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AANS Neurosurgeon | Volume 26, Number 1, 2017

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Interview With Peter W. Carmel, MD, FAANS

Andrew E. Sloan, MD, FAANS (AS): Why did you decide to become a neurosurgeon?

Peter W. Carmel, MD (PC): I took a circuitous route. I planned to be a psychiatrist because I hated biochemistry but was very interested in how the mind works. In my first year, I realized psychiatry was too imprecise for me so I started looking at other fields. During college, surgery was eliminated after becoming light-headed at the sight of blood so I started looking around at other options. After my first year of medical school, I worked on the neurology ward at the old Bellevue Psychiatry Hospital. The work was fascinating, and I thought neurology was “the cat’s meow.” My surgery rotation finally came and I was not squeamish at all; rather, I found myself drawn to the field. By my fourth year, I was working on the neurosurgery ward with Amilcar Rojas, MD, the chief resident in neurosurgery, who was also a member of the ruling family of Nicaragua. Dr. Rojas would let me operate, which was quite thrilling to me. I realized at the time that if there was something to do for a patient with neurologic disease, you had to send them to a neurosurgeon as the neurologists really did not have any treatments that were effective. That is how and why I became a neurosurgeon.

Leonard Malis, MD, became my mentor and felt that I should be a physician scientist. However, he also felt that my scientific background was “spotty,” so Dr. Malis insisted that I go to National Institutes of Health (NIH) after my internship at Bellevue. While doing basic science in Bob Livingston’s lab at NIH, I discovered “The Primate Thalamus,” a book by A. Earl Walker, MD. I felt that this is what a neurosurgical scientist should do. So, I applied and was accepted to the neurosurgical residency at John’s Hopkins under Dr. Walker.

Dr. Walker was awarded the first NIH neurosurgical training grant and decided all his residents would do three years in the lab prior to beginning clinical service. After two years in the NIH lab, this was not appealing. His proposed compromise had two other residents doing “extra” lab time to allow me to do one less lab year and graduate a year early. Concerned this would make me “unpopular” with the others, I went to speak with J. Lawrence Pool, MD, at the Neurological Institute (NI) of New York. I did my residency there and was subsequently appointed to the faculty. During this time, I continued to be very active in research and ran a lab with a colony of 54 rhesus macaques. My lab published more than 100 papers about the relationship between the hypothalamus and the pituitary, the release of hormones in portal blood, cyclical release of follicle-stimulating hormone (FSH) and gonadotropins into the portal blood and located areas in the infundibulum that were receptors for hormones and various peptides. We also did a lot of basic work on releasing hormones, target hormones and the hypothalamus.  

AS: Which neurosurgeons influenced you most?

PC: First and foremost was Dr. Malis. He was my first mentor in neurosurgery. I was devoted to him, and he continued to be a huge influence on me. He was a great surgeon and probably the smartest person I have ever known — certainly the smartest neurosurgeon.

Dr. Pool – a great, charismatic chief – was highly influential. He was a great surgeon and academic. He taught that to solve a challenge, you needed to develop a hypothesis with which you can answer the problem. When I got to the NI, he was using movie cameras mounted on the side-arm to record aneurysm clipping which nobody else was doing in 1963. Television was just developing at that time and microscopes, which record directly, had not yet been invented, so this was very innovative.

William H. Sweet, MD, DSc: During the 1970s, I operated on a series of craniopharyngiomas. At the NI, most surgeons did a “peak and shriek” operation, resulting in subtotal resection which was then followed by radiotherapy. These children ended up short, obese and intellectually compromised. I began to think we should be more aggressive with craniopharyngiomas and attempt complete resections, avoiding radiation when possible. I had a series of 6-7 cases where it was met with significant skepticism. Dr. Sweet, the chair of neurosurgery at Massachusetts General Hospital (MGH), had a lot of experience with craniopharyngiomas and was in the audience. He called me aside after my talk and told me that I was on “the right track,” advising me to ignore the critiques with his full support.

These three individuals helped me gain confidence to innovate and do what others felt was “unconventional.” For example, I was the first one at the NI to re-operate on a patient with a glioma. Some of my NI colleagues felt this was wrong and asked, “Aren’t you just prolonging the inevitable?” I pointed out that for most tumors, that was what we all were doing! I ultimately re-operated on the patient who had a recurrent low grade, and then 2-3 years later, when it became an Astro Grade III. All in all, I think I gave this man about eight years which I think he appreciated because he had young kids. 

AS: You have had a very storied career. Can you take us through your career path, how you came to found University of Medicine and Dentistry of New Jersey (UMDNJ) and what is now the Rutgers Neurosurgery Program?

PC: I was very happy at the NI and Columbia, but I wanted to be a chair while continuing to live in Manhattan. Rutgers was open, and I thought I would “give it a try” for two years. I have been here now for 23 years, and I am very proud of what we have accomplished. I was interviewed recently by New Jersey Magazine, who focused on my term as president of the American Medical Association (AMA) as the “pinnacle achievement” of my career. While I am very proud to have served as AMA president, the development of the Rutgers Department of Neurosurgery is the best thing I have done in my life. When I started, there was no residency program at Rutgers or in the entire state of New Jersey. Rutgers remains the only accredited allopathic residency program in the state.

AS: What advice would you give a neurosurgeon just beginning his or her career?

PC: Pick a field in neurosurgery that thrills you and pursue it. When I started, I thought I was going to be a functional and stereotactic neurosurgeon. But in fact, the children and their problems were so interesting and heartwarming I wanted to focus on pediatric neurosurgery. It is important to do stuff every day that fascinates you, that you are dedicated to and that you enjoy.

AS: If you were not a neurosurgeon, what career would you choose?

PC: I thought seriously for a long time about being a hand surgeon. I read Sterling Bunnell’s “Surgery of the Hand” as a third year medical student and thought it was a great book. He founded the field of hand surgery, and I became very interested in the field.

AS: What made you want to be president of the AMA, and how did you achieve this?   

PC: This was not a role I sought. While serving on the board of the Congress of Neurological Surgeons (CNS), I became frustrated and decided to step down. However, during the April 1986 Board meeting, the AMA representative resigned. The CNS nominated me. Reluctantly, I agreed to a two-year term, sure it would not suit. My first AMA House of Delegates in 1987 faced a range of problems. The biggest issue was poor specialty representation limited to the Specialty & Service Section, which met only once a year, and was not very active. The power in the AMA was entirely in the state societies. I wanted to increase specialty representation but there was no mention of specialty societies in the bylaws of the AMA.

The first thing I did was assigned vetting of new specialties to the Specialty & Service Section, giving it recognition in the bylaws. When I joined, there were less than 30 recognized specialties; now we have 194 with a big political role within medicine. Later, I was appointed to the council on long-range planning tackling new problems. When I stepped down from the council, I ran for the Board but was defeated. I was disappointed, but a friend told me I was obligated to run a successful campaign the next year. When I ran for president, it was a time of great turmoil since the Affordable Care Act (ACA) had recently passed. Even with two former AMA Board chairs running for president, I threw my own hat in the ring. When we got to Chicago, I was in a distant third place, but I did extremely well in the debate catalyzing a winning election!

AS: What is the role of the neurosurgeon in medicine?

PC: If all neurosurgeons were to go away tomorrow, the Centers for Medicare & Medicaid Services (CMS) would barely register a financial change. However, there is no substitute for those who need a neurosurgeon. Contrary to popular belief, neurosurgeons have prospered with increased incomes under the ACA. Neurosurgeons also generate high ancillary fees for the hospital making them appealing. We are also insulated from lots of changes in medicine. Unlike primary care, we are not threatened by nurses, nurse practitioners (NPs), physician assistants (PAs) or other ancillary service providers.

Neurosurgeons are unique, in high demand, with a looming shortage for optimal health care delivery. Since the Residency Review Committee (RRC) is not increasing training positions with very little specialty overlap – particularly in cranial surgery – we are well positioned with most hospital systems. Finally, neurosurgery has done well by absorbing more and more subspecialties into the field. There was a time when spine surgery was almost absorbed by orthopaedic surgeons. David L. Kelly, MD, FAANS(L), who was the chair at Bowman Gray, president of the AANS and later the president of the Society of Neurological Surgeons (SNS) was the single person who did the most to stop this. He felt every neurosurgery service should have a spine expert.

Since then, we have absorbed a variety of subspecialties under the roof of general neurosurgery. Now, interventional neuroradiology is increasingly done by neurosurgeons rather than radiologists; the fields of skull base surgery and functional/stereotactic neurosurgery are also firmly in neurosurgery, despite efforts from otorhinolaryngology (ENT) and neurology (respectively) to take over. Another threat was an effort by the American College of Surgeons (ACS) to create the specialty “Surgery of Trauma,” which would include neurotrauma. We blocked this on the grounds that patients are better served by a fully trained neurosurgeon. Thus, as neurosurgery continues to grow in scope and complexity, we will need more neurosurgeons because we are doing more. However, it is also true that we work harder than most physicians. We work harder than three decades ago and are, as a group, incredible workaholics, which has a toll. The neurosurgical divorce rate is over 50 percent.

AS: The new mantra in health care is “value.” However, neurosurgery is often very costly. What is the “value proposition” in neurosurgery?

PC: What is value, and who determines what value is? Policy makers are struggling to define this. Ultimately, “value” will not only be judged by return-to-work but by prolonged survival with some cognition and/or freedom from pain. Life is precious and worth preserving even if we cannot return to our previous level of function. 

AS: Thank you!

Dr. Carmel, is the chair emeritus of the Department of Neurological Surgery at the UMDNJ and a professor of Neurological Surgery at the New Jersey Medical School. He served as the founding chair of the department for 15 years and was the founding co-medical director of the Neurological Institute of New Jersey in Newark, N..J. He is an internationally prominent pediatric neurosurgeon who has traveled the world lecturing about this topic.

Board certified by the American Board of Neurological Surgeons (ABNS) and the American Board of Pediatric Neurological Surgery (ABPNS), Dr. Carmel heads the UMDNJ Pediatric Neurosurgery Program and provides services within the Brain Tumor Program and Skull Base/Endoscopic Surgery. One of the field’s premier doctors, he has received numerous awards and honors and has been listed in several physician-selected consumer guides for outstanding physicians, including American Health Magazine survey of the “Best Doctors in America,” and the book “The Best Doctors in America.”

Dr. Carmel’s research, often focusing on childhood brain tumors, congenital anomalies of the nervous system and the structure and function of the hypothalamic-pituitary axis, has resulted in the publication of over 100 scientific articles and 25 books and chapters. He has lectured extensively on neurological surgery throughout the U.S. and abroad, including France, Italy, Germany, Portugal, Scandinavia, Russia and Mexico.

Active in several professional organizations, Dr. Carmel has held leadership positions in the AANS, CNS, the National Coalition for Research in Neurological Diseases and Stroke and the National Foundation for Brain Research. Notably, Dr. Carmel also served as president of the AMA from 2011-2012.

After receiving his Bachelor’s of Art degree from the University of Chicago and an MD from New York University, Bellevue College of Medicine, Dr. Carmel completed his medical training at the New York University School of Medicine and was a research associate at the NIH. He completed his residency in neurosurgery at the NI of New York, and obtained his doctorate in neuroanatomy from Columbia University College of Physicians and Surgeons (P&S). At P&S, he was the founding chief of the division of pediatric neurosurgery and a professor of neurological surgery.

 

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