A Look at Academic Pediatric Neurosurgery

Session 44

Dr. Michael Egnor is an academic Pediatric Neurosurgeon based in NY. We discuss his long career in the field and his thoughts about what you should know. Michael has been out of fellowship training now for 26 years and is currently a faculty member at Stony Brook University.

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[01:25] His Interest in Medicine

When Michael was very young, his mother had a brain aneurysm that ruptured. She survived but she had some neurological sequelae. So even when he was young, he was already involved with neurosurgeons.

He thought that to be a neurosurgeon was the pinnacle of what one could accomplish in terms of profession. Moreover, he found medicine fascinating. He recalls that he read a book Not as a Stranger back in high school. It was a novel about a doctor but the title just fascinated him. The title actually came from a passage in the Chapter 19 of Job in the Bible. Job was asked how he deals with all of the horror he experienced and all the terrible things he has seen. He knows what he’s going through ultimately will allow him to see life and actually to see God, not as a stranger. That is if you would come to know him and what it means to be him in an intimate way.

He was also inspired by Dr. Christiaan Barnard, who was the first surgeon to perform a heart transplant. He recalls seeing the news about it as a kid and got fascinated by it. He is specifically fascinated by congenital heart defects. As well, the brain fascinated him. That said, he knew he wanted to be a doctor and a surgeon, he was just not sure what kind.

Then he went to the Army in high school because he needed money to go to college. He served as a medic in the Army for three years. And getting accepted to college, it gave him a deferred admission so he started college when he was 20. Right after college, he went to medical school. Being older going to college, he considers himself being more focused than some of his classmates. He knew what he wanted to do, so he worked really hard to get into medical school.

Out of medical school, still undecided between neurosurgery and cardiac surgery, he started general surgery internship in Mt. Sinai in New York. Halfway through his internship, he realized he wanted to do neurosurgery. He knew that 20-30 years down the road, he would still be fascinated by the brain and not as much by the heart.

So he applied outside of the match. He called neurosurgery programs. They needed a resident at the University of Miami, so he went there with his newly married wife. He spent six years in Miami, training in neurosurgery and came back to Long Island where his wife’s family is from. Then he got a job at Stony Brook as one of the faculty.

[05:50] Brain versus Heart

Not that the heart isn’t a wonderful topic of research, it struck him as a fascinating machine. But with the brain, he thinks you can take the knowledge much further. The other thing that enthralled him was neuroanatomy and how the brain was structured. To him, it was like almost as if he was learning a secret to what life was all about and it was in the structure of the brain. So he felt the brain would keep him interested indefinitely. While the heart was too mechanical for him.

[07:17] His Path to Pediatric Neurosurgery

He didn’t get out of training as a pediatric neurosurgery. He did general neurosurgery but he has always liked pediatrics. He likes the patients and has a fair amount of empathy for parents. He also has a personality for it. And in some ways, he thinks neurosurgeons and pediatricians are thought of being at the opposite ends of the spectrum of medical personalities. Pediatricians tend to be warm, nice people who are nice to the family and patients. Neurosurgeons are thought of to be egostistical and dysfunctional people who just operate like crazy. But these stereotypes are not entirely true.

Pediatricians respond well to neurosurgeons and vice versa. For a couple of years at Stony Book, they didn’t have a pediatric neurosurgeon. Since pediatricians like him, they sent him a lot of patients. So, the chairman of pediatrics ultimately asked if he was willing to just become a designated pediatric neurosurgeon. And so he agreed.

So there’s a way to get boarded in pediatric neurosurgery outside of the fellowship track. It was a matter of submitting case logs for several years and taking a written exam.

[09:30] Traits to Lead to Becoming a Good Pediatric Neurosurgeon

Michael explains it’s a blend of two very different species. Pediatricians tend to be people who are warm, nice people. They love kids and want to take care of them. Neurosurgeons are egotistical people and surgically oriented.

This path is great if you find you love the surgery and are fascinated by the brain. You like some of the technical challenges of neurosurgery and on the other hand you want to take care of kids. For example, you find conditions like hydrocephalus to be very challenging and fascinating from a scientific standpoint.

Neurosurgery is an interesting specialty. As much as he has met the nicest people who are neurosurgeons, there are those who are crazy too. Michael says, neurosurgeons have to have some degree of almost irrational confidence in their abilities. It’s something normal human beings don’t want to do. You’re taking tumor out of someone’s brain where you stand a reasonable chance of killing them if you make a mistake. It’s not something even people who are inclined to surgery have a particular comfort of doing it. So you have to be fairly egotistical to do this for a living.

And how does one pull that off in the real world? Neurosurgeons have different ways of doing it. Some neurosurgeons just concentrate on being technically as good as they possibly can. Others are psychopaths in a non-criminal way. What Michael means is some of them don’t take into account the humanity on the other end of the operating table. They just do the job as well as they can and then if it works out, great. If not, they’d call out the next patient.

Some neurosurgeons limit their practice so that they only do things they feel comfortable doing. While others don’t put it together well at all and don’t do such a good job.

[12:25] Types of Cases and Patients

As a pediatric neurosurgeon, a large fraction of his practice is children with hydrocephalus. And he follows them into adulthood so he also has a fair amount of adult patients.

Michael mentions the issue in pediatric neurosurgery is that pediatric neurosurgeons who work in adult hospitals question as to where they will follow their pediatric patients when they grow up and become adults? Some pediatric neurosurgeons who work in children’s hospitals can’t do that. This is because patients can’t be cared for at the hospital they work at. In Michael’s practice, he deals a lot with hydrocephalus in both children and adults. He also deals with hydrocephalus in older people. He sees elderly people who have normal pressure hydrocephalus. Other cases he deals with are brain tumors, Chiari malformations in both children and adults, as well as syringomyelia in their spinal cortices. He also sees patients with craniosynostosis, infants with deformed skulls, and of course, trauma both adult and pediatric.

As to what percentage of patients coming to him that already have a known issue, Micheal says it’s a very common scenario to see a child with brain tumor. And the pediatrician feels a lot of guilt about it because almost a child who has brain tumor has had several months of symptoms. And pediatricians work up a child with some vomiting and headache. And after 1-2 months of evaluation, they get scanned and the tumor is found.

And so he tells them that in some sense, the neurosurgeon has the easiest job; because virtually, patients come to him already with scans showing what’s wrong with them. The primary care people, the pediatricians, or the internists for adults have a tougher job because they see a large volume of patients. Only a small fraction of them have serious problems. Then they have to find the ones who have the serious problems.

The major issues he faces are: is the patient’s diagnosis responsible for the patient’s symptoms? This can be tricky. People can have headaches from the chiari malformation and don’t need surgery.

Michael finds it a challenge to sort out whether the symptoms of the patients are really caused by the disease identified on the scan. You have to be sure since the remedy you’re offering is surgery. You want to make sure you’re operating for good reasons.

[16:25] Typical Week of a Pediatric Neurosurgeon. Taking Calls, and Percentage of Patients Ending Up in the O.R.

Michael describes his week, since it basically depends on whether the hospital has a lot of trauma or not. But his typical week would be that he’d be on call once or twice during that week at night. He takes a general surgery call.

During the day, he has two operative days a week. On average, he takes 2-5 cases a week. He has 2-3 half-day clinics a week where he sees 15-20 patients per clinic. He has some academic time, usually one and a half days a week where he writes papers. They don’t have residency in neurosurgery so he’s a residency director for a program without a residency. This said, he’s in the process of applying for residency. He teaches medical students as they rotate through the service he teaches and in the ethics class.

Of the patients he sees in clinics, only a relatively small percentage, about 10%-20%, go to the operating room. Many of the patients he sees are follow-ups after the surgery. Many of them are children with shunts he sees annually. They don’t need surgery but he sees them manually. It’s very important that if you have a shunt for hydrocephalus, you have a neurosurgeon that knows you. And that you know them and that they neurosurgeon is always available to you. He finds that annual visits keep everything fresh so they know each other.

Common cases would be a kid who bumps his head on the baseball field, has a mild headache and gets a scan. And something would be seen on the scan that has pathological significance but the primary care doctor sends the child to him.

Most of the calls he takes would be coming to the hospital for surgery. They don’t have residents so any surgery is done by the attending. They have physician extenders but he still has to come in and do the surgery. Nowadays, generally, residents don’t operate alone so even if they had residents, he would have to come in. About a third of his calls, he would have nights coming in.

[19:45] The Path to Pediatric Neurosurgery, Competitiveness, and Research

Basically, neurosurgery residencies have been for five or six years including the internship year. That’s followed by a year or two of fellowship, if you want to do it. This past two years, the ACGME and the residency review committee (RRC) for neurosurgery have standardized neurosurgical training. Now, it’s a seven-year program including a year of fundamental clinical skills, which used to be the internship. And then six years of explicit neurosurgical training.

Now they try to fold in the fellowship experience into the seven-year residency. So you don’t have to do fellowship after you do it during the residency.

There is research involved in neurosurgery. In fact, programs are required to have a research curriculum, whether it’s training or research methods. Residents are expected to be academically active, to publish during their residency. And programs are reviewed by the RRC based in part on the research output of their faculty and residents.

Although he doesn’t have the numbers, Michael thinks that half of the applicants get into programs. He would rate it as moderately competitive. It’s a small specialty with about a hundred programs in the country. There are a whole lot of people interested in going into it but his sense is about 50% of applicants get in.

As to the reason for it competitiveness, it appeals to a fair number of people, particularly people who are highly motivated. You have to really want to practice medicine at a fairly intense level to want to get into neurosurgery.

Moreover, people may be attracted by the status or the financial aspects. Most neurosurgeons do fairly well financially. And there aren’t enough people repelled by the volume or nature of the work.

According to my data, there are are only 218 physicians. Michael agrees this is just about right. Pediatric neurosurgery is one of the less popular neurosurgical specialties. Within the neurosurgical profession, popular subspecialties include spinal neurosurgery, general neurosurgery, vascular. The reason for this is people don’t like dealing with shunts. Many neurosurgeons, too, don’t like dealing with kids or with families. Another reason is pediatric neurosurgery doesn’t pay as well as other neurosurgical specialties.

It seems to be a general rule across all pediatric subspecialties is that the pay isn’t as good as it is for adults. But Michael points out you don’t go into it for the money.

[24:00] How to Be Competitive for a Residency Spot

Besides being a good student and being a decent human being which always help you, Michael cites two things students should focus on. First is research. Have some publications appealing to a neurosurgical residency program. The second is to have some hands-on experience particularly with the programs you’re applying to.

When he was a resident in Miami, they took two residents a year. There was an unwritten rule that one resident was taken based on the CV and the other based on personal experience. When somebody would rotate through their service, you get to know them personally.

It turned out that the people who did the best in the residency were almost the people who had rotated to the service and who they knew personally. You’re going to work with the resident for seven years in fairly intimate ways in the middle of the night, saving lives, and doing all these stressful things. You really want to be somebody who you know you can work with, somebody you can trust and stand with for seven years.

Michael suggests that for people interested in neurosurgery, try to arrange external rotations at the programs you’re most interested in applying to. This way, when your application comes across their desk, they would know who they’re dealing with.

Nevertheless, the research is a big deal. But the programs have a lot of stress on them from the ACGME and from the RRC to have residents that do research. It’s one of the criteria by which re-certification of the program is determined. Plus, if you already have an established researcher in your program, it’s more likely for them to make their program look good. That said, having a research background is very appealing to programs. In the long run, having research background makes you a better resident and a better neurosurgeon.

[26:45] Biases Against DOs and Subspecialty Opportunities

Michael’s personal experience with osteopaths has been uniformly positive. Some of the best doctors he knows are osteopaths and his personal doctor is an osteopath. He thinks osteopaths are great doctors generally.

He also knows that osteopathic programs have been brought into the ACGME. There are osteopaths at neurosurgery programs that do well. Although now, he’s not sure how it’s working into allopathic training. But osteopathic students are in an excellent profession and they can be very good doctors and very good neurosurgeon.

In terms of other subspecialty opportunities, there is a boarding process for pediatric neurosurgeons. Although they’re not ACGME-certified. So there are boards, but they are not same status as the neurosurgery boards or the internal medicine boards. Beyond that, he’s not aware of any certification process. But there are pediatric neurosurgeons who have particular interest in areas like hydrocephalus, epilepsy surgery, vascular, tumor. So you can develop a niche within the pediatric neurosurgery world.

[28:50] Message to Pediatricians, Working with Other Specialties, and Turf Wars

Michael says it’s nice for neurosurgeons and pediatricians to become friends in terms of personal relationships. The pediatrician knows you personally. He gets a lot of calls from pediatricians just asking common sense questions. He finds that in the relationship between pediatricians and neurosurgeons, it’s nice to form long-term friendships. In return, there are also situations where he calls the pediatricians. He will have a patient who has a neurosurgical issue but also has some pediatric issues. Then he’ll speak with pediatrician about helping them out with that.

Michael works a lot with other specialists like intensivist both adult and pediatric, orthopedists, otolaryngologists, and neurologists.

For somebody who wants to go into neurosurgery because they’re interested in doing spine surgery, Michael explains that in general surgery, most of the operative stuff is spinal. General neurosurgeons deal with spine in generally 80% of their cases. And most of the spine they do overlaps with orthopedics. Most general surgery particularly in private practice deal with spine. And there are movements right now in general surgery to relinquish cranial privileges if you’re a private practice neurosurgeon. Many of them find that the cranial surgery, because it only forms only a small fraction of the cases they do, it does form a very large fraction of the difficult situations they encounter. So it’s not just worth it. Also, it makes the call much worse. If you’re doing cranial neurosurgery, you’re called in at night for that subdural in the ER. But if your practice is restricted to spinal neurosurgery, you don’t have to be called in for the cranial problem. So many of pediatric neurosurgeons restrict the practice of the spine. He actually has a friend in Florida who has been doing this for fifteen years. It makes for a very nice practice.

In terms of overlap with orthopedics, Michael sees a lot of them. He never thought of it as something very competitive although his spine colleagues might feel differently about that. But they have a good relationship with their orthopedic colleagues at Stony Brook. The difference in the work they do is that neurosurgeons don’t tend to do congenital deformities with scoliosis. On the other hand, Orthopedists don’t do intradural surgery.

[35:10] What He Wished He Knew Back Then

Michael doesn’t think he would have done anything differently. He thought a lot about it. He likes pediatric neurosurgery. He is very interested in hydrocephalus from a research standpoint. Most of his research is in hydrocephalus dynamics and the cranium related to it.

That said, there are tons of specialties within neurosurgeries that are great including spinal neurosurgery, tumor neurosurgery. But each of them has their drawbacks.

For spinal neurosurgery, you have to want to deal with spine patients who can be very difficult to deal with. They’re in chronic pain. So it should be something you like doing. Michael finds it’s not for him.

Tumor work is fascinating but many of your adult patients are dying. And to go into clinic everyday and see patient after patient with terminal illness is a hard thing to do.

Cerebrovascular neurosurgery is very powerful specialty now with a lot of good work but they deal with some very difficult clinical situations. And the call can be brutal because you’re taking call for strokes.

Functional neurosurgery is great work for people who are fascinated by the intellectual aspects of epilepsy and movement disorders. But you have to have a certain personality to do that. Functional cases are very detailed, high tech cases that you have to like doing.

[37:15] What He Likes the Most and Least about Pediatric Neurosurgery

Michael likes fixing shunts. Even some pediatric neurosurgeons don’t like that too much. But he finds hydrocephalus a fascinating condition. He’s very interested in the dynamics of it and thinks there’s much we don’t understand about it.

Hydrocephalus is the one neurosurgical condition where you can come into the hospital near death and walk out of the hospital a day or two later just fine. You can come blowing a pupil and go home in two days if they fix your shunt in time and the pupil comes down. In hydrocephalus, you can get incredibly dramatic results. I find managing shunts to be frankly challenging.

What he likes the least about his specialty is seeing patients not doing well. This something all doctors need to deal with to some extent. Even if an objective observer wouldn’t think of the outcome as a mistake, you still hold it in your heart and hod it in your head. That if you could have done something differently, could this patient have done better. Michael adds that one of the most important things about being a neurosurgeon is that you have to deal with the outcome. A neurosurgeon who has a major complication rate of 1%, means you’re a good neurosurgeon. A good complication rate for major cases. But if you’re doing 200 cases, it means that two patients a year are going to have major complications. And if you’re doing it for 30 years, there are 60 people out there who had major complications that’s your responsibility and you live with those faces in your head. So he tells students going into neurosurgery is you have to be able to deal with that. That can be hard. In fact, some neurosurgeons quit. And some do dysfunctional things. They drink. They take drugs. They become egotistical creeps. They have different ways of dealing with that. Some become religious. Some limit their practice to things they can do safely. But you deal with stressful cases and bad outcome and dealing with litigation which is every neurosurgeon’s pain. It’s hard and it’s a major part of the stress neurosurgeons go through.

There’s a neurosurgeon named Henry Marsh who wrote a book called Do No Harm. He is a very prominent British neurosurgeon and did doctors tend not to. He wrote a book about all his bad outcomes. So the book wasn’t about how gifted he was and all the great successes he had. Although he was a great neurosurgeon, the book was about his catastrophes. It’s a very honest book. Michael recommends this book to people thinking about going into neurosurgery.

[41:50] Future Changes in Neurosurgery

The most dramatic change that’s occurred in neurosurgery during his career has been cerebrovascular surgery with endovascular techniques. The ability to treat aneurysms with endovascular methods to treat AVMs and strokes. None of that was possible when he was training, so this has been a real revolution. It primarily affects endovascular neurosurgeons but it’s still a big change.

In terms of pediatric neurosurgery, he’s not seeing much changes except that they’re seeing a lot less spina bifida than they used to. Due to folate supplementation in bread and milk and other foods, it’s reducing the incidence of this condition. And also, prenatal diagnosis. Many of these babies are being aborted prenatally.

There’s a lot of research in tumors, but the basic management of tumors has not changed all that radically. In spine, there was a study done back looking at which neurosurgical operations are under performed and which are over performed. They felt that functional neurosurgery was under performed. While the spinal surgery was over performed. So the reality is there are more people having spinal surgery than really need spinal surgery. Many people could recover from their spinal problems with good physical therapy and non surgical management.

What he’s concerned about over the years is that insurance and the government will decide to reimburse spine in a much lower level and be much more stringent in the reimbursement, which would affect neurosurgery in a very profound way. Because most of their income stream comes from the spinal surgery.

[44:10] Michael’s Final Words of Wisdom

Consider this path if it’s going to something that’s going to be in your heart, it’s your passion and not something you do for money. You also have to take into account the emotional stress that comes with dealing with people’s lives on an intense personal level. He didn’t actually feel this stress until he became an attending. You’re going to have patients who don’t do well so you have to have the psychological and spiritual resources to deal with that.

Links:

If you have suggestions on people we should have on this podcast, shoot me an email at [email protected]. We’re looking for great guests!

Meded Media Network

Not as a Stranger by Morton Thompson

Do No Harm by Henry Marsh

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