Brain Surgeon
Author: Keith Black

Background

This book is an account of how one man got into ‘the elite field of neurosurgery‘ against all odds, and how he made his mark in the specialty. The autobiographical narrative traces the author’s determination to become a surgeon when, as a child, he operated on wounded birds, dissected the hearts of cows, and carried out heart valve operations on dogs. Armed  with the belief, inculcated in him by his parents, that there was nothing he could not do, he portrayed how he overcome the ‘overt racism of the South’, and the prejudices of medical training, to successfully complete a neurosurgical residency. The book also delves into the technical aspects of neurosurgical practice, probing the intangible dimensions of the field, and admiringly depicting the brain as ‘quite simply the most beautiful structure in the known universe’. The book is also a repository of non-surgical themes, from the ‘appalling’ cost-benefit analysis in which monetary value is ‘arbitrarily assigned to human life, to the wealth disparity which frequently dictates the type of treatment individuals are offered (pages 10, 23-32, 131, 142-150 and 159-165).

 

Synopsis

Perhaps the most fascinating theme of the book is the author’s depiction of his neurosurgical principles in which he metaphorically portrayed brain surgery as ‘a trek through…Tiger Country‘. He envisaged brain surgery as ‘an adventure into a beautiful but unforgiving and potentially dangerous world’ where ‘there are so many places where the tiger can lie in wait…always lurking, waiting to pounce‘. He argued that having this mindset enables him to gauge the risks and benefits of any procedure he performs, always having the safety of the patient as his highest priority. In outlining his technical approach to brain surgery, the author emphasised the need ‘to plan out every operation in full, and to have a game plan for any eventuality‘. He particularly stressed the importance of ‘finely developed motor skills, pinpoint accuracy, and the ability to remain cool in high-risk situations’, maintaining that ‘my goal is to never touch the brain itself’; rather, he said the operates like like ‘a thief in the night‘ who sneaks in ‘without the brain ever knowing I was there’. It is also his practice to require everyone in the operating room to focus ‘their full attention on the patient’, a philosophy that explains why he does not play music when operating (pages 6, 9, 34, 38, 63 and 76-77).

Brain tumours, the author’s clinical and research field of expertise, understandably received exhaustive coverage in the book. And central to this discussion is glioblastoma multiforme, the aggressive brain cancer that he said can double in size within a fortnight. Likening its advancing edge to ‘the tightly packed ranks of an advancing army,’ he portrayed the tumour as solid sheets which have ‘massed on a front and ready to charge into battle’. He also compared the behaviour of glioblastomas to that of a terrorist organisation  – ‘constantly changing and shifting its guerrilla strategies‘. Taking the subversive analogy further, he said ‘what makes the glioblastoma such a formidable enemy is its ability to become invisible to the immune system, much like ‘a terrorist hiding among the everyday population’. To the untrained eye, he asserted that ‘gliomas can look almost exactly like normal brain‘, and explaining that ‘it is often how it behaves to touch‘ that tells it apart from normal brain tissue. Noting that ‘99.9 percent‘ of the tumour must be removed ‘in order to have a significant impact on my patient’s survival‘, he said his operative aim when facing a glioblastoma is ‘image complete resection‘. The author also explored the non-operative techniques of treating brain tumours, from the conventional chemotherapy and immunotherapy, to the ‘revolutionary’ technologies of stereotactic radiosurgery, skull base surgery, and awake craniotomy (pages 4-5, 11, 52-55, 81 and 123-129).

The author narrated several gripping anecdotes which illustrated the intricate and complex neurosurgical cases he tackles. And one of the most compelling stories chronicled the operation he performed on a young man who had presented to him with ‘perhaps the largest clival chordoma‘ he had ever seen. He depicted this lesion as a ‘vast, hydra-headed monster’ which was ‘growing, like an ogre under a bridge’ and had ‘coiled itself around the brain stem and all of its surrounding blood vessels‘. With breathtaking prose, he depicted the multidisciplinary surgical approach he took in this case, describing how he split the man’s face open ‘and swung everything – jawbone, hard palate, teeth, tongue – out to either side’. He also described how he put the face back together at the end of the operation, referring to this procedure as a tricky undertaking because ‘if the reconstruction was so much as a millimeter off’, the man would ‘face a life of pain and would never be able to eat normally again’. Amongst the other challenging cases he described was operating on a man who had ‘woken up with the worst headache in his life’, and who harboured two brain aneurysms and a huge arteriovenous malformation which consisted of a ‘potentially lethal snarl of blood vessels’ (pages 41-59 and 35).

A major concern the author highlighted throughout the book is the threat posed to patient safety by the pride that he said was prevalent in his specialty. Acknowledging that confidence arises as the natural consequence of preparing, planning, and correctly estimating operative risks, he distinguished this from the ‘bold and swashbuckling‘ attitude that poses a risk to patients. Explaining that the egoism comes effortlessly to neurosurgeons because of the ease by which they cross ‘over the line‘ from confidence to arrogance, he cautioned against this audacity which he said ‘bordered on recklessness‘. Stressing that ‘restraint can be the difference between success and failure – or life and death‘, he urged young neurosurgeons ‘to become thoughtful warriors of the brain, doctors who are both knowledgeable enough and cautious enough to take only absolutely necessary risks for their patients’. Whilst he was clearly proud of his achievements, from being ‘one of the youngest full professors ever in the department of surgery at UCLA’, to being ‘one of just a few who do more than 250 surgeries a year‘, he nevertheless downplayed the significance of these accomplishments, further warning neurosurgeons not to ‘fall victim to the God complex‘, or be induced by praises and flattery down ‘the slippery slope’ that ends in ‘toxic’ hubris (pages 6, 8, 71-79 and 104).

The sanctity of the patient-surgeon relationship was another important subject the book exhaustively addressed. The most instructive aspect of this exploration is the reverence with which the author holds his patients, admiringly referring to their ‘steely resolve to fight the disease’ even when the odds of survival are ‘not so good’, and marvelling at their ability to ‘live an entire lifetime in six months or a year’. Further praising his patients for what they ‘teach us all about the meaning of a life well-lived‘, he contended that theirs is often ‘a much higher quality of life than that enjoyed by “normal people” who are caught up in the trivia of the day-to-day’. Because most of his patients are able ‘to zero in on what really matters‘, he said they channel their time and energy into building relationships and having meaningful conversations with loved ones, what he said were ‘the important things in life that those of us not facing death often never get around to’. It is therefore understandable that he considers empathy to be central to neurosurgical practice, pointing out that the difference between ‘being just a good technical neurosurgeon and being a truly great one’ is ‘bonding with your patient on a personal level‘. Arguing that the ability to merge ‘skill and expertise‘ with ‘empathy and compassion‘ is the secret to becoming ‘a thoughtful warrior in the brain’, he underscored the importance of empathy to patient outcomes when he said that ‘if you do not possess compassion for your patients – if you do not have the ability to see them as members of your own family – then you are going to hurt them‘ (pages 13-14, 39, 213, 75 and 86).

Opinion

This is an inspiring autobiography especially for those who have to break barriers to make their marks. It outlines the dedication and hard work required for success in any medical career. The book graphically demonstrates the art and business of neurosurgery quite clearly, and it is an inspiring narrative especially for all who venture into high-risk specialties such as neurosurgery. The book would have been enhanced if the author had also documented the errors which he learned from, or which altered his practice; as it is, the narrative may have conveyed an inaccurate rosy picture of neurosurgical outcomes.

Overall assessment

The combination of technical skills and compassionate care is at the heart of this insightful book, a lesson for all doctors who aspire to be outstanding in their fields. The book graphically entrenches the important lesson of putting the patient first above all other considerations in clinical decision-making. The overriding lesson the author conveyed, to always balance the risks and benefits of any intervention, rings loudly throughout. The book is replete with the core values that should guide excellent clinical practice and I recommend it to all doctors.

Book details

Publisher, Place, Year: Grand Central Life&Style, New York, 2009
Number of chapters: 11
Number of pages: 226
ISBN: 978-0-446-19814-1
Star rating: 5
Price: £5.99