GENERAL SCIENTIFIC SESSION 3 GENERAL SCIENTIFIC SESSION 3
Neurosurgeons as Healers “If a doctor’s life may not be a divine vocation, then no life is a vocation and nothing is divine.”—Harvey Cushing “Curing means eliminating all evidence of disease, while healing means becoming whole.”—Lissa Rankin, MD Anil Nanda, MD, MPH Richard Murray, MD Department of Neurosurgery, LSU Health Sciences Center Shreveport, Shreveport, Louisiana Correspondence: Anil Nanda, MD, MPH, FACS, Department of Neurosurgery, LSU Health Sciences Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71105. E-mail: [email protected] Copyright © 2015 by the Congress of Neurological Surgeons.
The 2014 CNS Annual Meeting presentation on which this article is based is available at http://bit.ly/1EOv0nu.
CLINICAL NEUROSURGERY
T
he ultimate purpose of the medical sciences is to assist in the healing and recovery of patients from disease. Within this statement, the roles of the different entities involved in this complex relationship are defined. The patient and his or her disease are at the center of the construct. The physician at the periphery acts as guide to the process. By looking at medical history, neurosurgeons must find a balance between acting as curer and healer to survive and thrive in today’s medical society. Separate, but not separable, a patient and his disease are more than just the sum of his or her healthy self with the added symptoms of disease. Illness and its impact on daily functioning and quality of life stretch far beyond a simple overlay of symptoms. At the same time, all patients carry within themselves not only the burden of their disease but also the unique ability to heal and recover. The physician’s scientific role within this process is to consider diagnostic possibilities, on the basis of his clinical experience and special investigations, to arrive at a working diagnosis, and then to recommend a treatment course. The execution of this process is then tailored to every patient’s unique healing and recovery potential. However, the physician’s role is not purely scientific. Without compassion and care, true healing cannot occur. Although a patient can be cured by surgery or medicine, a physician must also act as a healer to make a patient whole again. Central to this process is the unique role of the doctor-patient relationship, which serves multiple purposes. The trust engendered in this relationship allows the discussion of sensitive and personal topics in discussions of medical history and physical examination. Patients undergo tests, treatments, and procedures that are often inconvenient, are sometimes painful, and carry inherent risks. For a patient to accept
such a process, he or she has to believe the physician’s intentions will lead to inherent benefit for the patient. Finally, a positive outlook by the physician helps to maintain hope, crucial to the continued participation and functioning of the individual. Hippocrates said it best: “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.”1 Henry Siegert, a noted medical historian, said in 1932: “Medicine is closely associated with the general culture. Every change in medical thinking is the outcome of the world point of view of the time.”2 Spirituality is generally intertwined with culture, so spirituality has, in turn, influenced the doctor-patient relationship. This relationship has evolved over the years, in the same way that society and popular culture have evolved. It is worth examining the major changes to understand where the current stance lies and in which direction it could potentially move in the future. In the days of Ancient Greece, illness was regarded as a divine punishment, and healing occurred as a gift from the gods.3 Places of healing were often places of worship to specific deities such as the Temple of Asclepius at Pergamon. At this temple, patients were encouraged to sleep inside the temple to pray for intervention to their chosen gods. Illness then was not an individual entity but rather a state of systemic disease in which the human body was affected in total and which the gods sent as a sign of displeasure. Treatments then were aimed at appeasing these gods and included prayer, sacrifices, and religious ceremonies.3 The Greeks even celebrated a god of medicine, Asclepius. Known as the Divine Physician, modern medicine continues to honor the deity by using the Rod of Asclepius as a symbol for hospitals, clinics, and ambulances.4 Neurosurgery also has a place in Greek mythology. When Zeus suffered from an intractable headache, Hephaestus used his axe to split his skull, performing a god-like craniotomy (Figure 1). The splitting of the skull revealed Zeus’ daughter, Athena, and relieved his headache.5 Neurosurgery
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 129
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NANDA AND MURRAY
FIGURE 1. Michael Maier’s Atalanta Fugiens emblem. Hephaestus performs a craniotomy on Zeus, freeing and birthing the goddess Athena.
is represented in other forms of ancient mythology, too. In Chinese myths, Hua Tuo, a famous doctor, performed a craniotomy on Cao Cao, the King of the Wei Kingdom, to treat his severe headache caused by a brain tumor.6 An Egyptian myth dating to approximately 3000 BC describes the oldest recorded neurosurgical operation. Isis, the mother god, and Thoth, god and inventor of medicine, resurrected Osiris, reversing a cervical spine injury.7 In Hindu mythology, the god Ganesha receives a head transplant (Figure 2), making this the earliest record of a neurosurgical brain transplantation.8 Even during ancient periods, medicine and spirituality are intertwined. Entering into this milieu, Hippocrates of Kos revolutionized the medical thoughts of the day. He separated medicine from religion and credited disease as the product of diet, living habits, and environmental factors. In his writing on epilepsy, “On the Sacred Disease,” he stated, “It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from the originates like other affections. Men regard its nature and cause as divine from ignorance and wonder. . ..” His influence on modern medicine went further still, with his work “On the Physician.” He described the basics of professionalism, recommending that “physicians should be well kempt, honest, calm, understanding, and serious.” And within the Hippocratic Corpus, the body of works ascribed to Hippocrates, one also finds the Hippocratic Oath, a document that defines the role of the physician and binds him or her to a strict ethical code.9 In the Roman Empire, Scribonius, a physician in the court of Emperor Claudius, used the word profession in a book of prescriptions from 47 AD. Scribonius defined profession as “a commitment to compassion or clemency in the relief of
130 | VOLUME 62 | NUMBER 1 | AUGUST 2015
FIGURE 2. Ganesha, a figure in Indian mythology, serves as first evidence of a brain transplantation.
suffering.” Humanistic values such as benevolence and compassion became part of the practice of medicine, adding to physicians’ role as both curer and healer.10 Beneficence, in which a physician acts as the guardian of the patient, making decisions in what he or she judges to be the best interests of the patient, has been in place since the earliest days. Hippocrates himself, although a very forward-thinking individual in many other ways, stated that most information should be kept from the patient to better heal him or her.9 The physician’s primary task was seen to be to inspire the trust and confidence of the patient, thereby promoting healing, with patient participation in decision making discouraged; a patient was unlikely to have a better understanding of the pathology, thus participation was likely to interfere with healing. The communication of difficulties or a grace prognosis was seen as potentially eroding trust in the physician. In the 1300s, a prominent French surgeon, Henri de Mondeville, stated that a cure should be promised to every patient in the hope that this positive outlook would inspire a better prognosis.11 Thomas Percival, a British physician who wrote Medical Ethics in 1803, said that patients had a right to the truth but that, if a physician could provide better treatment by
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NEUROSURGEONS AS HEALERS
lying or withholding treatment, then the physician should do as he or she thinks best.12 Sir William Osler, a Canadian physician who assisted in the creation of Johns Hopkins Hospital, brought the theory of Aequanimitas to the realm of modern medicine (Figure 3). Osler regarded Aequanimitas as the premiere quality in a physician and expressed the theory in his essay of the same name. He refers to the trait as remaining calm during difficult, stressful periods, maintaining a clear sense of judgment to make the best decision for a patient. The practice also means being a comfort to patients, even when the outlook is bleak. For example, when a visiting Englishman died in Montreal unexpectedly, Osler sought out his parents to tell them not only of the news but also about the man’s last hours. He spoke of his family and faith and asked to be read Isaiah 43. This telling of spirituality and compassion comforted the family and proved Osler’s passion for Aequanimitas.13 Starting in the 1970s in the United States, as a result of social change and progressive education of the general public, this dominant model of beneficence was challenged and progressively displaced with more contemporary models. In 1972, Robert Veach first proposed a “Contractual Model of collaborative decision making” in which he defined 4 types of physician-patient relationship: priestly, engineering, collegial, and contractual. This
was further refined 2 decades later by the publication of Ezekiel Emanuel and Linda Emanuel’s “Four Models of the PhysicianPatient Relationship.” In this document, the authors proposed 4 different types of models by which the physician-patient relationship could be practiced, ranging from a purely paternalistic approach to a collaborative decision-making process in which mutual dialog and information are shared to arrive at a treatment plan that is in keeping with a patient’s value system.14 The modern definition of physician healer then is much different from that which has been the standard over the millennia. Modern healers are scientists who excel at the eradication of disease but at the same time are in touch with the human element of the physician’s art. Although our knowledge, capabilities, and tools have expanded tremendously, our patients are still human and still require the fulfillment of basic human needs: understanding, respect, knowledge, comfort, caring, and hope. Maintaining the human element of healing can be difficult in today’s fast-paced medical community, but it remains as important as, if not more important than, diagnosis. For example, a 1999 study in the Journal of Clinical Oncology found that enhanced compassion was short, simple, and effective in decreasing participants’ anxiety. Further research is needed in this area to fully understand the effects of compassion, especially in a clinical setting.15 A study in radiology involved including patients’ photos with their radiologic images, adding a human element to a practice that receives little human interaction. The study proved more thorough readings in cases with a patient’s photograph.16 Simply put, humanism makes physicians better. It helps physicians understand their patients, which is imperative in healing and curing. Studies in spirituality have explored potential health benefits of faith. A 1997 study in blood pressure changes in nuns suggests that living in a stress-free, monastic environment can prohibit high blood pressure.17
ARE WE, AS NEUROSURGEONS, STILL HEALERS?
FIGURE 3. Sir William Osler’s use of aequanimitas showcased a means to show compassion in modern medicine.
CLINICAL NEUROSURGERY
Neurosurgery functions in a unique position in the modern medical world. In situations that are often life-threatening, in which comprehension and cognition are impaired or the potential for life-altering damage exists, neurosurgeons perform at their peak. Lesions judged inoperable or unmanageable a few decades ago can now be routinely addressed. We operate on diseases that speak to the very core of personal identity, emotion, and cognitive abilities. We counsel patients, guide healthcare teams, console and encourage families, and guide the path to healing. So yes, neurosurgeons are still healers, although they are healers within a very different modern medical world. As a result of external pressures, neurosurgeons are at risk of losing their role as healers. The very technological advances that enabled our field to flourish have the seductive ability to objectify our patients. Imaging studies allow us to visualize disease with remarkable accuracy; the operating microscope allows us to delimit
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 131
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NANDA AND MURRAY
disease into questions about which perforator to sacrifice or which white matter tract to leave untouched. This risks dehumanizing our patients and converts the very real risks that we take on their behalf into merely technical decisions. Gone are the days of the neurosurgeon functioning in isolation, controlling all aspects of a specific patient’s treatment and recovery. The increasing complexity of modern medicine necessitates that we function as members of larger teams, with physician extenders often serving at the front lines of patient contact and neurosurgeons steering this process from behind a busy operating schedule. Superspecialization within medicine limits the time that any one physician has with a patient. Decreasing reimbursement necessitates decreased contact time and increased clinic efficiency. This removes us from human contact and separates us from the patient, thus impoverishing the relationship that is formed. During their surgeries, neurosurgery patients are asleep and not aware of the delicacy and care with which we perform their surgery. During preoperative planning and conferences, neurosurgeons spend time thinking about the patient’s problem, discussing it with colleagues, and planning the surgery. In this very process, although the therapeutic relationship is forged on the part of the surgeon, the patient often remains unaware of the time, energy, and effort that went into this process; therefore, the patient remains unaware of how much work of healing has been done. The very acuity of the situation in which neurosurgeons function often limits the ability to interact. The patient with the emergent epidural hematoma might need to be rushed to the operating room without anyone being available to discuss the implications or to obtain consent. “Emergency consent implied” is common for neurosurgery patients. In a society that values achievement and results above affiliation and association, we ourselves risk impoverishing the experience and our careers by neglecting the human element in the healing process. It is the human interaction, on the part of both the patient and the surgeon, that ennobles our professional lives, heals our patients, and allows us to participate in the healing process.
132 | VOLUME 62 | NUMBER 1 | AUGUST 2015
Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Karff S. Illuminating the art of medicine. AMA J Ethics. 2009;11(10):788-792. 2. Noble J. The role of the physician as a healer in the twenty-first century. J Gen Intern Med. 1990;5(6):510-515. 3. Lips Castro W, Urenda Arias C. A review of the principle mythical gods in ancient Greek medicine [in Spanish]. Gacta Med Mex. 2014;150(suppl 3):377-385. 4. Rabinerson D, Salzer L, Gabbay-Benziv R. Oh gods, snakes and staff: the emblem of the medical profession [in Hebrew]. Harefuah. 2014;153(10): 617-620, 623. 5. Brasiliense LB, Safavi-Abbasi S, Crawford NR, Spetzler RF, Theodore N. The legacy of Hephaestus: the first craniotomy. Neurosurgery. 2010;67(4):881-884. 6. Wai FK. On Hua Tuo’s position in the history of Chinese medicine. Am J Chin Med. 2004;32(2):313-320. 7. Filler AG. A historical hypothesis of the first recorded neurosurgical operation: Isis, Osiris, Thoth, and the origin of the djed cross. Neurosurg Focus. 2007;23(1):E6. 8. Kumar R, Kaira SK, Mahapatra AK. Lord Ganesha: the idol neurosurgeon. Childs Nerv Syst. 2008;24(3):287-288. 9. Emery AE. Hippocrates and the oath. J Med Biogr. 2013;21(4):198-199. 10. Pellegrino ED, Pellegrino AA. Humanism and ethics in Roman medicine: translation and commentary on a text of Scribonius Largus. Lit Med. 1988;7(10): 22-38. 11. Vrebos J. Thoughts on a neglected French medieval surgeon: Henri de Mondeville (1/21260-1320). Acta Chir Belg. 2011;111(2):107-115. 12. Namm JP, Siegler M, Brander C, Kim TY, Lowe C, Angelos P. History and evolution of surgical ethics: John Gregory to the twenty-first century. World J Surg. 2014;38(7):1568-1573. 13. Rodin AE, Key JD. William Osler and Aequanimitas: an appraisal of his reactions to adversity. J R Soc Med. 1994;87(12):758-763. 14. Da Rocha AC. Back to basics in bioethics: reconciling patient autonomy with physician responsibility. Philos Compass. 2008;4(1):56-68. 15. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371-379. 16. Turner YN, Hadas-Halpern I. The effects of including a patient’s photograph to the radiographic examination. Paper presented at: RSNA Conference; 2008. 17. Timio M, Lippi G, Venanzi S, et al. Blood pressure trend and cardiovascular events in nuns in a secluded order: a 30-year follow-up study. Blood Press. 1997; 6(2):81-87.
Acknowledgement We thank Tara Bullock for assistance with this article.
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
Neurosurgeons as Healers “If a doctor’s life may not be a divine vocation, then no life is a vocation and nothing is divine.”—Harvey Cushing “Curing means eliminating all evidence of disease, while healing means becoming whole.”—Lissa Rankin, MD Anil Nanda, MD, MPH Richard Murray, MD Department of Neurosurgery, LSU Health Sciences Center Shreveport, Shreveport, Louisiana Correspondence: Anil Nanda, MD, MPH, FACS, Department of Neurosurgery, LSU Health Sciences Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71105. E-mail: [email protected] Copyright © 2015 by the Congress of Neurological Surgeons.
The 2014 CNS Annual Meeting presentation on which this article is based is available at http://bit.ly/1EOv0nu.
CLINICAL NEUROSURGERY
T
he ultimate purpose of the medical sciences is to assist in the healing and recovery of patients from disease. Within this statement, the roles of the different entities involved in this complex relationship are defined. The patient and his or her disease are at the center of the construct. The physician at the periphery acts as guide to the process. By looking at medical history, neurosurgeons must find a balance between acting as curer and healer to survive and thrive in today’s medical society. Separate, but not separable, a patient and his disease are more than just the sum of his or her healthy self with the added symptoms of disease. Illness and its impact on daily functioning and quality of life stretch far beyond a simple overlay of symptoms. At the same time, all patients carry within themselves not only the burden of their disease but also the unique ability to heal and recover. The physician’s scientific role within this process is to consider diagnostic possibilities, on the basis of his clinical experience and special investigations, to arrive at a working diagnosis, and then to recommend a treatment course. The execution of this process is then tailored to every patient’s unique healing and recovery potential. However, the physician’s role is not purely scientific. Without compassion and care, true healing cannot occur. Although a patient can be cured by surgery or medicine, a physician must also act as a healer to make a patient whole again. Central to this process is the unique role of the doctor-patient relationship, which serves multiple purposes. The trust engendered in this relationship allows the discussion of sensitive and personal topics in discussions of medical history and physical examination. Patients undergo tests, treatments, and procedures that are often inconvenient, are sometimes painful, and carry inherent risks. For a patient to accept
such a process, he or she has to believe the physician’s intentions will lead to inherent benefit for the patient. Finally, a positive outlook by the physician helps to maintain hope, crucial to the continued participation and functioning of the individual. Hippocrates said it best: “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.”1 Henry Siegert, a noted medical historian, said in 1932: “Medicine is closely associated with the general culture. Every change in medical thinking is the outcome of the world point of view of the time.”2 Spirituality is generally intertwined with culture, so spirituality has, in turn, influenced the doctor-patient relationship. This relationship has evolved over the years, in the same way that society and popular culture have evolved. It is worth examining the major changes to understand where the current stance lies and in which direction it could potentially move in the future. In the days of Ancient Greece, illness was regarded as a divine punishment, and healing occurred as a gift from the gods.3 Places of healing were often places of worship to specific deities such as the Temple of Asclepius at Pergamon. At this temple, patients were encouraged to sleep inside the temple to pray for intervention to their chosen gods. Illness then was not an individual entity but rather a state of systemic disease in which the human body was affected in total and which the gods sent as a sign of displeasure. Treatments then were aimed at appeasing these gods and included prayer, sacrifices, and religious ceremonies.3 The Greeks even celebrated a god of medicine, Asclepius. Known as the Divine Physician, modern medicine continues to honor the deity by using the Rod of Asclepius as a symbol for hospitals, clinics, and ambulances.4 Neurosurgery also has a place in Greek mythology. When Zeus suffered from an intractable headache, Hephaestus used his axe to split his skull, performing a god-like craniotomy (Figure 1). The splitting of the skull revealed Zeus’ daughter, Athena, and relieved his headache.5 Neurosurgery
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 129
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NANDA AND MURRAY
FIGURE 1. Michael Maier’s Atalanta Fugiens emblem. Hephaestus performs a craniotomy on Zeus, freeing and birthing the goddess Athena.
is represented in other forms of ancient mythology, too. In Chinese myths, Hua Tuo, a famous doctor, performed a craniotomy on Cao Cao, the King of the Wei Kingdom, to treat his severe headache caused by a brain tumor.6 An Egyptian myth dating to approximately 3000 BC describes the oldest recorded neurosurgical operation. Isis, the mother god, and Thoth, god and inventor of medicine, resurrected Osiris, reversing a cervical spine injury.7 In Hindu mythology, the god Ganesha receives a head transplant (Figure 2), making this the earliest record of a neurosurgical brain transplantation.8 Even during ancient periods, medicine and spirituality are intertwined. Entering into this milieu, Hippocrates of Kos revolutionized the medical thoughts of the day. He separated medicine from religion and credited disease as the product of diet, living habits, and environmental factors. In his writing on epilepsy, “On the Sacred Disease,” he stated, “It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from the originates like other affections. Men regard its nature and cause as divine from ignorance and wonder. . ..” His influence on modern medicine went further still, with his work “On the Physician.” He described the basics of professionalism, recommending that “physicians should be well kempt, honest, calm, understanding, and serious.” And within the Hippocratic Corpus, the body of works ascribed to Hippocrates, one also finds the Hippocratic Oath, a document that defines the role of the physician and binds him or her to a strict ethical code.9 In the Roman Empire, Scribonius, a physician in the court of Emperor Claudius, used the word profession in a book of prescriptions from 47 AD. Scribonius defined profession as “a commitment to compassion or clemency in the relief of
130 | VOLUME 62 | NUMBER 1 | AUGUST 2015
FIGURE 2. Ganesha, a figure in Indian mythology, serves as first evidence of a brain transplantation.
suffering.” Humanistic values such as benevolence and compassion became part of the practice of medicine, adding to physicians’ role as both curer and healer.10 Beneficence, in which a physician acts as the guardian of the patient, making decisions in what he or she judges to be the best interests of the patient, has been in place since the earliest days. Hippocrates himself, although a very forward-thinking individual in many other ways, stated that most information should be kept from the patient to better heal him or her.9 The physician’s primary task was seen to be to inspire the trust and confidence of the patient, thereby promoting healing, with patient participation in decision making discouraged; a patient was unlikely to have a better understanding of the pathology, thus participation was likely to interfere with healing. The communication of difficulties or a grace prognosis was seen as potentially eroding trust in the physician. In the 1300s, a prominent French surgeon, Henri de Mondeville, stated that a cure should be promised to every patient in the hope that this positive outlook would inspire a better prognosis.11 Thomas Percival, a British physician who wrote Medical Ethics in 1803, said that patients had a right to the truth but that, if a physician could provide better treatment by
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NEUROSURGEONS AS HEALERS
lying or withholding treatment, then the physician should do as he or she thinks best.12 Sir William Osler, a Canadian physician who assisted in the creation of Johns Hopkins Hospital, brought the theory of Aequanimitas to the realm of modern medicine (Figure 3). Osler regarded Aequanimitas as the premiere quality in a physician and expressed the theory in his essay of the same name. He refers to the trait as remaining calm during difficult, stressful periods, maintaining a clear sense of judgment to make the best decision for a patient. The practice also means being a comfort to patients, even when the outlook is bleak. For example, when a visiting Englishman died in Montreal unexpectedly, Osler sought out his parents to tell them not only of the news but also about the man’s last hours. He spoke of his family and faith and asked to be read Isaiah 43. This telling of spirituality and compassion comforted the family and proved Osler’s passion for Aequanimitas.13 Starting in the 1970s in the United States, as a result of social change and progressive education of the general public, this dominant model of beneficence was challenged and progressively displaced with more contemporary models. In 1972, Robert Veach first proposed a “Contractual Model of collaborative decision making” in which he defined 4 types of physician-patient relationship: priestly, engineering, collegial, and contractual. This
was further refined 2 decades later by the publication of Ezekiel Emanuel and Linda Emanuel’s “Four Models of the PhysicianPatient Relationship.” In this document, the authors proposed 4 different types of models by which the physician-patient relationship could be practiced, ranging from a purely paternalistic approach to a collaborative decision-making process in which mutual dialog and information are shared to arrive at a treatment plan that is in keeping with a patient’s value system.14 The modern definition of physician healer then is much different from that which has been the standard over the millennia. Modern healers are scientists who excel at the eradication of disease but at the same time are in touch with the human element of the physician’s art. Although our knowledge, capabilities, and tools have expanded tremendously, our patients are still human and still require the fulfillment of basic human needs: understanding, respect, knowledge, comfort, caring, and hope. Maintaining the human element of healing can be difficult in today’s fast-paced medical community, but it remains as important as, if not more important than, diagnosis. For example, a 1999 study in the Journal of Clinical Oncology found that enhanced compassion was short, simple, and effective in decreasing participants’ anxiety. Further research is needed in this area to fully understand the effects of compassion, especially in a clinical setting.15 A study in radiology involved including patients’ photos with their radiologic images, adding a human element to a practice that receives little human interaction. The study proved more thorough readings in cases with a patient’s photograph.16 Simply put, humanism makes physicians better. It helps physicians understand their patients, which is imperative in healing and curing. Studies in spirituality have explored potential health benefits of faith. A 1997 study in blood pressure changes in nuns suggests that living in a stress-free, monastic environment can prohibit high blood pressure.17
ARE WE, AS NEUROSURGEONS, STILL HEALERS?
FIGURE 3. Sir William Osler’s use of aequanimitas showcased a means to show compassion in modern medicine.
CLINICAL NEUROSURGERY
Neurosurgery functions in a unique position in the modern medical world. In situations that are often life-threatening, in which comprehension and cognition are impaired or the potential for life-altering damage exists, neurosurgeons perform at their peak. Lesions judged inoperable or unmanageable a few decades ago can now be routinely addressed. We operate on diseases that speak to the very core of personal identity, emotion, and cognitive abilities. We counsel patients, guide healthcare teams, console and encourage families, and guide the path to healing. So yes, neurosurgeons are still healers, although they are healers within a very different modern medical world. As a result of external pressures, neurosurgeons are at risk of losing their role as healers. The very technological advances that enabled our field to flourish have the seductive ability to objectify our patients. Imaging studies allow us to visualize disease with remarkable accuracy; the operating microscope allows us to delimit
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 131
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
NANDA AND MURRAY
disease into questions about which perforator to sacrifice or which white matter tract to leave untouched. This risks dehumanizing our patients and converts the very real risks that we take on their behalf into merely technical decisions. Gone are the days of the neurosurgeon functioning in isolation, controlling all aspects of a specific patient’s treatment and recovery. The increasing complexity of modern medicine necessitates that we function as members of larger teams, with physician extenders often serving at the front lines of patient contact and neurosurgeons steering this process from behind a busy operating schedule. Superspecialization within medicine limits the time that any one physician has with a patient. Decreasing reimbursement necessitates decreased contact time and increased clinic efficiency. This removes us from human contact and separates us from the patient, thus impoverishing the relationship that is formed. During their surgeries, neurosurgery patients are asleep and not aware of the delicacy and care with which we perform their surgery. During preoperative planning and conferences, neurosurgeons spend time thinking about the patient’s problem, discussing it with colleagues, and planning the surgery. In this very process, although the therapeutic relationship is forged on the part of the surgeon, the patient often remains unaware of the time, energy, and effort that went into this process; therefore, the patient remains unaware of how much work of healing has been done. The very acuity of the situation in which neurosurgeons function often limits the ability to interact. The patient with the emergent epidural hematoma might need to be rushed to the operating room without anyone being available to discuss the implications or to obtain consent. “Emergency consent implied” is common for neurosurgery patients. In a society that values achievement and results above affiliation and association, we ourselves risk impoverishing the experience and our careers by neglecting the human element in the healing process. It is the human interaction, on the part of both the patient and the surgeon, that ennobles our professional lives, heals our patients, and allows us to participate in the healing process.
132 | VOLUME 62 | NUMBER 1 | AUGUST 2015
Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Karff S. Illuminating the art of medicine. AMA J Ethics. 2009;11(10):788-792. 2. Noble J. The role of the physician as a healer in the twenty-first century. J Gen Intern Med. 1990;5(6):510-515. 3. Lips Castro W, Urenda Arias C. A review of the principle mythical gods in ancient Greek medicine [in Spanish]. Gacta Med Mex. 2014;150(suppl 3):377-385. 4. Rabinerson D, Salzer L, Gabbay-Benziv R. Oh gods, snakes and staff: the emblem of the medical profession [in Hebrew]. Harefuah. 2014;153(10): 617-620, 623. 5. Brasiliense LB, Safavi-Abbasi S, Crawford NR, Spetzler RF, Theodore N. The legacy of Hephaestus: the first craniotomy. Neurosurgery. 2010;67(4):881-884. 6. Wai FK. On Hua Tuo’s position in the history of Chinese medicine. Am J Chin Med. 2004;32(2):313-320. 7. Filler AG. A historical hypothesis of the first recorded neurosurgical operation: Isis, Osiris, Thoth, and the origin of the djed cross. Neurosurg Focus. 2007;23(1):E6. 8. Kumar R, Kaira SK, Mahapatra AK. Lord Ganesha: the idol neurosurgeon. Childs Nerv Syst. 2008;24(3):287-288. 9. Emery AE. Hippocrates and the oath. J Med Biogr. 2013;21(4):198-199. 10. Pellegrino ED, Pellegrino AA. Humanism and ethics in Roman medicine: translation and commentary on a text of Scribonius Largus. Lit Med. 1988;7(10): 22-38. 11. Vrebos J. Thoughts on a neglected French medieval surgeon: Henri de Mondeville (1/21260-1320). Acta Chir Belg. 2011;111(2):107-115. 12. Namm JP, Siegler M, Brander C, Kim TY, Lowe C, Angelos P. History and evolution of surgical ethics: John Gregory to the twenty-first century. World J Surg. 2014;38(7):1568-1573. 13. Rodin AE, Key JD. William Osler and Aequanimitas: an appraisal of his reactions to adversity. J R Soc Med. 1994;87(12):758-763. 14. Da Rocha AC. Back to basics in bioethics: reconciling patient autonomy with physician responsibility. Philos Compass. 2008;4(1):56-68. 15. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371-379. 16. Turner YN, Hadas-Halpern I. The effects of including a patient’s photograph to the radiographic examination. Paper presented at: RSNA Conference; 2008. 17. Timio M, Lippi G, Venanzi S, et al. Blood pressure trend and cardiovascular events in nuns in a secluded order: a 30-year follow-up study. Blood Press. 1997; 6(2):81-87.
Acknowledgement We thank Tara Bullock for assistance with this article.
www.neurosurgery-online.com
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