The Exchanges

Q Let me walk through some of the things you highlighted. So with all of these equipment and preparation, it just seems like there's a lot to do. How much of that gets codified on a checklist, like in a, the classic Atul Gawande manifesto, and how much of it is just, you know, to do this?

A Well, the organization I'm involved with that I work at, we're very safety oriented. So these checklists have been a mixed blessing for physicians. Of course, it takes extra time and effort, but we think it's worth doing. So there are several, several levels of this. And I think it's become necessary because of the increasing complexity, not only of the equipment and so forth, but also because of the, the team. We like to think of ourselves as Teams, teams of teams, you know, so there's teams of anesthesiologists and teams of everybody involved, and so you have to make sure that everybody's on the same page, and so this checklist era is, I think, here to stay and ever expanding, so it starts with what we call the huddle, so we at the, before the patient's asleep and some families around the bedside, we do a huddle where we make sure that you actually Agree that the surgery you're having is the one that you thought you were having. And so we go over that. So that's the huddle. And we make sure we know any details about you that might be forgotten. Everybody forgot the allergy or something. And then when you were asleep, before we do the surgery, we'd stop and recall this, you know, the timeout. And the idea of the timeout is that everybody in the room stops what they're doing because there's constant activity. So during this timeout, usually led by the surgeon or somebody that I…

AI assessment note: “this checklist era is, I think, here to stay and ever expanding”

Q Clearly at some point in time, you have to make a decision about whether it's going to make sense to operate on someone's brain. What is the process for coming to that decision?

A Well, with experience, sometimes the decision to do surgery is fairly simple, so I know that the tumor has to come out, or the bleeding has to be stopped, but what's not simple, of course, is to get everybody that's involved on the same page, because people want to know this is the brain, as you said, so people want to know what are the risks, what could happen, what would happen if we do nothing, what are the expectations, and so quite a bit of time goes into Not really even making the decision. Sometimes the decision has already been made, but getting everybody on the same page and, and getting them to a point where they understand the risks and the benefits and the alternatives. You know, there's a lot of things that have to go. So a lot of explaining, a lot of answering questions and so forth. And then inevitably at some point it gets to, well, this is what I recommend. And people tend to trust, you know, they expect a neurosurgeon to be an expert. And so they often You can't expect them to make the decision. So you have to guide them along with kindness and empathy to the point where everybody's on the same page.

AI assessment note: “getting them to a point where they understand the risks and the benefits”

Q sounds super smooth, not just from the soothing tone of your voice, but you know, talk about all this, right? All of these processes and, and you have to think, okay, when you're going through a multi hour procedure and you don't exactly know what will happen, there's all kinds of modifications. How do you work your way through that process? As things don't go as you might have anticipated?

A Well, things happen, yes. The main thing in neurosurgery, it's kind of a thing we say, I don't know where I heard this first, but one of my mentors told me, first we set the table, and then we eat. And you know, it sounds sort of simple maybe, but it's very true, especially in a field like neurosurgery, because most of the surgery, if you say four hours, there's maybe a half an hour in the middle where the really the important things happen. So there's a lot of opening, and positioning, and all that, and at the end, there's a lot of closing again, because we're going into, it's not like a mole on your skin, you know, so there's a whole approach, and then going out again. So the best way to avoid these spikes, you know, sudden bleeding, or, oh, the anesthesiologist has some concern, or whatever things happen, is the preparation is extremely important. That's where this, let's set the table thing. So you can't afford to rush into Because you know, the devil would love this. Once we're at the important part, that's always when it starts bleeding, or that's when the phone rings in your assistant's pocket, or that's when maybe we're overemphasize it, but I don't think you can overemphasize it, because it just hedges your bets, basically, that when you get to the point where something does happen, at least you have the first 80% covered. Now then, when it does happen anyway, you stil…

AI assessment note: “when you get to the point where something does happen, at least you have”

Q Are there other tools that you've figured out over the years, and how to make surgeries more successful?

A One way of making it, this is kind of an indirect question, is defining your metrics better. Because, I mean, what is a successful operation? So we've gone through this, for example, uh, let me give an example. Like, let's say with back surgery, we all know you just have to go to a barbecue and there'll be somebody who had back surgery. Either they're very happy or they've had seven surgeries. So in other words, the metric of what you use of what success is. So if surgeons use the metric, you know, there's a A solid fusion that has been achieved with instrumentation. That metric might not directly translate into what the patient was hoping for, which was to play tennis with his children or something. And we're becoming a bit more aware of that. I think in previous eras, we were more interested in achieving the surgical result. The tumor is out, but oh, by the way, the patient can't, you know, there's some dysfunction or something, or the fusion is done, but the patient still has pain. Because we do the surgery successful, but the point is to marry the success that you're measuring as a professional to the patient's expectation.

AI assessment note: “One way of making it... is defining your metrics better.”

Q The concept of you need to separate what happened and then move forward because you have important work to do going forward feels quite different from the emotion of being triggered in that. How did you learn, or is it still a process of learning to make that effective for your future patients?

A I'll answer it in two ways. First of all, our emotions and our adrenaline rush and our adrenal glands and all of these things, the stress response, the fight and flight response, you can't avoid these things. So no matter who you are and how expert you are at what you do, you will feel it. I think the most seasoned professionals in all fields, including mine, you will still feel that adrenaline rush. You can't, you can't unlearn that. You recognize it when you feel it, where the first time you experience that you, it kind of shocks you, you know, well, I never thought I'd feel a little shaky now. So that helps a little bit, and then understanding it, you can't avoid it. So I sometimes tell people, Okay, mandatory walk around. That's what I say, and then I step away from the microscope, and I walk around the room for what feels like an eternity, but it's maybe five seconds or something, you know, and then I just walk back. So that's the way of coping with the emotional rush, which is basically a chemical reaction in our body that we can't, we just can't escape. You can't unlearn it. I think some people have learned to turn that to their advantage, Joe, and In other fields, where they use that rush, or the aggression, or something to their advantage. Now, in my field, that's not really applicable, so you have to just allow it to overcome. The other part is the more the longer ter…

AI assessment note: “So that's the way of coping with the emotional rush”

Q The technology is becoming increasingly pervasive across all different industries, and I know you hear a little bit about sort of the intuitive surgical robots or certain types of procedures. Where do you see technology coming in to your field?

A Well, I think some of the most exciting fields in neurosurgery is the whole concept of brain machine interface. So people are interested at several levels. The most advanced of these has been, um, deep brain stimulation or spinal cord stimulators, which have been aimed at certain types of disease like dystonia or Parkinson's and so on, and also to chronic pain and so forth. So this, this ability to use, um, Stimulation and the technology that enables it has been a big change. And I think the horizon there would be, there are fascinating studies where it has been found, for example, that the area in front of the motor region in the brain called the supplementary motor area gives a signal before you move. So researchers are working on harvesting that. So if you're thinking of moving your arm, it hasn't moved yet. You know, that signal can then, uh, transmit into a receptor, which then can stimulate your exoskeleton, sort of like Iron Man, or maybe directly on the muscle, so that people can think about moving their arm, and then move it, or perhaps move a cursor, or something like that. The more provocative things have to do with, uh, trying to see what people are thinking, which of course, that's quite nebulous. To see if you can make somebody think better, or be smarter, or think faster, or something. There are some very interesting entrepreneurial activity out there, but it's i…

AI assessment note: “some of the most exciting fields in neurosurgery is the whole concept of brain machine interface.”

Q So once you're going ahead with the surgery, we're now in the operating room. This is a very serious life or death situation if something goes wrong. How do you think about managing risk?

A Well, for us, it's all about preparation. You know, neurosurgery is one of these things where you really have to prepare properly and you have to go through the steps. You just can't afford to cut any corners. Maybe I should take you through just my own process. First of all, you know, I try to show up early on the day that I operate. We don't want to be rushing through the traffic and so forth. You know, sometimes patients ask me because we sign consent forms just before they go in. Doc, we hope you had a good sleep, you know, and it's true. So the preparation and the risk and all this starts with me, right? So I try to make sure that I'm there early and relaxed. Go to the bathroom, you know, it sounds silly, but our surgeries are long, right? So we've been there for hours. Make sure you have a little something to eat. I've got my own little ritual I go through. I put on my scrubs, and I'm starting to focus on the patient and not really on all the other things going on because we get Calls all the time. There's lots of other patients, but now I'm trying to hone in my thoughts on this particular patient. I have a little ritual where I take off my wedding band and I tie it to my, the scrubs have sort of a drawstring on the front, so I tie my ring in there because I don't want to worry where I left it, and I turn off the pages, you know, I tell the assistants, take your pages and…

AI assessment note: “Well, for us, it's all about preparation.”

Q How do you go about the process of learning and growing as a surgeon?

A You have to keep in touch with your colleagues. You can't be isolated. If you get isolated, you know, you're always at risk of, of drifting a little bit this way or that way. Now, no two surgeons do something exactly the same. There is a circle. There's not a dot, as I like to say, but I mean, the circle is well-defined. So I go to a lot of conferences, I listen, I speak, I teach, I learn, and in all of these processes, you know, you, you're constantly testing yourself. It's an international family. There aren't that many neurosurgeons in the world. So when I speak to colleagues from Brazil or India or South Africa, They may know things that, or they may have encountered something that I haven't, so it's a lot of communication. We also like doing conferences where there's a small group, because large conferences are not always personal, so we sometimes have small conferences, and then we share things that went wrong or complications, which requires trust and honesty and transparency. That I find quite helpful at this stage in my career, because once you feel you've mastered the subject, and you know most Things that's available. You learn from other people because there aren't that many mistakes or errors or improvements, so you can learn from other people. I find that very helpful.

AI assessment note: “So I go to a lot of conferences, I listen, I speak, I teach, I learn”

Q From your friendships that you developed while you were in business school, I know you have a bunch of friends that are involved in the financial markets. What have you learned about the application of what you do to investing and vice versa?

A Well, it was fascinating to me. Um, the best friend I made, Roger Bowler is a seasoned trader for many years. And we discussed these things. He asked me many of the same questions you've asked me and I asked him questions. I noticed there were a lot of similarities. Between making decisions under stress and what Roger called the teacup, the thinking clearly under pressure. And so I think this is a commonality between some aspects of finance and perhaps surgery. The big difference was that I noticed in my field, there were these absolute, you know, people die. Markets go back and forth. There was one difference. There was also perhaps a more, uh, accessible scientific base to medicine, whereas finance and economics are often based on theory and on retrospective type of analyses and long run averages and things like that. So there was another difference, but there were definitely commonalities in that humans were doing both of these activities and humans are susceptible to the same temptations. Struggles. So I enjoyed knowing that there were other fields that had the same kind of, because that made me feel, well, I understand what they're going through, and maybe we could learn from each other and throw ideas around and see if we could improve our respective practices.

AI assessment note: “I noticed there were a lot of similarities. Between making decisions under stress”

Q How do you think about the risk of hurting yourself, and as it affects your ability to perform?

A That's kind of a funny topic in our home, because my wife, I like Fooling around with my chainsaw and, you know, cutting down brands, and you really shouldn't be doing that. You're a neurosurgeon, you know, and many of my friends are horrified when I do these things, and I say, well, you know, I use other more dangerous power tools, but I do think about it a little bit. I don't like sticking my fingers in things or getting things in my eyes and so on, and I've learned as I get older, your body reminds you, even if you're not thinking of it, you know, you need to, if your back hurts, well, you know, Don't do that again, because tomorrow when you're operating, you know, you're not my tamper, your performance. So I'm just a little bit more aware of not doing things where I'm hurting myself unnecessarily.

AI assessment note: “tomorrow when you're operating, you know, you're not my tamper, your performance”

Q Alright, so we're gonna walk through that exercise of the whole process of someone coming to surgery and just see what comes of it in terms of parallels and decision-making processes. So, I'm not sure where to start, but when you think about, ultimately, you have a patient in surgery, where does that process start?

A Yes, I'm glad you asked that way, because it really does start right in the beginning, you know, when somebody gets referred to me, or I meet somebody through the emergency department, and there's that first moment where you see a neurosurgeon, you know, and that's not something many people have done, and I try to remind myself of that, Just on a side note, my wife once said to me, have you noticed how afraid people are when they come to see you? And I said, really? Wow, I thought I was quite nice. She says, no, you're very nice as surgeons go. Have you ever thought what it feels like to go and see a neurosurgeon? And I said, well, you know, I'm kind of nervous getting a flu shot. So that's the first thing. So I spend the initial time, you know, getting to know people. I like asking them where they're from and getting to meet their family. There's usually a bunch of people in the room because, you know, the, You're going to see the neurosurgeon now, and so I take time meeting everybody and finding out who this person is, because, you know, sometimes I meet somebody and they're, they're incapable, or they're in a coma, or they're badly injured, so one needs to find the context of the situation first, so that's where I start, and then of course from there on it goes to finding out exactly what it was that happened, because often these things are very unpredictable, you know, some…

AI assessment note: “it really does start right in the beginning, you know, when somebody gets referred”

Q Over the course of the many surgeries you've done, How much variability do you think you have in your own performance?

A It does vary. We know that. It's hard to measure specifically, but you know, on some days, you know yourself, you might not feel as sharp or something like that, and you have to be more careful. Now, fortunately, we work together, you know, so assistants and other people will ask you, you know, you look a little, don't you want to go out and have a cup of coffee or something? That happens rarely, but those are more the extremes that everybody can notice, or somebody is just annoyed, or they're going through some personal things, or they're just recovered from illness or something, you know. So I think those things are well taken care of. The part that's More nebulous is how do you know that somebody, you know, is just going through the motions, or whether they're really involved, and so on. And my way of making sure about that is also just small little things. Sometimes when I operate on people, I talk to them, even though they're asleep. So I'll say, come on, Ted, help me out here. Stop bleeding, or something. So it's just a, maybe a silly way, but to remind me that the patient that's there under all these drapes is actually a person who Of course, but you know, in the mayhem of it all, one can easily, and that tends to focus your thoughts, and makes you remember. Measuring variability, we look at outcomes, and of course, big hospital systems, all hospitals have systems that c…

AI assessment note: “It does vary. We know that. It's hard to measure specifically”