The Practice of Precision: A Brain and Spine Tumor Surgeon

Session 218

Today’s guest is Dr. Kumar Vasudevan, a surgeon who specializes in Brain and Spine tumors. Let’s talk about his journey to where he is now and what it’s like being a Neurosurgeon.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:05] Interest in Neurosurgery

Kumar says he had a personal brush with the field that inspired him to go into neurosurgery when his grandmother got diagnosed with a brain tumor when he was young. It first dawned on him that people who dealt with the brain medically existed and thought it was very cool.

At that time, he didn’t understand what was going on with her. But he knew the brain was very fascinating. He latched onto that while he explored a lot of other things, in the years to come. He never left that interest behind.

When he started learning more about the anatomy of it in medical school, he just fell in love with it even more. And once he got the chance to go to the operating room, he decided it was where he wanted to spend his time.

[03:16] Traits that Lead to Becoming a Good Neurosurgeon

Kumar highlights the importance of having attention to detail and a constant need to want to improve. As with any other job in medicine, you oftentimes learn more in the first few years of your career than during your training.

It’s a constant assessment and reassessment of what you’re doing well and what you’re doing poorly.

And with a very technical field like neurosurgery, sometimes that means having to practice techniques or go into the lab and study more. Kumar says the most successful surgeons he admires the most are the ones who do that the most.

[04:42] Other Specialties He Was Initially Drawn To

Kumar says he enjoyed all of his rotations and approached it in a way that it was his one chance to learn about it and understand it’s a field they may not be going into.

One thing that surprised him was how much he enjoyed internal medicine and the complexity of the problems and the decision-making. He thinks it dovetails nicely with what he does now, especially taking care of cancer patients.

There’s a need to at least wrap your head around the individual as a whole, whatever medical problems they bring to bear. Because that really affects the treatment of their cancer, even they are just considering the brain and the spine. In terms of their tumor treatment, the whole treatment rests on understanding those other problems.

[05:56] New Diagnosis vs. Coming for Treatment

Kumar explains you can’t have one without the other. Fundamentally, their specialty is a surgical field of anatomy. Most of the things they do are to fix anatomy that is broken, disrupted, whether it’s by a tumor or a vascular problem, or a spinal issue. And so, that fundamental fact is there and it probably won’t change for any surgical subspecialty.

For instance, before he exposes somebody to the risk of biopsy for a brain lesion, he has to fully understand and be able to appreciate the wide range of diagnoses that there could be. Make sure those are appropriately ruled out by your workup. That being said the diagnostic aspect of that is always there.

[08:26] Typical Day, Taking Calls, & Life Outside of Hospital

Kumar spends a couple of days reserved for the operating room and a couple of days in the clinic per week. And then one day is a flex day to offload other aspects of his job. His operative days will start at around 7:30 am and he’s done at 5 pm.

Currently, Kumar is taking calls about five to six times, five to six days per month. It’s not too bad at the particular hospital where he works. There are other neurosurgeons who work at trauma centers where the call is much more burdensome. So that aspect of your career can be somewhat individualized.

In terms of what it looks like, there are very rare things that can happen. For instance, pituitary tumors can hemorrhage and cause visual loss. Those are true surgical emergencies.

For the most part, brain tumors can be treated urgently, but not emergently. For instance, spine tumors can cause sudden paralysis, and those sort of things, they tend to act on immediately. Thankfully, they tend to be fairly rare.

The common things that a lot of neurosurgeons see would be hydrocephalus bleeds within the brain of various kinds and subarachnoid hemorrhage as a result of ruptured aneurysms.

At this point of his career, Kumar thinks he has a life outside of the hospital. Although he tries to build up his practice and try to be as much help to people as possible, even then, you have to silo time away. It’s also important to rely on a very helpful partner, and his wife helps him to do that and make that happen.

[11:27] The Training Path

After four years of medical school, you enter a neurosurgery residency program. The minimum for all neurosurgery residency programs now is seven years. After that, many neurosurgeons go on to general neurosurgery practice. Some choose to take extra fellowship time, which can be a year or sometimes two years after your neurosurgery residency.

The reason the path is a seven-year residency, Kumar says based on his personal experience, is that the field is so interdisciplinary relying on knowledge of so many other things.

The first year is very foundational and you’re rotating through lots of different disciplines. Then the second year is spent purely boots on the ground learning to take care of neurosurgical patients and do their critical care in the ICU as well. They operated through those first two years and learn the basics of the operating room. But a lot of time is spent really on just that foundational approach.

What seems to be built into most neurosurgery programs towards the end of the residency is a transition to practice. The amount of autonomy given to senior neurosurgery residents is quite a bit. It includes operative autonomy and decision-making autonomy, of course, with oversight from attending physicians. But the stakes tend to be very high.

This is something that Kumar appreciates it as well as other folks, appreciating that model to handle high stakes decision-making later on, and that takes years to develop.

[14:44] What Makes Students Stand Out in the Residency Match

In his experience, Kumar says that the board scores and grades are very important to get your foot in the door. That being said, a lot of the decision-makers rely on word of mouth and personal recommendations.

They want to see students trying to do the right thing and pushing for patients to be well taken care of. And sometimes, that means running up against the inefficiencies of every hospital system.

'Neurosurgery is such a small field and so interconnected. The folks who are the decision-makers really rely a lot on word of mouth and personal recommendations.'Click To Tweet

Learning how to work around that and just get things done is an underappreciated skill that is not measured by test-taking. But it’s definitely noticed when application time comes.

[16:20] Other Special Opportunities for Specialization

Kumar says there’s no end to the training. When you get down to that level, you’re talking about going to visit certain individual people to look at how they do XYZ. As neurosurgeons, they not only treat things operatively, but they do radiation and radiosurgery. And there are dedicated training programs for that.

There is no end to what you can learn and should learn. But for most people, after they do a fellowship or something, they can always figure out a way to pick up those skills through other means.

[17:19] Overcoming the Negative Bias Against DOs

UndefinedKumar says there are some programs dedicated to osteopathic students within neurosurgery. He had also seen either foreign medical grads or osteopathic students that have found success in finding a mentor that is well connected within the field. They were doing work with them and proving their abilities in other ways over a longer period of time.

For some folks, that means spending summer or a year or something with those folks. Again, a personal recommendation from somebody well connected in the field means a lot.

[18:48] Message to Primary Care Physicians and Neurologists

As surgeons, Kumar says they are really trying to increase their success and improve their outcomes. And they recognize that they can only do that in collaboration with those physicians.

And so, it’s very helpful if they can just pick up the phone and call them to discuss a case. They might have something to offer surgically that might be more minimally invasive than originally thought, or might be from a different route than originally thought.

[20:06] What He Wished He Knew Before

Kumar says that as a medical student, you think you understand the concept of lifelong learning. And that you really don’t understand it as much as you do when you’re done with training. And you understand just how much you don’t know.

Although he looks at it as a welcome challenge now, he wishes medical students that understood no matter what you go into, things are changing so rapidly. And it takes a level of dedication or even more than you had as a medical student to do the best for your patients.

[20:54] The Most and Least Liked Things

Kumar likes being able to build strong relationships with patients. Being able to around hard conversations, give them comfort, and perform an operation that can help them solve their problem – there’s nothing like building a relationship on that ground.

On the flip side, the least likable thing about his job is seeing unfortunate outcomes because of the nature of the disease they’re dealing with.

That being said, things have changed so rapidly in the treatment of many brain tumors, in particular, metastatic brain tumors. But things like glioblastoma and other types of brain injuries still have a long way to go on. It’s hard to see that, but it’s motivating at the same time.

Kumar says it makes a difference to be able to build a strong relationship with the patient before surgery happens. It’s also important to manage those expectations and this shifts the conversation from being the last resort to solving the problem together. And that not only takes some of the stress away but leads to better outcomes for everyone.

[24:44] The Advent of Targeted Therapies

In the oncology world, targeted therapies are bringing a lot better outcomes for patients. The same is true in the neurosurgery world and Kumar thinks it’s night and day in terms of management.

When he started his training, if you saw somebody with metastatic melanoma to the brain, they hardly ever offered an operation because the outcomes associated with that finding were poor.

Now with immunotherapies, folks are living very, very long with the other nonoperative interventions they have in neurosurgery. For instance, in radiosurgery, they have gone from having patients with widespread metastatic disease in the brain to watching them stay stable in terms of their intracranial disease for years and years.

It has been a revolution in the nonoperative treatment of these folk. And there have been just as many operative therapies that have come along to help. So it has been truly night and day since those were introduced.

[26:07] Final Words of Wisdom

If he had to do it all over again, Kumar would still choose to be a neurosurgeon specializing in those brain and spine tumors. He says can’t imagine doing anything else.

Finally, to the students thinking about neurosurgery and Brain and Spine Tumors as a potential career, Kumar sends his words of encouragement to never be intimidated.

It’s about finding the right people to attach to. In neurosurgery, there are some passionate educators out there who want to bring students into the field to show them just how great it is. And if you have some interest in what they do, take a chance, even as a first-year medical student or even before that. Talk to somebody, get into the operating room, and see what they do.