of legendary, he would be there!
He was an astute clinician, a superbly dexterous surgeon, a keen observer, methodical chronicler, energetic activist and the Pulitzer prize-winning prolific writer. A dexterous surgeon, a brilliant clinician, a scientist, an artist, a philosopher, a humanist……add some eccentricity and some ego and you have the concoction called Harvey Cushing.
He was also an excellent, albeit a strict and eccentric teacher. In fact…..his work was so enormous that anyone working with him could not escape learning…..just by observing him.
I am using the word “escape” because, apparently, there were enough and more reasons for his students to try and escape from his presence……as he was a perfectionist and a hard task-master. But due to the expanse of his work…they could not escape from learning neurosurgery.
His major work was done between the years 1900 and 1930…….when even general surgery was not well-developed….let alone brain surgery. One sentence written by his contemporary summarises the importance of his work. One of his colleagues has written…..
“Before Cushing, eighty out of hundred patients undergoing neurosurgery died in or just after surgery. After Cushing, eighty out of hundred patients survived.”
….And mind you…..this was the era before antibiotics and microscopes.
Cushing wrote well and prolifically. As to how he found time to do so beats me. 
His writings came straight from his experience and his philosophy was not only mental musing. They had direct bearing and a palpable impact on not only the branch of neurosurgery but medicine as a whole. In 1923, he wrote
“A physician is obliged to consider more than a diseased organ, more even than the whole man-he must view the man in his world”. I remember this sentence everyday while operating on brain or spine. “I must view the man in his world”
For example…putting it grossly…. if a farmer gets a tumour in his language area…….I can venture more aggressively and remove it completely but a similar tumour in a professor has to be dealt with more conservatively.This dilemma of complete tumour removal versus possible post-operative neuro deficits is perpetually playing on my mind during every brain surgery.
On another occasion, Cushing writes…..
“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”
……now this is, clearly an exaggeration as nowhere in medicine is manual dexterity and it’s brilliance more needed than while operating on the brain. Brain can be a frustratingly unforgiving organ for a surgeon and it gives you a very narrow window to operate through….and I don’t only mean a narrow anatomical window, but a narrow window of time and approach also.
Cushing himself was a brilliant with his hands.What he suggests in this really revealing quote is that if you operate well and neglect other aspects like correct diagnosis and careful case selection, you will be doomed to certain failure.
If you are a brilliant technician but have no depth of mind to see “the patient in his world”…..it’s of no use.
This quote is especially relevant today.
If you look around carefully you will understand the real meaning of this quote.
A lot has been discussed over the years about an ingredient of ego in Cushing’s personality…. and I would like to dwell on a neurosurgeon’s ego a bit. Plenty of tongue-in-cheek remarks float around…..in the popular press and elsewhere in  typical hospital banter.There is usually a ‘friendly cold war’ brewing between the physicians and surgeons, or the surgeons and anaesthetists. There are joking allusions and undercurrents of supposed intellectual superiority of  the physicians versus the pure dashing brawn surgeons are “accused” of possessing.
Having thought in great earnest about these issues, I think one has to make a difference between ego and vanity. The very idea of opening someone’s skull to…say remove a tumour or clip an aneurysm or resect an arteriovenous malformation…..all in the face of potential temporary or permanent neurological damage…..to be able to explain to the relatives what could have possibly happened… and to accept that one doesn’t fully understand the processes….and to do this nearly every day of one’s professional life…What would a lay person think about this? Would he or she think this to be normally conceivable?
I think it is not. And that too…..In a society which expects miracles from you and can easily turn abusive or litigious!
When I look at it from the perspective of a lay person…….this very endeavour……of opening up someone’s skull or spine…..seems outrageously superhuman.
And if you have to be able to do this activity with a calm mind and steady hands…I think you have to have some ego. A neurosurgeon has to feel convinced in his mind that he can and will surmount and defeat the disease. And that he has the necessary audacity to do so. The ego is also based on years of hard training and the sacrifices made. And this gruelling training is physically, mentally, emotionally and spiritually challenging. Not only challenging…. but draining too.
You must have heard about a recent paper about burnout in young doctors….but that is another subject and let’s not digress……
So,……Unlike someone prescribing medicines, the surgeon has to “commit” with his hands….and there is a definite feeling of purposeful commission of the act….albeit in good faith…. in the atmosphere around an ongoing surgery.
This is a thin and razor sharp blade you are walking on. On the one side is the danger of diffidence which will make it impossible to operate. And on the other side is the danger of overconfidence and vanity…..while on the third side is the danger of cynicism.
Yes…I have seen some surgeons becoming cynical and unnecessarily philosophical over a period of time. I think it is a clear and ever-present danger.
But……to sail through this predicament, any surgeon…..and more specifically a neurosurgeon has to have the correct degree of ego and self-belief.
And as if this is not enough, like any other profession undertaken by the human race, there are professional rivalries, tendencies to pull one another down amongst  doctors also. The drama of ego clashes and insecurities are very much present in the medical world as in any other human undertaking.
So you see……ego is not bad…..indeed it is necessary. A justifiable feeling of confidence and superiority are the prerequisites to dare surgically.
And the cost?…… Sure…Eternal vigilance is the cost….I mean vigilance on the part of the surgeon…..to see to it that this ego does not decay into God-playing vanity on one side and cynical diffidence on the other.
If you look at Cushing’s quotes……you will know that this man had his wits with him.
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