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'Neurosurgeons aren't super-people'

There are various stereotypes of neurosurgeons as God-like, often perpetuated by televised melodrama (I’m looking at you, Grey’s Anatomy). They’ve studied for well-over a decade, are among the highest paid medical professionals in the world, and have the tremendous responsibility of ridding the body of maladies invading the human nervous system, most of which can result in debilitating degenerative symptoms. In addition to never hearing the word ‘stat!’ yelled in an operating theatre, I don’t buy into the stereotype – at least not with the negative connotation. These are people who have condemned themselves to servitude amongst a biologic battleground of death and destruction, whose primary purpose is to rescue people from disease.

It’s probably widely accepted amongst the medical community that ‘rate my doctor’ websites are not great. From the patient’s perspective, however, it can provide a sense of comfort knowing that their friend, relative or they themselves are in good hands. In preparation for this interview I couldn’t help but look, and the top comment was particularly striking; ‘Kate kept my dad going for 11 years with GBM (glioblastoma multiforme)’. Instinctively, she recalls this patient. ‘Yes. We’ve had a few. That would be…I know exactly who that is. He was great, but the treatment was not easy. I wish I could’ve given him eleven perfect years. What we gave him was eleven years, but they were sometimes tough.’

Professor Kate Drummond (AM) is the Director of Neurosurgery at the Royal Melbourne Hospital, and Head of Central Nervous System Tumours for the Victorian Comprehensive Cancer Centre (Parkville Precinct). She is also the Neurosurgery Editor of the Journal of Clinical Neuroscience, Chief Examiner in neurosurgery for the Royal Australasian College of Surgeons, and the Chair of PANGEA, an organization dedicated to providing health education in low and middle income countries – largely Africa. Drummond is in blue scrubs and a white doctor coat in her office at the Royal Melbourne Hospital when we meet. She comfortably leans back and places her black Chuck Taylor clad feet on her desk before we get started. Wearing these many hats in addition to the day to day management of an academic neurosurgery centre, I can’t help but wonder how she manages the mental chaos of so many responsibilities.

‘I think as you go through your career you develop enormous resilience. And you get very good at starting your day one way, and then everything goes to s**t, and so you change plan, reprioritise and keep going. But I think, I just have an enormous understanding that you go home, you have dinner, you go to bed, and it’ll all be better in the morning. I try not catastrophize it, and you know you’ll be looking after the patients, there’ll be beautiful bright spots in your day where something goes right, or you have a beautiful interaction with a patient or something, and that’ll make it all okay…’

Throughout our conversation Drummond appears to be firmly grounded by perspective, which seems highly practical. She is clearly energized by her patients without failing to recognise that it absolutely can and will have emotional effect on doctors, but is surprised when considering the notion that there are neurosurgeons who may not adjust accordingly. ‘Come on, get over yourself. You’ve got a great job, you’re earning an enormous amount of money – people won’t say that, but much more than majority of the population does – for a job that’s extremely satisfying, living in a wonderful country…get over yourself (laughs). Really? Really? You really think that things are not good? You have so many options. Don’t like your job? Give it up – go and work in industry. Go and work in medicolegal. Go and work in a lab. Go and work in Coles, who cares. You have so many options. You’ve already got a lot of dollars in super, I mean really, get your act together and stop it (laughs).’

Growing up in Westleigh, near Hornsby, in Sydney’s upper north shore, Drummond’s mother was a piano teacher and her father originally a draftsman who rose to management and design of fixed fire protection. She was a student of her mother’s for a very brief period of time, but was certainly interested in music. ‘I tried to learn the piano but that was a disaster. I was a poor violinist and a moderately good singer. I did music for my final year at school…to get the marks to get into medicine…I didn’t even decide to do medicine until the second half of my last year of school. It wasn’t even on the cards, I didn’t even know anyone who had done medicine – I didn’t know anyone who’d been to university!’

She considers her upbringing to be a very fortunate one. ‘Middle class, comfortable, not a lot of extra money, but you know, thankfully not extra money. So you know, you had to – if you wanted something special – you had to earn it yourself, which is a good lesson to learn. Happy family.’ She also credits her work ethic to her parents. When I ask if her if they fostered her interest in science and medicine, Kate says that her parents encouraged her to ‘work hard, do it right the first time’ but also cites ‘just a general encouragement that I could do whatever I wanted, but also that they just wanted me to be happy. So if I had’ve decided half way through medicine that it was all too hard and I didn’t want to do it and I wanted to go and do something else? That would’ve been fine.’

Graduating from the University of Sydney in 1988, Drummond trained in medicine in both Sydney and Melbourne, with research fellowships at Brigham and Women’s Hospital and Harvard in Boston, eventually obtaining her MD from the University of Melbourne in 2008. Along her journey she has met and worked with leaders of the field, and cites Professors’ Michael Morgan, Andrew Kaye and Peter Black as her greatest influences. ‘Michael Morgan and Andrew Kaye, because of their absolute dedication to their craft. And they’re hardworking. And their academic practice. Peter Black because he was a genuine innovator, I mean he basically developed the intraoperative MRI with his collaborators.’ The notion of a neurosurgeon that isn’t dedicated to their craft is perplexing, given the rigour of tertiary, medical and surgical training. Do people get into neurosurgery for the wrong reasons?

‘People get into careers for the wrong reasons all the time, that’s not just about neurosurgery. When you look at people’s medical careers, there’s a whole lot of people who think they want to do neurosurgery. And it’s a very romantic idea, ‘oh I’m really interested in the brain’…whatever. And then the reality of the work weeds a lot of them out.’ ‘Then you get people who can get quite far along in neurosurgery training, and they suddenly realise – I think there are two things – they either don’t like how hard you have to work, or they don’t like the responsibility of the death and disability…. that goes with the job. Or they don’t like the culture, they don’t like the people they’re working with. And so some people sort of stop then. Then there are other people, they get through but like any job they’re just not super happy in it.’

‘Neurosurgeons aren’t super-people, they’re just people who do a job, and some of them really love it and some of them whinge their way through it.’

Unsurprisingly, physicians and medical students have higher rates of burnout and depression than the general population. Books written by the likes of Henry Marsh, Siddhartha Mukherjee, Paul Kalanithi, as well as the wonderful biographies of Harvey Cushing and Sir William Osler, have each provided me with an overwhelming sense of magnitude regarding the dedication necessary to succeed or survive in medicine, not unlike what Drummond has described.

‘There’s also that stupid idea of work life balance, which is the most unhelpful concept in the history of the universe. Because anyone who chooses their career based on what they don’t do is stupid. And miserable. So anyone who chooses a career because ‘I want a career because there’s not too many hours, and because I won’t have to do this’…is crazy! Choose the career you love, and then make it fit. Work life balance…it’s so stupid to think ‘work’s this’ and ‘life’s this’’ – work is life and vice versa – as well as all the many other things that are life’.

Oppressive administration has been cited as one of the major factors influencing burnout in healthcare, and Prof Drummond most certainly agrees. When I ask if she’s experienced bureaucracy along her journey, her response is candid.

‘Are you insane? Healthcare is bureaucracy. If you look at any of the surveys on physician burnout in the U.S or in Australia, ridiculous bureaucracy and compliance, and the number of clicks on the EMR (Electronic Medical Record) that you have to do to get anything done…all of the roadblocks that are put up towards patient care, is the thing that people most cite as the reason that they don’t enjoy their job. It used to be that – and I don’t know that this is the right model, I could be completely wrong about this – but it used to be that doctors ran the hospital. That did have a certain level of getting things done that doesn’t happen now. Now it probably also brought other problems, so who knows. But the level of clipboard carrying bureaucracy that has flourished since I was intern in 1988 is extraordinary. And I’m sure that hasn’t made things any better, either.’

With the confluence of clipboards and medicine, there is a triage-like process of decision-making. ‘You fight the battles that matter, like ‘oh we don’t have a bed for this 47 year-old man with a subarachnoid haemorrhage’. You fight those battles. And you just ignore the battles that aren’t worth your energy…and you whinge about it to your colleagues’. Neurosurgery is often regarded as the apex of medical specialities. Given the mental and physical demands of neurosurgical training, I’m curious if Drummond frequently observes burnout. ‘I don’t know if it’s common. I’ve seen…it’s a very overused word. People say ‘I was a bit burnout last week’…I think it’s a little more chronic than that. I don’t think you can just be ‘a little bit burnt out last week’, but I don’t know, maybe you can – I’m not a mental health professional. I think neurosurgeons certainly do get burned out, and I think the ones that do probably don’t ask for the right help. I think the sort of platitudes of help offered by the “wellbeing officer” is probably not helpful, because I think neurosurgeons feel – rightly or wrongly – that their stressors are special. Now, that may not be true, because people’s stressors are just stressors, whether they think they’re special or not. And I think they mostly deal with it by taking time off and spending time with family and colleagues, though I wouldn’t know if most of my colleagues were seeking professional help. But I’m sure some of them are…I can’t imagine that they would avail themselves of the healthcare ‘wellbeing cult’’.

Our conversation eventually steers away from administrative furore and towards her awake craniotomy practice. Drummond is acutely aware of what her colleagues in the U.S and EU are doing; we discuss techniques and philosophies of Prof Hugues Duffau, Prof Lorenzo Bello, Prof Mitch Berger, and others, who each in their own way have described a high volume of research suggesting that brain mapping in glioma surgery can contribute to a wider – and safe – extent of resection, but also provide insights towards a “meta-network” of neurocognitive function.

‘Like most of us, it would be ridiculous for me to build a practice just focused on low grade glioma. I’d love to, but it’s not going to happen. (Duffau) has a unique and extremely academic perspective and I think ‘thank god he’s there’, pushing those boundaries. Mitch has a completely different perspective in a completely different universe. I think there’s variability (in technique) because we all have different types of practices and we all have to work on very different types of populations. It’s only recently in Australia that people have even become very comfortable with awake craniotomy, or they come and say ‘I want to have my operation awake’ or ‘I’ve read on the internet that this is the right thing to do’. Amidst peer-reviewed medical research focused on awake brain tumour surgery, Duffau has described meta-networks of cognitive function, Bello the comprehensive neurophysiologic approaches, and Berger a very high career-spanning volume of patients. Each employ a similar philosophy with a varying surgical technique using different combinations of medical technology to achieve their goal, which is universal: to remove as much cancerous tissue in the brain that reduces the spread of disease whilst preserving neurological function. Regarding Drummond’s approach; ‘I’m just trying to the best I can with what I’ve got (laughs). As simple and as straightforward as possible. I don’t use a lot of stuff that I don’t think is useful. Functional MRI I think is not accurate, DTI – recently published to be highly subjective – good for research, bad for actually working out what’s going on. To me, the intraoperative functional mapping is the thing to do. I’ve never done asleep mapping, which I’m sure is very good, but it’s not really been available to me. I learned to do awake craniotomies in Boston, so I do the Boston craniotomy, I thought that was very good and I’ve kind of developed it (further) since then. There’s probably some things that I do that I could do a little better, which I’m working on, but…it works. You can make it a massive palaver with forty people in the room, or you can just do the operation.’

‘Most people think that an awake craniotomy is all about avoiding a deficit…actually there’s a very high risk of an early deficit. And that’s fine, I think that’s acceptable. I tell all of my patient’s there’s a 50% chance of having a serious deficit at the end of the awake craniotomy (and) that’s okay, it’ll get better – and they’ll have the best resection possible. It’s very interesting…we’re talking about, you know, advanced testing for things like for theory of mind and other ethereal but important functions, well okay, but then you’re still taking out the medial frontal lobe because it needs to come out, and the patient usually recovers, but a few probably won’t.’

When we discuss what kind of technological advances will be considered the next frontier in neurosurgery, Drummond cites the continued development of neuromodulation technology. ‘I think functional neurosurgery, with the promise with psychiatric diseases and deep brain stimulation (DBS), that would just be massive if we can help those people that would be fantastic.’

When we discuss the potential advances that DBS would have with respect to psychiatric disorders, Drummond identifies disparity in regulatory practices between neuromodulation and spinal instrumentation devices. ‘Luckily, while partly industry driven, DBS has also had strong multidisciplinary medical input in Australia. The regulation is not completely industry driven, compared to ‘purple widget’ versus ‘green widget’ in spinal fusion. If the device industry was regulated in the same way as the drug industry, many products would not exist. Because they only ever get tested for safety, and non-inferiority. Never for efficacy. Never for efficacy. The spinal industry needs to be subjected to a greater level of rigour. And if they think their products are good, why do they rail against it? Why not just do it? It’s not like there aren’t a million operations being done out there.’

Our conversation inevitably steers towards brain-computer interfaces, and companies like Neuralink. ‘Sure. Yes, oh look, it’s interesting. But let’s look at the world in a more global sense. This is the first generation where life expectancy will go backwards in the west. Because we’re killing ourselves with fat, and drugs. So unless he wants to fix those big problems of our own self-control, any amount of ‘being smart enhancement’ isn’t going to fix anything. And the rest of the world is dying of drugs and overeating – and being poor – And yet we can’t fix that, which is ridiculous because we have enough resources, but we just can’t distribute them properly.’

‘He can make an AI – it’s like making a Tesla, great, beautiful car, fantastic, whatever…beautiful technology. Does it change anything for 99.9% of the world? No. To me it’s just not the right focus. The focus for me is logistics of getting healthcare and food to everybody – and sorry, education. Healthcare, food and education to everybody. The logistics of doing that – I mean, just pick India – India’s got plenty of food – it’s got plenty of arable land – but they’ve got a distribution problem. And then America – richest country in the world. Why are they not the top of the life expectancy table? Why are they WAY down? You can enhance all you like the people who live in Beverly Hills, there’s still going to be everyone dying of obesity in Montana. Interesting, but we don’t focus on the main game. We just don’t focus on the main game.’ It’s a carefully considered perspective.

‘Value for money…educating a 14-year-old girl in Africa…(or)…treating a 65 year old man with a glioblastoma in Australia. Dollar for dollar? (pause) I don’t know…I don’t know what the answer is. I’m only trying to be a small part of the answer. But to me, Elon Musk – lovely, lovely, lovely, very fancy, likes getting on the television, nice car I’m sure, blah blah blah blah blah, I had a ride in one once it seemed quite nice, but really, not the main game.’ ‘(I’m) just pointing out that we have a lot of crazy ideas about what’s going to happen in the universe and most people spend zero hours a week trying to make the world a better place…not because they’re bad people, but because of our culture. If every Australian gave up seven hours of television watching a week…so that’s one hour a night, of ‘Married at First Sight’, or whatever other fluff they’re watching, and dedicated that to any version of doing good in the world, whether it be raising money for Africa, looking after homeless people in Melbourne, reading to children, volunteering at this or that… the world would change overnight. And Australia would change overnight.’

When Drummond started practicing as a surgeon in 1997, only around 2% of all surgeons in Australia and New Zealand were female. She was Australia’s fourth female neurosurgeon, and first female head of unit at The Royal Melbourne Hospital. Today, it’s reported that approximately 25% of ANZ surgeons are female. When I ask Kate as to whether she’s observed any paradigm shift socially and/or politically, she speaks with vigour. ‘I do think that it’s important that any profession is representative of the people it serves. But it’s not just about ‘fairness’, it’s actually not about being ‘fair’ and saying ‘oh well, because there’s 50% of women we should just have 50% of female neurosurgeons’. It’s about the best person for the job, and doing the job well, and working out (what) the systemic biases are that stop the talented people from doing the job. And we know there are systematic biases. Is it worse in surgery than anything else? No, not really. I don’t think so. There’s certainly been a paradigm shift in surgery that people now think it’s a good idea to have gender equity. People now understand enough of gender politics to understand that the reason that so many women don’t apply for surgery is not because they don’t want to do it, or they’re just not interested, and they understand that those negative messages and ideas are planted much earlier than the time to apply for surgery, through a million messages and micro-aggressions, and all sorts of other things, and also looking at an un-welcoming culture, so people know that. But surgery also lives in a world of much wider gender politics, and that still makes it tough.’

‘The reality is that the majority of men still think that they’re “helping” when it comes to childcare and household duties. You speak to someone and they go ‘oh, I help my wife all the time’. It’s not helping! It’s your job! Helping means that you’re doing what someone else should do. So even just using those words is not correct. Women still bear the brunt of household and other responsibilities. Even if it’s just organizing it. Even organizing to pay for someone else to do it, which still takes mental energy. There’s still a lot of politics about a woman earning – not for all men, a lot of men are actually much better with this now – earning more or having a more prestigious job than their partner. You know there’s a lot of stuff that surgery sits in amongst, which is not always about surgery.’

In her day-to-day activities, Prof Drummond is forthright about where her strengths lie. ‘I’m not sure how I’d describe my teaching style. I try and just be really practical, I’m not very esoteric. I’m not the smartest person in the universe – I’m good at what I’m good at, I teach what I know, and I’m fairly relaxed and I try and do it in a practical way.’

‘I’m not a smart researcher, not at all. So my role for research is to be the facilitator, and the guide, and the collaborator for projects for smart people. My job is to make sure that these young people have the time and the space to do the work, that they’re supported, that we have tissue, that we have data, that we have a research culture, that they have a forum to present their work…that’s my job. I’ve got lots of fingers in lots of pies.’

As Chair of PANGEA, she has visited Africa almost every year since 2009. ‘We’re very niche education. It makes me nuts that a lot of people want to go and teach spinal fusion or other advanced techniques in Africa. They don’t need spinal fusion, they need to learn how to do the Glasgow Coma Scale (GCS), and pre-hospital care for trauma and head injury management. I mean, I get it, low and middle income countries want to do that (spinal fusion) because they want the horizon, the best practice, the next step, and I understand that and there’s a place for it. But that’s not what Africa needs. We’re pretty niche, we’re pretty basic. I don’t teach much neurosurgery there, other than some really basic care. I mean, you’ve only got one nurse per 100 patients overnight on the wards in Malawi. Detecting the deteriorating patient is probably your biggest priority.’

With regards to intraoperative neurophysiology, Prof is cognisant of the important relationship between competence and effectiveness. She refers to a spinal cord detethering procedure where at the filum everything was ‘lighting up’ neurophysiologically, preventing a safe dissection. I happened to be in an adjacent operating theatre and was made aware of the situation, and encouraged the scientist to switch from a monopolar probe to a concentric bipolar probe, which remedied the situation and enabled the dissection.

‘To me that was a learning point that, you know, it’s not just point and shoot, and that you need a partnership, that you need some expert help when you’re doing something. Even like frozen section, you hear the pathologist who doesn’t routinely do neuropathology doing your frozen section because of rostering and you think, this might not be as accurate as the person who does neuropathology all the time. And so it’s the same thing with monitoring, or neurosurgery, or with physio, or with anything. That it’s the person who has some basic understanding but isn’t (an) expert, then you’re not going to get the same result.’

Being godlike implies perfection. There’s a connotation that screams self-important and arrogant, and almost exploitative in ability. On television shows like Grey’s Anatomy, this is probably represented by a consultant neurosurgeon operating on their own brain tumour because they’re the only one on the planet with the hands and expertise capable of removing that particular lesion. In reality, it isn’t a spectacle, and it isn’t a stunt. It seems to me that Prof Drummond has long since accepted that whilst being a neurosurgeon is an ongoing clinical, administrative and political plight, it’s also an ongoing pilgrimage to humanity, as opposed to one of transcendence. When I finish the interview by asking what inspires her, she responds without hesitation.

‘My patients’.

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