All right, we are honored to hear from Dr. Derek Bruce today. Dr. Bruce was born in Falkirk, Scotland, hopefully I'm not butchering that, and completed medical school at the University of Edinburgh. He went on to neurosurgical training at the University of Pennsylvania and stayed on as faculty for over 10 years, during which time he focused on the care of children at the Children's Hospital of Philadelphia. He went on to a role of Chief of Pediatric Neurosurgery at the University of Texas Southwestern for about 15 years before moving on to Children's National Medical Center in Washington, D.C. Dr. Bruce has published extensively on many aspects of pediatric neurosurgery over his career and has given many invited lectures both nationally and internationally. Dr. Bruce is speaking to us today on his career reflections and on a personal note, he was a co-resident to my chair in residency and I spent about seven years hearing many colorful stories of all the shenanigans they would get up to in training, so hopefully we get a glimpse of that in his talk today. Thank you. APPLAUSE Well, good afternoon, I guess it is. When I was asked to talk and given the choice, of course my first choice as a neurosurgeon was to tell you all the correct way to operate on pineal tumors, complex craniofacials, chordomas, but then it occurred to me that you, like I, already know that you know how to do all these things, so that would sort of be a waste of time. What we have here... I'm sorry. There's the arrow. These are four of my colleagues, that's Hector James, Neil Cassell and Larry Marshall. We were all residents together at one point at Penn. So I thought what I would talk about then was the things I may have learned that I think made me a better neurosurgeon. This is 1966, here am I getting my medical degree from Edinburgh, with the future being hopefully bright and available. And here I am 10 years later, probably at the peak of my career, with the original James Bond, Aston Martin, 007, a girl on my arm, and being an American, a gun in my hand, right? However, there was more to come from that. And what I'd like to spend the rest of the time on really is just trying to point out the things that I think helped me go on enjoying my career. And one of the important things that you've heard about today already is a whole question of being inquisitive and keeping an open mind. From my point of view, I was lucky as a resident, I was interested in ICP, cerebral blood flow and brain oedema. And then in 1974, we got the first CAT scan and Mike already showed you some of these beautiful pictures. And so my focus then was on head trauma, firstly in adults and then in children. And then we got the MRI scan in about 1983, and I had to redo all the stuff with tumors and craniofacials because we had no idea what we were looking at. And then when I left Philadelphia and then went to Dallas and then on, I ended up again being able to get interested in more craniofacial stuff. It was the beginning of rhizotomies and so baclofen pumps. And then epilepsy became important for children and vagal nerve stimulators. So I would simply say to you all that, you know, there's plenty of opportunity to keep busy, to keep thinking. And as far as I'm concerned, really, burnout and boredom, I think, are very closely related. And so I would encourage you. Somewhere along the way, I managed to find time to do some other things as well. And would I do it again? Would I be a pediatric neurosurgeon? Absolutely. I can't think of anything else I would rather do. Here are a bunch. This lady had a pineal tumor at 16. This is a little kid from Africa who had her pituitary gland sitting on her tongue, and there she is after surgery. One of the first chordomas I ever saw, clibal chordoma, in this lady who is now 17 or 18 years old. So I would certainly say to you all that if I were to do this again, I'd pick the same thing. Some of the thoughts, because this is supposed to be a little bit philosophical and what we're thinking about is what we will do next. The first thing important to say is that in 42 years of being in practice, I never had a kid that we couldn't get done in the hospital I worked in. And I know that things have changed and we always had at least 50% of the practice were obviously as they are now, kids on Medicare or kids with no funding at all. And yet, it was our job to get them in. And I think it is important to remember that we're still the primary advocate for our kids and that we have to go to bat for them. Whether or not they have the wherewithal to certify our administrators, if we really believe that they should be able to be done in our place than anywhere else, then you go to bat for it. I heard a lot too about mentoring and mentors. And my program chairman and certainly my intellectual mentor, and in many ways my writing coach was Tom Lankford. I remember at first year through probably 10 years getting papers back from Tom that were unreadable because they were completely covered in red ink. And my writing was prolix and too long. So that was certainly the beginning of mentorship for me. But obviously, the person who was my major mentor was Louis. And really no words to describe his influence on my career and in some ways in my life. And Louis was my mentor in everything from wine to wisdom and everything in between. And Louis died recently. So cheers, Louis, and thanks a lot. The next thing to think about is how well do we criticize ourselves and how well do we think? And I think it's very important for us to start every day without preconceptions, without assuming that we know what's going to happen that day or that the things we see will behave the way we want them to. So at the end of our careers, which slide will we fall into? Will we be saints or will we be remembered as sinners? Now ideally, probably be nice to remember there's a bit of both, which is probably what will happen to most of us. But when we think about what makes a profession, and I think the concept of professionalism seems to be a little bit lost these days. But the difference between a profession and a job is that the person at the end of the profession, the patient, is the most important thing. And these are things that are clear. And with regard to ethics, the question of what system, what do you do? But this, for me, is a very important little thought, which is to the extent that questions of how I behave and how I order my relations with other people are concerned with doing the right thing. They are, at heart, ethical questions. And I think that's a simple way to think of it all day. And therefore, one might ask, why do I and why do you all behave the way we do? And it's important for each of us to develop that insight and to realize that the way we function on a daily basis is really very much dictated by our own histories, and that the rationale we use arises from these deeply held beliefs, the history of our own lives, and can result in behavior that may not be nearly as admirable as we might think. Because I'm a pediatric neurosurgeon, obviously I'm going to do the right thing. And finally, if we don't know the story we live in, then we have no chance of evaluating externally what goes on. And I think this is true for all of us. We're often our own worst enemies, for sure. This is a good old Scots dry-skinned dike. The point being that each stone is movable, but once you get a great big pile of them, they're immovable. And if we do not know what stones are planted within our own brains, or how they got there, then we are trapped by that barrier. And our behavior may be as much of a mystery to ourselves as it is to the people looking in from the outside. And I think that definitely affects the way we treat our patients and their families. So how can we justify decisions that are not in the best interests of the child or the parent? And it is this ability to live with our own story that makes it easy for the best intentioned of us to support inappropriate, dangerous, and even fatal surgical procedures that he or she is not capable of doing, or that do not require to be done. And it's something that we have to think about every single day. And I don't think we can do that unless we have some insight into what our own motivations are. Dwyer's comment that trustworthiness is the pivotal criterion of professional status. And in a world where honesty and trustworthiness seems to have completely gone by the board, and everything is fake news, I think for us, this is still, for me, something that's very important. We also have to go on through our career learning. That the knowledge we have when we finish residency is obviously not going to stay up to date. We have to read, we have to go on studying. We have to develop critical thinking, the ability for each of us to think within ourselves. We have to have empathy for our patients, for the people we work with, for their families. We need confidence, so we can't do what we do. You can't have a bad result one day and then not come to work anymore because you've lost your confidence. But we have to also, in that confidence, retain humility. And enough humanity to get us through each day. These two Greek words, philanthropia, excuse me, and philotechnica, love of the art of practice, are really two things that overlap in our daily lives as surgeons. We love being in the operating room in that sort of closet where we can do our best work. On the other hand, we interact always and every day with other people. And it is this dichotomy between these two concepts that was well recognized by Hippocrates. And I put to you is still this dichotomy is still at the heart of many correct, but also many poor medical decisions, that we get the two mixed up. I sometimes think that it was maybe a lot easier for my generation of neurosurgeons to push the boundaries, to try things we hadn't been taught to do, because the results were so terribly bad. I never saw anybody take out a craniopharyngioma when I was a resident. I never saw a pineal tumor operated on that didn't die. And by and large, if you left the hospital alive from a neurosurgical service, it was a great achievement. Well, but the very fact that we are doing better, that we have more technology, that the results are better, can in fact inhibit your generation from making the progress that needs to be made. It can trigger it, but it can also inhibit it. And let me just point this out, that there is no question whatsoever, if two years, ten years out from your residency, you're doing the same as you were taught in residency, you're quite distinctly and definitely falling behind. Whether it's using the same suture or whether it's using the same technique. You have to change, we have to think. Now, Boulogne made this comment, to linger in the observation of things other than the self implies a profound conviction of their worth. Now, as pediatric neurosurgeons who like to think we spend our day thinking about the children and their parents, one might say this is automatically true and feel very pleased about it. But of course, it's not. So we have to decide priorities. Who is most important? Always, always, always the child. Then, the parents. And finally, way down the bottom, the doctor. We have to allow ourselves some thoughts because we have to go back there every day and do work. But this is the priority list. And for my residents, my fellows, for you guys, Osler's comment that half of what you were taught is wrong has not changed. So as you go through your career, you have to keep up with that half that you're going to miss. And this is something I must say I only came across recently. This is Lord Lister in his textbook of surgery in 1837. And what he says is, it is of the utmost importance to attend to the state of the patient's mind and feelings. He ought not to be kept in suspense, but encouraged and assured, and his apprehension must be allayed. If this cannot be effected, if he is dejected and despondent, talks of the great risks and of the certainty of his dying, it is better that the operation be abandoned or at least delayed. Now, that blew my mind that here at that early on in surgery, with a man who has not a particularly sensitive reputation, was writing that. My own experience with that, unfortunately, was not long after I finished my residency, doing a major blastoma, a huge one on a little beautiful four-year-old girl. The surgery went beautifully, she woke up. Three days later, she died, and she had spent the week in hospital telling her parents and me she was going to die, and two things came out of that. One, I figured he was right, because we never found out. At autopsy, there was no obvious reason, but more importantly, I found the parents were catering to me. We know you did your best, Dr. Bruce, da, da, da, da, da. No, no, I should have been the one comforting them. And it's easy for us to fall into these positions. This other very famous neurosurgeon I like a lot, too, this is Bob the Builder, for those of you who don't know him. And when asked, can I do it, always his answer is, yes, I can, as are we. But I would put it to you that we should add the question, should I do it, in every circumstance? So, in terms of surgery, too, imagery is a big thing for professional athletes. And I think it's a very important thing for professional neurosurgeons. I think it's very important to think your surgery through before you do it. To have some idea what you're going to encounter, to have some idea how you might handle it. As I said there earlier, don't assume, because the minute we assume we know something, we stop learning anything new. The other thing is, in surgery, you have to understand that the lesion does not have to obey your surgical rules. And therefore, you have to be malleable, you have to be willing to work on what is present. And not what you decide should be present, or the way this tumor should present, or what it should do. And always to be patient, and never assume. Always ascertain what you're going to do, and that it's safe to do it before you do it, not after you've done it and then have to come up with a curse word. I think it's important to remember that we, as the doctors, have an ability to suffer for the good and bad results. But we suffer with the child, and we suffer with the family. We cannot suffer for them. And I think for all of us at the beginning of our careers, that's sort of what we want to do. And you have to learn how much of a role you can play, and avoid, as I did, having the family making me feel better for when I had actually killed their child. To recognize that the measure of the result in pediatric neurosurgery is years down the line. It's not when the patient leaves our OR. It's not when the child leaves the hospital. It's often 20 years later. And to remember that, and to try to get as much feedback on that as we can. And finally, to be critical of oneself. It's easy, and we all tend to go through a post-mortem when we have a bad result. But I put it to you, it's not the best time to learn. What you're really doing is working out your guilt. It's much better to take the best operation you've ever done, and think about how you could have done that one better. When we had CT scans and MRIs coming in, one of the reasons for doing a post-op MRI was to look at the rest of the brain. Where had you put the retractor? And if there was retraction there or bleeding somewhere else, that was the time, no matter how well the patient had done, to say to yourself, I didn't do that very well. I could definitely do it better. Honesty, yep, absolutely. We have to be patient, honest with our patients. We have to be honest with our parents and colleagues. And I'm trying to point out, we need to be honest with ourselves, which is the hardest part of all. But in surgery, I do think it's terribly important that everybody is comfortable. These things can go on for a long time. There has to be an atmosphere, and I think, working with kids, maybe this magic is more acceptable. But there has to be an atmosphere that everybody believes and wants things to go well. Because I do believe it can make a difference. And finally, to be focused on the task in hand, and to make sure that everyone, as I say, everyone wants a good result. My advice to you all, be brave, but cautious. Be guided, but not restricted by what you were taught. It's your job to progress our specialty now. Always seek for a better way or a better result. Even if the results seem good, and they're certainly a lot better than when I started. Quote your results, not the best results in someone else's paper. And this is hard, this is very hard. But that's honesty, I'm sorry, there was another one there, well, I guess not. So, Isaac Watts, another Englishman, do not hover always on the surface of things, nor take up suddenly with mere appearances. But penetrate into the depth of matters, as far as your time and circumstances allow, especially in those things that relate to your profession. And for me, what this means is, all the stuff I've been saying before, don't let it wash over you. What happens each day can be a stepping stone to doing a better job the next day. To be avoided, financial considerations. We should never do a surgery because we're getting paid. We should not do a surgery because we're not getting paid. And that's getting tougher maybe. Completing a series unless it's actually in an approved trial. Being absolutely honest with the families about our own results, not what's best in the literature. Avoid sort of trying to frighten families into having something done, if we're not absolutely sure that that is going to happen. And that we are the child and family's most important advocates. This may be arguable, but I think, unfortunately, it's true, certainly here in the States, that ego and money are the two largest factors driving the delivery of care to the children we treat, and it's our responsibility as professionals to have insights into our own history, our own modes of justifying what should be unacceptable behavior to make it acceptable to us. And when faced with these difficult decisions, this was a thought from Johnson, and it's quite complex. But I would simply say this, that we require constant conscious exploration of our own thoughts, our own decisions, and insight into our own behavior. And if we can't be the prime defenders of what's best, not just doing this operation, but what's best for our children and their families, then we have to question whether we really should be delivering that care. So, as I come to an end, it's easy to believe that what we are doing is indeed killing dragons. We're the knight on the white horse, and we're doing a good deal. But we have to remember that the other option is that maybe we're tilting at windmills, as Cervantes did. And maybe we have to, on any given day, be quite certain which of these endeavors we're actually involved in. So I would say to you, when I started my career, there was a big abyss, and who knew what the future would bring. There's lots and lots for all of you still to do. I've got a smile on my face because I'm checking out. Success or failure in my career, there's plenty of room for you to advance our specialty. And the smile is because it's now your job, not mine. Thank you very much. Thank you.

Dr. Derek Bruce

neurosurgeon

career reflections

patient well-being

technology impact

striving for improvement