We're going to have Dr. Zipfel, the chair of the cerebrovascular section, come up and introduce the Lussenhaupt lecturer. So thanks. I hope everybody's having a good meeting, and I'm really excited today to introduce Dr. Jacques Morkos as our 2018 Yazgierl lecturer. So this lectureship was started in 2011, and Dr. Yazgierl gave the inaugural talk, and you see the other distinguished lecturers to date, and it's a real pleasure and honor to add Dr. Morkos' name to this distinguished list. As introduction, I don't want to at all try to go through everything that Dr. Yazgierl has done, but I thought going back to when he was named Neurosurgery's Man of the Century might be a small place to start in terms of what Dr. Yazgierl has done and meant to the field of neurosurgery. This is a monograph that Dr. Tu wrote in that journal where he was named Man of the Century. I like this quote. He thought that, onto this opportune scene in scientific history came a man with the intense bearing of Cushing, the patience and surgical skill of Dandy, and the daring verve of Krauss. And the patience and surgical skill of Dandy caught my eye as I thought about who might serve as this year's Yazgierl lecturer. Dr. Flam also had a monograph in this issue of neurosurgery talking about his appreciation as a former apprentice. He had this quote, we must always remember the strong spirit of a man totally devoted to the field of neurosurgery, its progress, and the impact of these methods on the well-being of his patients. And also, the totally devoted to the field of neurosurgery caught my eye as I thought about who might serve this year. So I'm proud to announce that Dr. Morkos is the Yazgierl lecturer in 2018. A few introductory slides, courtesy some of Dr. Levy. Dr. Morkos was born and raised in Beirut, Lebanon. He was a precocious child, as you see to the left, and his adoring parents to the right. He graduated from college as well as medical school from the American University of Beirut here in graduation garb. He then had an odyssey of training that went multiple places, and I'm going to go through a few of those. He started as a surgical intern at the American University of Beirut Medical Center, pictured here. He spent time at Doncaster Royal Infirmary in Doncaster, UK, as you see here. Was at Wessex Neurological Center for a short period of time in Southampton, UK, as you see pictured here. St. George Hospital, London, as you see depicted here, and spent several years of neurosurgical training at the National Hospital for Nervous Diseases at Queen Square. He then came to the U.S. and was a resident with Dr. Haros at the University of Minnesota for several years. When he completed residency, he then had specialized fellowship training with Dr. Day at the University of Florida, and a year of fellowship training with Dr. Spetzler in Phoenix. During this period of time of training, he also married his lovely wife, Fiona, while he was in England. He had three children, Isabella, John, and Christina, and Jacques is a wonderful family man, as you see pictured here. Jacques, for those of you who don't know him, is a fun-loving, energetic, and passionate individual who's a real treat to be around. But when I think of Jacques, I think of this, the quintessential anatomist and microsurgeon. As I think about Dr. Morkos and some of the characteristics that he displays, similar to that Dr. Yazgiel, a few things come to mind. Both were talented, ambitious, and determined immigrants. Here's the pathway that Dr. Yazgiel took from Turkey to Germany, to Switzerland, back to Germany, to Vermont, to Switzerland, and then finally at Arkansas. Here's Dr. Morkos' path from Beirut, Lebanon, to London, to Minnesota, Florida, Phoenix, and then back to Miami, where he's been since the 90s. Both have a strong admiration and have been very much influenced by their neurosurgical mentors, Dr. Kronvold for Dr. Yazgiel and Dr. Haros for Dr. Morkos. I think that both are exacting anatomists who really set a very high bar for their trainees in terms of description and understanding of anatomy and how it pertains to microsurgery. As you see listed to the left, a micro neurosurgery textbook of Dr. Yazgiel and articles such as this from Dr. Morkos' lab. I think they're both inspiring teachers, with Dr. Yazgiel having hundreds of fellows, including some that you see listed here, Dr. Morkos has, to my count, trained 24 fellows, including myself, Dr. Buskaya, and Dr. Kim, who's at WashU with me. And I know all of us feel very privileged to have had the tutelage of Dr. Morkos for our fellowship time. I also think they're both indefatigable. I was amazed at the long cases that Dr. Morkos would undertake, and he seemed to be the same person at 7 in the morning as he was at noon, as he was at 5 p.m., and sometimes as he was at 10 p.m. and midnight for a very long case, and was amazed at how he prepared and how he conducted himself throughout long days such as that. And they're both clearly master microsurgeons. Again from Dr. Flam, Yazgiel persisted in emphasizing how important it was to pay scrupulous attention to the most minute details during dissection. I witnessed this firsthand from my year of fellowship with Dr. Morkos and understand how much that meant to my own surgical career. So with that, I'd like to introduce Dr. Yazgiel, the 2018 Yazgiel Lecturer, Master Microsurgeon, Dr. Jacques Morkos. Wow, to have the name with Yazgiel is uncanny, of course highly undeserved, but this is quite something. Yes, Greg Zipfel was my fellow in 2003, and really except for his hairstyle that hasn't changed very much over those years, he's become an unbelievable leader, surgeon, scientist, and clearly has exceeded all his mentors, including myself. So I thank you for this honor. I'm the tall man next to the giant in this picture, and that giant exemplifies mastery, legacy, skill, and art intertwined together, which explains the choice of my title for today, Mastery and Legacy in CV Surgery, the art in your skill, and the skill in your art. If you're expecting a bunch of surgical videos and so forth, you will be sorely disappointed. This is going to be, I hope, philosophical. The young among you have not seen skills like this. This is a video that is unsped. This is Yazgiel at his peak in the 80s. Mastery like this, I don't think, has been quite replicated. So I'm going to talk about nature of mastery. I'm going to talk about surgical skill, professionalism, nature of legacy through mentorship. I'm going to talk about our world, the world of CV surgery, only as it pertains to the art in it, and perhaps some biases and a conclude with the future. There is no textbook today without the word mastery in it. Everybody wants to become a master. What is a master? A skilled practitioner of a particular art or activity. But mastery is very rarely, if ever, a gift. If people only knew how hard I worked to gain my mastery, it wouldn't seem so wonderful at all, Michelangelo has said. Mastery implies creativity and rebellion. Picasso famously said, learn the rules like a pro so you can break them like an artist. What is surgical skill? Let's visit some other disciplines. The cardiothoracic surgeons of the 1980s were very similar to us, I think, in stance and respectability. And when you think of a master surgeon, Denton Cooley comes to mind. Denton Cooley ran four simultaneous rooms, 13 to 20 open heart surgery cases a day. This is a typical, I got this from a good friend of his, typical OR schedule, 1982. Talk about simultaneous surgery today, those days are clearly gone. This is a Texas Heart Institute surgery schedule on Friday, May 28, 1982, 12 ORs, 44 cases. The road to mastery is arduous. Of the first 20 cases performed with cardiac or cardiopulmonary bypass, 19 died. You know the parallels in our field. By 2001, they had performed 100,000 open heart surgeries. We elite surgeons love to count our numbers, don't we? I mean, we know the 6,000 aneurysms among the elite surgeons, including my wonderful and spectacular friend, Michael Lawton, in spite that he's only at seven aneurysms at the moment. Is he in the audience? I love you, you know that. Surgical skill, the problem with surgical skill is the forgotten data point in measuring surgical outcome. It is a taboo topic. It's superseded by unbelievably less relevant predictors. Length of stay, UTI, DVT, survey results from hospital janitors, quality of hospital food, and let's face it, photogenicity of the surgeon as he or she smiles to referring physicians. They seem to count more than surgical skill. But you know, it is understandable because it is hard to define. So who's a better, more skilled surgeon? The flashy and slick or the steady and safe? The efficient versus the effective? It's hard to quantify. All of us have good days, have bad days. And of course, it has tremendous implications for reputation. But can it be measured? Well, it started in 97 with the OSAT scale. Probably many of you are familiar with it. It's straightforward. You look at the criteria of what a skill is on the left, respecting tissue, time and motion and so forth. And you quantify it. Amazingly, it does not take a surgeon to judge another surgical skill by watching their videos. The so-called wisdom of the crowd. You can show surgical videos to laymen and they will correlate beautifully with what an expert would say who's more skilled and who's less skilled. Essentially, you know it when you see it. And this has been validated numerous times, although I must say, just recently. This is 2014. It's probably the first validation among surgery, general surgery residents, OSATs. Andrew Jay validated it in pediatric neurosurgery. Josh Batterson put GoPro cameras on the head of his residents, had them do the surgery and graded the skills. You can do it with cadaveric temporal bone. Can skill be improved? Of course, it can with virtual reality, with simulation in neurosurgical training, and of course, visiting the lab and the cadaveric lab and spending hours improving your skills. But this is very helpful, these new techniques in VR. You can do it for simulated brain tumors. You can do it in 3D dimensional printing. And all of those studies show definite gains. Endoscopic endonasal surgery with a neurotouch. You can see the curve of improvement with training. And I don't need to tell this audience the role of simulators in endovascular training. What is the relevance? If somebody asks you this question, please answer them, outcomes are stupid because it does make a difference. Again, very surprisingly, hasn't been measured until recently. 2004 bariatric surgery correlated surgical skill with complication rates. Interestingly, what counted? Mean annual procedure volume, mean operating room times, but not duration of practice, not completion of fellowship or practicing at the teaching hospital. So they divided the surgeons in four quartiles from the most skilled to the least skilled. And I don't think we need to be bariatric surgeons to realize the video on the left is from a top quartile surgeon. The video on the right is from a bottom quartile surgeon. I don't need to tell you what those words mean at the bottom. You all know them. You all have them. And of course, skill correlated with drop in complications, drop in mortality, decreased operative time, decreased re-operations, decreased re-admissions. Here it is in graph form. Yes, of course, the mentee at the top is struggling to put this bypass. This is some of the first he's done. But what a wonderful feeling to see those mentees later on equal and surpass their mentors. Isn't that what we're here for? And again, field after field, complications relate to skill and relate to experience. This is cataract surgery. The black graphs are likelihood of less complications with years of experience. Interestingly, you can improve but up to a point. You see the dashed line becomes solid line only early in your career. So kind of there is a plateau after which training will probably not improve your skills. But let's face it, technical skill is only a small part of mastery. I invite you to read this book, How to Achieve Mastery. What does it take? Find your calling, apprenticeship, mentorship, then having some form of social intelligence. You get into your creative phase. Lastly, you become a master. I don't have time to talk about all those things. But I think a neglected one is this one, deep observation of the master, of your mentor. I don't think, honestly, residents today are very good at this. We're not talking about passive observation. We're talking about active analysis of what a master is doing, not only in the OR, in the relationship with patients and so forth. But just a word about social intelligence and avoid the seven deadly realities. Social intelligence is very important. You need to have empathy towards others and then use them as mirrors to correct your own deficiencies. What are those seven deadly realities? I'm going to list them, envy, conformism, rigidity, self-obsessiveness, laziness, flightiness, and passive aggression. I challenge you to find a true master in neurosurgery that has really any of those. It is absolutely true. You know this famous wheel from unconscious incompetence to unconscious competence. You know the different names. I like to call them like this. You start with blissful ignorance, tortured ignorance through training, and then practice from forced knowledge to intuitive knowledge. So we want to get our residents from blissful ignorance to intuitive knowledge. Word about professionalism. What is a profession? Yeah, you know, I mean, we know what it is, but when you try to define it, it's hard. Focus on the words in red. We're doing good for people. Specialized, hopefully not financially motivated, ethical, complex knowledge base, you exercise discretion and judgment. Let's think about it this way. Before you try to do the thing right, do the right thing. So morality should come before competence. Well, you know, they told us we need to measure those six competencies in our residents. You know what they are. Language is always muddies the water. So I like to translate what really they want us to talk about, to train them for. Morality, competence, knowledge, adaptability, sociability, resourcefulness. But still, you know, the language has weakened over the years. And I'm going to quote the great philosopher of sarcasm, one of my favorite comedians, George Carlin, I'm not sure how many know him, he's passed now. He had a beautiful thing. He said, you know, in battle, in First World War, you used to call that psychological stress shell shock. By Second World War, you called it battle fatigue. It's already weakening. By the Korean War, it became operational exhaustion. And what happened by the Vietnam War? Post-traumatic stress disorder. I bet you if we still called it shell shock, our poorly treated vets today would have a better deal. You know, here is MOC components. Again, weak language. I bet most of us in this room live in the left column. We follow technical, rational things. You can read them for yourselves. I suggest we all, all of us, try to move a little bit in the right column. Let's understand the value of creativity, of professional judgment, the entire physician behavior. Let's embrace uncertainty. Not everything has to be certain. Mystery versus mastery. My favorite physicist to read is Richard Feynman. I think it's much more interesting to live not knowing than to have answers which might be wrong. And, of course, you can't get through a talk without an Einstein quotation. The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift. So now you've become a master. What's your legacy and how do you do it? What is legacy? Again, Shakespeare, the meaning of life is to find your gift. The purpose of it is to give it away. And this is a beautiful quote. Legacy is not leaving something for people. It is leaving something in people. And how do you do it? Mentorship. I'm not going to tell you the Greek mythology behind Mentor and Telemachus and Odysseus' son. But let's remember, immaturity is the incapacity to use one's intelligence without the guidance of another. So it is not our duty as educators to teach our residents intelligence. It is our duty to teach them how to use it. Mentorship, the mentorship apprenticeship model started in England about 400 years ago, this one-on-one relationship. Of course, you know the Johns Hopkins William Halstead School of the 1890s, the residency program. But let's face it, as you all know, there are significant challenges which you can all read today in mentoring young trainees. I invite you to read some of the work of a general surgeon, John Rombo, who's emeritus professor at UPenn. He's suggesting a change in mentorship model. He's suggesting four changes. Reverse the academic mentorship pyramid. Create what's called mosaic mentoring. Have a different mentor at different stages in one's life. Simulation lab environment. And let's return to that scrub sink OR environment. You do that, you see benefits in performance and skill. Everybody mentors us, our parents, your country of birth, your country that you came to to spend the rest of your life in, your family, and, of course, your professional neurosurgical mentors. Everybody is a source of true mentoring. Let's come to our world of CV surgery. So where is the art here? This is a famous painting. Why is it famous? It's very beautiful. But more importantly, it's been discovered by art critics. It's not one person who painted it. It's a little bit like a surgery we all do. There's a bit from the junior resident, a bit from the chief resident, a bit from the attending. And what's going on here? Well, the leg on the right is not painted as well as Christ's leg. The background is much more beautiful than this pedestrian kind of palm tree. But what's more striking are these two angels. The angel on the left is a more skilled artist who painted this than the angel on the right. You can tell that through X-ray crystallography and so forth. Well, who's the author of the painting? It's Verrocchio. And the person who outdid him in this painting is his famous apprentice, a young Leonardo da Vinci. Of course, most of you know this picture of da Vinci. Well, we've got our own da Vinci in neurosurgery. And this is a person that has merged science and art to an unbelievable degree, a person who talks about art probably more often than he talks about science, but a truly master. I asked Yazar Gil when I was running the WFNS Congress in 2009, Dr. Yazar Gil, I'm planning a session, my life as dot, dot, dot. What would you fill in that dot, dot, dot? He said, an addiction to the neurosciences. You listened to Grit, I think, today, the speaker. This runs through the supreme achievers in every field. He is clearly addicted in a nice way, in a most productive way. No master is born perfect. This is Leonardo da Vinci. He screwed up in this painting. I'm not going to spend too much time, but he made errors in perspective, the length of the Virgin Mary's arm and so forth. This is a man who went to dissect horses to understand how to paint them. This is what we should all be doing, of course, in our field. And I bet you none of you knows these images of the Vitruvian Man. You've never seen them before. They were drawn by people that are not Leonardo. And the one that survived is this one that we all know why. It's science and art. It's proportions all together. It's aesthetics and exactitude. That's what we should be doing in our everyday life as well. Now, nobody is as extreme as Leonardo to write a to-do list for one day. This is a job for one day. He had to get hold of a skull, describe the tongue of the woodpecker and the jaw of a crocodile, give the measurement of the dead using his finger, observe the holes, listen to this, observe the holes in the substance of the brain where there are more or less of them. This is 1470s. Get your books on anatomy bound and some other stuff. This is the mind of an incredible thinker and creator. But he wasn't born like this, you know. Talent, we heard today, talent is a third of where you get in life. Effort counts twice. So I invite you to read that book. Those are the seven ways to become a Leonardo-like person. Curiosity, demonstration, constantly sharpening the senses, the sfumato. That Mona Lisa smile is a sfumato because it's comfortable with ambiguity. Merging arts and science, develop poise and maintain a big picture perspective. I suggest those seven qualities beat MOC, beat the six competencies that we are supposed to teach our residents. Let's go to that. Where is art in our field? Well, it's everywhere. First of all, let me start with this. This is an unbelievably talented Parisian artist, Bernard Pras, who takes garbage, positions it in the right way, and if you look at it from one angle, it is a very famous work of art. You may have already seen what it's going to lead to. Pure garbage positioned properly, just look at it, just through the right angle, and magic happens. Unbelievable, unbelievable. Now, art and science, talented manipulation of garbage may be effective in art, but certainly should have no role in science. It is our job collectively to make sure of that. So where is the art in our science today? Of course, that alone is a whole lecture. There is art in technique. Those unbelievable endovascular creations that are fantastic in moving the field forward, it is very artistic indeed. The web, the pulse rider, coiling an aneurysm without using any contrast, just merging DynaCT with MRA, that's very artistic. Those incredible trans-circulation approaches going through the PCOM to access the SCA, this is skill and art indeed, no question. The endovascular devices, you know them a lot more than I do. They are multiplying, and they are indeed evidence of art in our field. Chris Ogilvie created a scoring system for tendency to re-canalize and re-treat, and you look at the data that he published, there is obviously a certain amount of re-canalization that correlated very well with the severity of the ARSS score. This is up to 61%. This is, you know, significant. So what does that mean? It means there is still a role for surgery. Today, if it disappears one day, fine, let it be. But today there is a role for this. There is a role for this. There is a role for this, and this, and this, for all these unmanageable aneurysms in any other way. There is art in forming a bypass that treats something like this, no question. Like there is art in endovascular. Let's face it. You know what the residency numbers say. We are suffering. We're not doing enough open surgery. I suggest if there is equipoise in your own mind, you're the man or the woman taking care of that patient, I think you should err towards open surgery, to just keep the skill alive while it's needed. We're not talking about planning what's happening in 20 years. Today patients, like I showed you earlier, need a skilled surgeon to take care of them. There is art in decision-making, not just technique. Happy 50th plus one birthday for the bypass surgery. And it shouldn't escape you that it's amazingly also happy 500th birthday minus one, not birthday, anniversary of Leonardo's death on Wednesday, May 2nd, would be $4.99 exactly when this meeting closes. So there is, as I said, there is art in decision-making. So those smart stroke neurologists who are still referring me and others, patients for bypass for ischemia, are applying art in their decision-making. They read through the costs. They read through other randomized studies. And this is a volume I'm getting as referred. This is art, applying art in decision-making. Those patients get better unquestionably. Very selected, but they get better. This is pre-op MRS, post-op MRS for Moyamoya. This is it for atherosclerotic ischemia. Eighty-five to 90% get better in both groups if you select properly. Biases in our field. What is bias? Bias originate with a game of balls. It's a predictable tendency in thinking to favor one perspective over others. Biases diminish the accuracy, but not necessarily the precision of an observation. If you think other people in this room are biased and you're not, welcome to the blind spot bias. We are all biased by nature. I'll give you an example. I can give you hundreds of examples. But this is the same year meta-analysis of MCA aneurysms. Should they be coiled? Should they be clipped? Same data, same raw data. One paper ends up with the conclusion no definite conclusions can be drawn. The other meta-analysis results. We recommend surgical clipping for unraptured MCA aneurysms. What happens? The first one gets published there. The second one gets published there. Perhaps there is bias on both sides. I'm not suggesting one is true and one is false, but this is bias. Why? Human cognition is like this. We have what we call dual process theory. We have intuitive thinking and we have conscious thinking. The first one relies on heuristics and is more prone to bias. The second one is less. How do we make decision making? Most expert cognition relies on heuristics, so it's very hard. You all know it. It's very hard to explain your own medical reasoning to your students or your trainees because our minds work like this, and this is just to reach a diagnosis and management. All these circles and the feedback loops that are occurring cognitively in our mind, this is just preparing for surgery. This is intraoperative management. This is not counting if a disaster happens intraoperatively. Then you start another loop of thinking. We think intuitively or rule-based or analytical or creative, but this is where, of course, the expert surgeon has an advantage because the expert surgeon, unlike the novice, has fluidity of thought, insight, self-assessment, and that interesting word metacognition, your ability to stand out of your own body, look down at what you're doing, and thinking about your thinking. The novice does not have that because it's all so complicated, the way we think. It is said that sapience, other term for wisdom, lives in Brodmann Area 10. For you to achieve true intellect, it's not enough to be intelligent. It's not enough to have affect or be creative. You need that nebulous wisdom. Then true intellect occurs. There are 180 biases. Obviously, I'm not going to count them, but just a couple of them. Mimetic desire and affect heuristic. I refer you to the work of Rene Girard that started this whole field. Bottom line, people want something because somebody they admire or like want it. This is the advertisement industry. It's in our field, too. We're here at the AANS. If Greg Zipfel, who people in general like, is trying to say you should clip something, people will follow that. I'm taking Jay Mokko. I haven't taken anybody else. Says we should flow diverter that, people will follow that. The affect heuristic is interesting. If you dislike something, you're more likely to inflate its risk. If you like it, you're more likely to inflate its benefit. You do it whether you accept it or not. It is absolutely true. I'm going to summarize five instances of most common biases in medicine. The representative heuristic, meaning when you over-rely on things that look alike rather than probabilities. The availability heuristic, you treat the patient based on your last patient treated. Overconfidence is when not knowing what you don't know. Confirmation bias, you know this classic experiment. They created fake abstracts and essentially get the same people to grade it and clearly shown same methods. If the conclusion corresponded to what you like, of course you graded them higher. I mean, this is rampant everywhere and illusory. How do we avoid those things? It's very hard, but metacognition, mindfulness, self-reflection, thinking about your thinking. And I'll close with this. If you fell asleep during my talk, this is my one slide summary to the young people mostly. Perfect your technical skills. Be aware it is only a small part of your destiny. Avoid the seven deadly realities. Cultivate your professionalism. Shape your environment. Mentor the next generation. Think like Leonardo and Ghazi. Recognize your biases and rectify their impact because you cannot rectify your own bias. And this last one, I'm calling this the cascade of responsibility. And here it is. In that order, very important. The tools are at the service of your art. The art is at the service of your science. Science is at the service of us, the providers. And we are at the service of our patients. And perhaps if we're all like this, there wouldn't be just one Mona Lisa, but each one of you would produce a Mona Lisa. Thank you very much.

cardiovascular surgery

surgical skill

mentorship

arts and science

biases

mindfulness

professionalism