Another Day in the Frontal Lobe
Author: Katrina Firlik

Background

This book is a lighthearted reflection of the life of a neurosurgical trainee as she navigated her way through the brain, and as she negotiated the realities of her specialty. The book explores themes that range from the delicate skills of brain surgery, to the ‘cool technology‘ advancing its practice.  With insightful observations, the book also portrays the positive and negative peculiarities of neurosurgeons, depicting qualities that are consistent with their perceived stereotype, but also showing a surprising degree of divergence. The author particularly revealed how she endured in a male-dominated field, frequently overlooking and excusing sexist remarks and behaviours. She also explored the human aspects of her specialty, revealing how her ‘excessive introspection‘ humanised what she characterises as an otherwise insensitive enterprise. With themes ranging from the clinical to the academic, and from the routine to the challenging, this is an enlightening perspective of what is arguably the most intricate of surgical specialties (pages 93-99).

 

Synopsis

The author’s frank and hard-hitting characterisation of neurosurgeons is of stereotypically competitive and confident men who are ‘part scientist, part mechanic’. But arguing that neurosurgeons vary significantly in their personalities and technical attitudes, she pointed out that ‘some neurosurgeons tend toward the more brainy, nerdy end of the spectrum, whereas others are more of the jock or frat boy variety’. She also noted that neurosurgeons display ‘the entire gamut of clinical decision making, from the most conservative to the most aggressive‘, and that their reaction to stress also spans a range of emotions, from calmness to temper tantrums and foot stomping. Defending the characteristic ‘cool external demeanor‘ that neurosurgeons adopt in emergencies, the author maintains that this does not reflect a lack of feeling or of humanity, but is a requirement of ‘the practicality of getting a job done’. And with typical disdain for ‘other brain specialists‘ who only ‘pontificate from outside the cranium’, the author basked in the truism that neurosurgeons enjoy their ‘additional manual relationship’ with the complex brain (pages 4, 46-47, 51, 78-79 and 221).

A key theme the book is the author’s exploration of the macho aspects of neurosurgical culture. Admitting that ‘aggressive action is a highly valued trait in a neurosurgical trainee’, she explained that ‘if you appear weak or indecisive, people will walk all over you’. She also referred to the ‘blunt‘, and at times unseemly and callous, nature of the conversations neurosurgery residents have about their patients, and she illustrated this with how they sometimes depict their patients with poor prognoses as ‘toast‘. She however excused their use of ‘juvenile black humor‘, arguing that this helps them to deal with situations which are ‘so disturbing as to defy normal conversation’. Indeed, she maintained that such sarcasm was not a sign of cruelty towards patients, but a ‘sure way to lighten the situation and allow us to keep working especially when we’re overly exhausted and ready to snap‘. She similarly brushed away her experience of sexism in a male-dominated specialty in which women constituted only 5% of its members; this was evident when she condoned a ‘Tall Cool Red One‘ poster of a redhead in a bikini which hung in the residents’ call room even though she acknowledged that the picture gave the room ‘a decidedly masculine feel’ (pages 63, 122, 133-134, 15, 40 and 69).

The backbreaking nature of neurosurgical practice was expectedly a central theme of the book, the author showing how the work spans ‘the spectrum from pure enjoyment to tedious boredom or even frustration‘. Illustrating the ‘unremitting routine’ of neurosurgical practice, the author described how her typical work day, which commences as early as 4.30 am, consists of ward rounds, team meetings, and operations – a schedule that left her ‘chronically sleep-deprived‘ and at risk of burnout. To mitigate this hazard, she identified what she considered to be the ingredients of joyful surgery, and these included ‘sharp and well-maintained instruments, a thin patient, glitch-free technology, good music…and a quiet pager‘. It also helped that she had interests in the non-surgical aspects of the brain, and in her case, she was fascinated with ‘the enigma of consciousness‘, a topic that she said was previously considered ‘too messy‘, but has since emerged as a subject worthy of ‘serious scientific study’. Pointing out that such notable figures as Francis Crick and Christof Koch believe that consciousness ‘is most likely mediated by relatively few specific neurons‘, she explored the speculations that these cells likely reside in the claustrum – a structure that is uniquely ‘connected to just about every other region‘ of the brain (pages 70-71, 100-101 and 81-82).

A fascinating feature of the book is the author’s description of the daring feats of neurosurgery she has observed and performed. One such encounter which made an indelible impact was witnessing a cocky surgeon operating on a young woman with a very large ‘handshake’ arteriovenous malformation (AVM). She depicted the surgery as ‘a technical tour de force‘, recounting how the AVM ‘did not give in easily’ as it has ‘spent its entire existence within the dark confines of her skull, sharing space with her brain’. The author poignantly noted that although the surgery was successful, the patient’s recovery was complicated by catastrophic and fatal bleeding – unsurprising because the lesion was ‘a native and natural part of her, not an invader’. This experience taught her that in high-risk situations, inaction may be the best action especially as ‘the patient is the one taking the risk, not the surgeon’. The case also taught her that when it comes to controlling catastrophic bleeding, there is a danger when self-confidence triumphs over ‘straightforward acquisition of manual skills‘, a lesson that she used to acquire the skills that became a source of pride for her amongst her colleagues – an achievement that made her feel like ‘one of the guys‘ (pages 103-106, 49, 70-74, 100-101 and 85-88).

Emotions was a theme that featured quite prominently and unexpectedly for a book that is about a prototypical dispassionate surgical specialty. In this exploration, the author described the ambivalent attitude most neurosurgeons have towards managing their patients’ emotions, both when they are discussing the risk of surgery and when they are breaking bad news. Whilst some neurosurgeons ‘loathe‘ dealing with the emotional aspect of patient care, because they find this complicated and time-consuming, she showed that others like her find it most rewarding. Illustrating these divergent approaches, she contrasted the sadistic blunt surgeon who communicates with a ‘sharklike demeanor‘, a ‘monotone voice‘, and ‘an uncanny ability to make a patient and their family burst into tears‘, with ‘the warm hand-holder who peppered religious speak into his counselling‘. The prevailing approach however is to keep emotions under control, the reason why the author was relieved that none of her colleagues witnessed the breakdown of her ‘calm demeanor‘ and ‘unbridled outpouring of grief‘ when she delivered ‘a death sentence‘ of a brain tumour to an otherwise healthy young man. She explained that the reason neurosurgeons erect a protective armour around their emotions is the fear that expressing empathy will mark them out as weak, and that getting too involved in patient-related emotional issues would make them vulnerable to ‘a chronic depressive state‘ when faced with conditions that they cannot cure (pages 107-108, 115-128, 144 and 127).

Opinion

This is a very revealing look into the world of the neurosurgical resident which exalts the specialty just as it confronts it darker sides. As she explores the hard realities of neurosurgical training and the diversity of neurosurgeons and their practices, the author blends the technical with the human elements of the specialty. She also honestly reflects on the human paradoxes of the field, reluctant to express emotions on one hand, and yet fully aware of the feelings of their patients on the other. The author occasionally veered off to contemplate subjects such as religion which seemed excessive and not directly relevant to the subject matter of the book. The book’s themes are otherwise cogent and lie right at the heart of medical practice.

Overall assessment

This book brings out important lessons concerning specialist medical training and practice which apply across the specialities. The author’s observant and philosophical approach to the subject revealed the contradictory aspects of a rapidly evolving specialty, noting its highly technical foundation, but pointing out areas of concern regarding physician behaviour and patient care. The book is well-written, the contents relevant, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  Random House, New York, 2006
Number of chapters: 20
Number of pages: 271
ISBN: 9781400063208
Star rating: 4
Price: £1.08