I have found that many physicians are not happy. I wanted to share with them some ways to find “amrita” in life. Then we can face life with joyful countenance, ready to receive the Maker when we hear the knock, as described in Revelation 3:20. It is important to associate with virtuosity. La Chaim!
The excitement: Albert Camus said that the “struggles that one encounters in life are by themselves the purpose of life” at a time when Jean-Paul Sartre and others were promoting existentialist views of life and questioning the very purpose of life and why we shouldn’t commit suicide.
The life of a neurosurgeon is full of struggles, and that is not to say that other professions are as easy as calling something “duck soup.” I want to share with the readers, particularly those who choose to become neurosurgeons, ways to find happiness and contentment despite the obstacles of reduced reimbursements, excessive record-keeping, governmental and bureaucratic oversight, and discontentment owing to subconscious lamentation for days gone by.
Dr. Anil Nanda, professor of neurosurgery at Louisiana State University, titled his talk “Curiosity, Compassion, and Composure” at the white coat ceremony of 2011. It was printed in World Neurosurgery in the July/August 2012 issue. He mentioned Dr. Lawrence Craven, the internist who observed that chewing aspirin-containing gum caused excessive bleeding during tonsillectomy and introduced aspirin to his cardiac patients to prevent myocardial infarction. He also talked about Drs. Marshall and Warren’s perseverance in proving that Helicobacter was an important factor in causing peptic ulcer disease and the compassion and gratitude expressed by Dr. William Osler for his patients. I have injected myself with the courage of such people. Courage, I believe, is an absolute necessity to become a neurosurgeon. It is not something one develops, but rather an ingredient that leads to happiness through its power to impart “helpfulness” as it marinates with intelligence. Dr. Nanda mentioned the composure of President Teddy Roosevelt after he lost his mother and wife on the same day.
I believe that happiness arrives like a friend that knocks on the door of life softly, waiting for us to open the door and let it in.
We don’t know what it is yet when it enters our cells, but it invades the body and works in every mitochondrion as a source of our energy. I believe that when we were asked during interviews, “Why do you want to be a neurosurgeon?” most of us said we were curious about the nervous system and wanted to be skillful surgeons to help people afflicted with maladies affecting this system. The discipline came naturally as I followed the rigorous lifestyle of sleeping about four hours, studying, examining patients, observing in the operating room, preparing for grand rounds, and writing papers. I don’t believe there was a day in my life when I thought this was not what I had planned, although there were days when I fell asleep before finishing my dinner. Every day was exciting in what I saw and what I learned. Everything was an accomplishment. I still remember the first spinal tap, the first tracheostomy, the first chest tube, and the first craniotomy. It was the attainment of various skills that gave me the thrill.
Dr. Hunt, professor of neurosurgery at Ohio State University, said that intelligence cannot be imparted, only kindled to follow one’s dreams to attain the goal one is destined to reach. A professor like Dr. Hunt is difficult to emulate because his bedside manners were impeccable, his temper always controlled, and his skill unmatched. There were times when we discussed philosophy and religion, and he knew that the Pharisees believed in predestination and the Sadducees believed in free will. We discussed the fact that compassion is not a parade of platitudinous gestures but arises from goodness inside. He demonstrated daily how to be loving, caring, and compassionate. He said it was important to behave as professionals in all our endeavors because, as physicians, we enjoyed certain privileges society allowed us because of our title. He wrote down on a piece of paper when I told him that the five wounds of Christ signify resurrection, redemption, forgiveness (introspection), salvation, and compassion. I said I needed a lot of introspection to avoid being judgmental in my opinions. He thought that taming the tongue was of utmost importance in life and that speaking the truth required tact and finesse so as not to promote ourselves while denigrating someone else.
I remembered reading that Dionysus told Euripides in the underground, “My tongue spake but my mind was not prepared.”
Professor J. A. Schumpeter, in The Theory of Economic Development, presciently stated that in capitalism, creative entrepreneurs will use new methods to generate new products that promise to generate higher revenue. Consequently or subsequently, less profitable enterprises will decrease and become extinct. At present, most surgeons are employees of large corporations and are often subtly reminded to perform procedures (if possible) that generate greater revenue to maintain their “keep,” so to speak. Medicine has become more procedure-oriented (it pays more) and less people-oriented. Aristotle said we are humans essentially and (our professionalism) accidentally. Therefore, when bundled payments for diagnosis-related groups became necessary, procedures filled the gap of deficient reimbursements. Just a few years ago, many performed three epidural injections routinely for treating back pain, despite the information suggesting its potential deleterious effects. But the procedures actually paid more than laminectomy. I’m sure it wasn’t intentional. I was told by one of the administrators that there were many coding opportunities that needed to be captured. I retired soon after that missive (verbal). C’est la vie!
My training and continuous efforts—observing infectious disease doctors and orthopedic surgeons in my spare time during residency, spending extra time in radiology, learning to catheterize blood vessels, and learning to embolize abnormal vessels and tumors—helped me become a physician. I noticed that my license to practice medicine was actually a license to be a “physician.” I learned medicine and the principles of surgery, which enabled me to pass the neurosurgical board examination.
I learned to perform stellate blocks, celiac blocks, inject alcohol or glycerol inside the spine or into the foramen ovale, perform percutaneous cordotomy, place spinal cord stimulators, and use lasers or microscopes where needed. I learned stereotactic surgery by attending different courses. This education gave me opportunities to fulfill my dream of becoming the kind of doctor I always dreamed of being. I enjoyed working in Louisville. I was able to perform the first phrenic stimulator in the state. I was able to embolize and resect difficult AVMs from the brain and spinal cord (once using cyanoacrylate—crazy glue—when sterile bucrylate was not available).
I used stereotactic surgery for biopsies (navigation was not available), clipped aneurysms, and performed operations on carotid and vertebral arteries, the spine, spinal cord, and brain. But the most fulfilling experience for me has been being an international volunteer for the last twenty-five years.
My training and instinct taught me that “he who makes the cut owns the problem.” My compassion taught me that saying, “The operation is successful and fusion looks great,” when the patient is not doing better than pre-op, is not really effective or valuable to the patient. Mentioning the radiological evidence of satisfactory fusion might satiate my conscience, but it doesn’t serve the patient.
I learned over the years that my instinct and intuition must draw strength from objective data and that the indications for an operation must be entwined with reasoning that could withstand the scrutiny of the most dispassionate critic. I made arrangements with St. Mary and Elizabeth Hospital that they would not charge patients I operated on for free. Many patients who needed help but were restrained by financial constraints did not feel isolated. Many paid me with live chickens or skinned squirrels in jars, or simply by mowing my yard or giving my wife a free massage during her visit to the salon, or doing her nails for free. We became bound by mutual love, which propelled us toward better seats in the arena of eternal life. I felt the love of my Maker. I could listen to Pavarotti sing or Don Giovanni repent with my eyes closed, without getting a bump from my wife’s elbow—she might have assumed I was sleeping, bored.
I believe a competent surgeon knows not only which back needs an operation (and when) but, more importantly, can discern when to say no, even if a patient says, “I heard you’re the best.” It is important not to step into the muck of self-adulation, enticed by sycophantic patients.
The pain game, as Dr. Fordyce (professor at the University of Washington, Seattle) described in the early seventies, is an eternal trap that has enticed many surgeons. Self-adulation is hard to overcome, particularly for surgeons. So I chose not to operate on every bizarre arm pain as thoracic outlet syndrome, on all adjacent asymptomatic disc degeneration as future burglars that would steal the “juice from the nerves,” or on every spondylolisthesis or spinal stenosis found after work injuries or car accidents by stating they were caused by the accidents in question.
Instead, I learned to accept my shortcomings. On one occasion, after I testified that a certain problem was not related to a car accident but it progressed after the case settled, I performed the necessary operation for free. Mr. Eric Lamb represented that person in the accident. I wrote a letter accepting my error in judgment. It takes courage to be a neurosurgeon!
Working in foreign lands is difficult. I had to be well-read, and more importantly, I had to learn to work with different personalities in varied cultures and live under unfamiliar conditions. But the advantage was that I usually did not have to operate at night, and I could drink beer. Drs. John Guarnaschelli, Richard Jelsma, and Robert Sexton covered for me while I was gone for months to distant lands. I am grateful to them for helping me.
Mr. Mark Webster, a prominent local attorney, traveled to Nicaragua to volunteer to build houses, and there he spoke to people who knew what kind of neurosurgery we were able to perform. A young medical student went to Ethiopia with me, and it transformed him. He is at Tulane to become a neurosurgeon. The joy of neurosurgery for me has been the ability to work in Nepal, Brazil, Peru, Honduras, Zimbabwe, Nicaragua, Ethiopia, Mongolia, and Siberia. Here, I have loved and felt the pain of those who don’t have the benefits we enjoy at home. I have been able to work with younger doctors and physician colleagues who work daily under trying circumstances. One time in Arequipa, Peru, I performed operations on three different patients in one day. One had an anterior communicating aneurysm, the second needed a transsphenoidal approach for a pituitary tumor, and the third had an L5-S1 disc herniation. The last operation was performed in twenty-eight minutes under flashlight illumination because there was a “seismo” from nearby Misti, the volcano. It is in these circumstances that patients’ families have broken bread with me or served me Chinggis vodka as I tried to work as a disciple of my Lord. I have been fulfilled by the joy of giving and receiving and caramelized in the love of those I would never have known had I not been trained in America and gone out to help. I am grateful for all the opportunities.
Tolerance and the ability to improvise are essential to work effectively in different countries where fewer resources may be available. It brings great joy to perform an aneurysm operation using a Black & Decker drill, prepare a sandwich with pieces of a glove and gelfoam to place next to the brainstem instead of Teflon or Ivalon to stop the pain of trigeminal neuralgia or hemifacial spasm, or operate under minimal illumination on a Friday because the guy who changes the bulbs only works on Wednesdays!
As a young boy lying on a mat in the field in front of our house, I asked my grandfather, “Where do the clouds go?” He said the different clouds had different shapes and colors because those attributes provided the staying power to travel to different lands. In the penultimate chapter of my life, I realize the value of that story.
I think of Govinda (Siddhartha, Herman Hesse), who realized that the cloud, the mountain, and the river were all the same, only in different stages of life. The joy of neurosurgery is in understanding Leaves of Grass (Walt Whitman), seeing the true beauty of life in ordinary things and everything in it. Life is most joyous when the mind is calm and in a state of Mahamudra, when one might hear the sound of one hand clapping while God holds the other to guide and subdue noise during the transition from matter to energy.
Timir Banerjee is a neurosurgeon.
