3.1 What Makes a Neurosurgeon an Expert?

 

Introduction

Having brain surgery is the last thing you want to hear. Instead, there are three things you need to do initially:

1. Do something to ease the pain. You need a break. You cannot explore your options or make a rational decision if you are in so much pain you cannot think.

2. Get a proper diagnosis. You cannot treat your pain if you do not know what is causing it.

3. Once you know what is causing the pain, consider all the available options (including medical, surgical, and integrative) and select the best one for you now and in the long term.

Part of the diagnostic process is getting a proper magnetic resonance imaging (MRI) scan. Orofacial pain specialists and neurosurgeons know the type of MRI to order and how to read them. If the scan shows a pulsation or vascular compression, they should talk about the importance of considering microvascular decompression (MVD) surgery sooner rather than later.

There are two types of procedures to bring relief to people with trigeminal neuralgia. The first, an MVD, is the only procedure that is not intended to damage the nerve. Although technically brain surgery, an MVD is minimally invasive. It treats the cause of the problem by separating the blood vessel from the nerve that it is damaging. It offers the most long-lasting relief and minimizes the risk of postoperative numbness. Most people are eligible for this, even elderly people and people who have other medical conditions.

The other procedures are ablative, that is, destructive. Even radio-frequency procedures, such as gamma knife and CyberKnife surgeries, are ablative. Pain relief from ablative procedures is not always immediate. The relief does not last as long as relief from an MVD. Repeat ablative procedures are less effective than the initial ones. The numbness after an ablative procedure can be as uncomfortable as the initial pain. Although one can have an MVD after an ablative procedure, it may not be as effective as having an MVD initially if the ablative procedure left residual uncomfortable numbness.

Most people treat their pain with medications until the pain or the side effects of the medications become unbearable. Then, they move to surgical options. It is useful to see a neurosurgeon before you need surgery. A consultation with a neurosurgeon does not mean that you need to have surgery right away or at all. If you need surgery, you will be in pain and unable to make good decisions regarding selecting a surgeon or procedure. Knowing a neurosurgeon will be like having a security blanket, a connection with a doctor you trust. Experts can guide you and comment on the accuracy of your diagnosis, suggest different medications, and lead you to the best treatment.

From Jeffrey A. Brown, MD, FACS, FAANS (USA)

How does a neurosurgeon stand out among colleagues as an expert after all their training? Training is important. What comes next is what makes one an expert. Experience, dedication, passion, team development, personal contribution to the advancement of the field, the capacity for humanity, and empathy for others make the difference.

Let us take experience first: A seminal article reviewed data from a US study found that there were significantly fewer complications from MVD surgery by neurosurgeons who had performed at least 29 MVDs per year. Low-volume neurosurgeons’ patients had a significantly higher incidence of brain hemorrhages after surgery and a need to drain spinal fluid after surgery (a sign of greater intraoperative bleeding). Twenty-nine percent (29%) of all MVDs in the study were performed by a neurosurgeon doing only one MVD a year. The hospital in which the surgery was performed was also an important consideration, especially for patients older than 65 years. Hospitals in which at least 20 MVDs were done yearly discharged significantly more patients to their homes than to another facility, such as a nursing home or rehabilitation center (5.1% vs 1.6%). For neurosurgeons, the corresponding percentages were 6.1% vs. 0.5% (only one of every 208 patients) for surgeons performing more than 29 MVDs a year. Complications were twice as frequent at low-volume hospitals and 12 times higher for low-volume neurosurgeons. It is not just the neurosurgeon who needs the experience. It is also the team built around that surgeon in all aspects, including both the hospital and the team recruited by it.

What about those other aspects that make a surgeon stand out among other colleagues? The ability to communicate is essential. Does the doctor sit at your eye level when meeting with you, summarize the essentials of your health situation, and then elaborate, in understandable language, what they believe is your diagnosis and their recommendations for its treatment? Does the doctor then discuss the risks of any surgery recommended, the likelihood of each complication occurring, ideally the likelihood in their personal experience, and even the risk of not proceeding with surgery? This is the beginning of the informed-consent process. Note that it is an interactive process, not just a piece of paper slipped to you the morning of surgery. Does the doctor provide an opportunity for you to pose questions and then respond? All this takes time. Does the doctor allow for it? An expert technician must be matched by their expertise in the elements of being human, the essence of professionalism.

What does that mean? It means

• Integrity,
• Eye contact, and
• Use of power words — helping phrases.

Does the doctor exhibit the elements of compassion and personal engagement? These can be perceived in the doctor’s “ESP”:

• Emotion: The doctor reflects back their behavioral and emotional observation of you, the patient.
• Stop: The doctor stops to listen without interruption.
• Plan: The doctor provides a plan and summarizes.

And when leaving the room, do they ask an open-ended question, such as, “Is there anything we missed?”

A key to what makes an expert is how they handle an unexpected complication. Is the complication rapidly identified, and are all efforts made to limit the injury from it?

What if the surgeon believes that the best treatment is not something in their expertise? The ability to understand the limits of one’s knowledge is also essential. Does the surgeon help find another doctor and/or a facility with that expertise?

What is done after surgery can also be critical. There may be more to do. The problem may be ongoing.

An expert should not be an “expert” in only one thing. They should have other options to offer, other answers to the question, “What if this doesn’t work?” We all hope that it does — but must be prepared if it does not.