Interview With Erlick Pereira
Senior lecturer in neurosurgery, consultant neurosurgeon and director of Functional Neurosurgery, St George’s, University of London and Atkinson Morley Neurosciences Unit, St George’s Hospital, London, UK; Consultant neurosurgeon and spinal surgeon, The London Clinic, London, UK.
What a treat! Erlick Pereira, MA BM BCh DM FRCS(SN) SFHEa agreed to participate in an interview for this issue’s international section, Dr. Pereira has a unique practice of pain, spine and functional neurosurgery. I have had the pleasure of completing a book with. However, the unexpected pleasure of this interview is the perspective on nationalized health care and a look ahead at its effects on procedures for us in the U.S. Join me in reading this insightful interview.
Jamie J. Van Gompel, MD, FAANS (JV): Coming from the United Kingdom (UK), your medical care system has evolved ahead of the American system in that socialized medicine is more advanced – do you think it is good for neurosurgery?
Dr. Pereira (EP): I am a great fan of socialized medicine and believe that civilized societies are judged on how they treat their weakest and most vulnerable members, which must include the sick: Neurosurgical patients are some of the most unwell. A great challenge in modern medicine is to balance cost with utility. When I was in medical school and started training (which in the UK is all done free, at National Health Service (NHS) hospitals), British neurosurgery was in its heyday with regard to expensive and sophisticated treatments. Everything from image guidance to hemostatic products to disc replacements to implanted neurostimulators were used for clinical indications based upon evidence but not as rigorously as it is now. This was great for clinical and operative training and led to much innovation from many early adopters of new technologies and techniques.
The last half-decade has seen assertive curbs to excess, both in terms of level of evidence required to give a treatment and budget cuts to neurosurgical departments. Fusion for back pain and deep brain stimulation (DBS) for pain are no longer allowed on the NHS, for example. Public sector organizations can lose money hand over foot through poor coding and bad theatre utilization, but even well-run departments suffer with the increasing efficiencies now demanded by successively more austere governments. I do fear in the near future that UK NHS neurosurgery will be for life-saving emergencies only, largely tumor, vascular and trauma, and that elective operations and those that improve quality of life will become increasingly limited by the NHS or driven into the private sector. Whether this is a good thing depends on your perspective. It is liberating not to worry about a patient’s funding status when treating them, but neurosurgical attendings in the UK who stay purely in the NHS can be overworked and underpaid compared to other professionals of similar standing in society. A less socialized health care system will probably improve their work and lifestyle choices, although it will probably narrow the breadth and depth of UK neurosurgical training.
JV: Dr. Pereira, please describe your practice.
EP: I am an academic neurosurgeon at one of London’s oldest teaching hospitals, St George’s. I work in Atkinson Morley’s neurosurgical department founded by Sir Wylie McKissock, which has a rich tradition of evidence-based complex neurosurgery. It is one of the few truly comprehensive neurosurgical units in London. It is a Level 1 trauma center serving a diverse urban and rural population of over 3 million adults and children. I am one of 10 consultant neurosurgeons (faculty attendings) and we maintain quite a broad neurosurgical practice for the UK. I cover everything on-call from vascular, which involves clipping the odd hot aneurysm, to pediatric, which involves the occasional neonatal shunt revision.
In our department, we tend to pass malignant brain tumors and pediatric cases to particular subspecialist consultants the next day after our on call but otherwise operate on everything. Five of us have vascular subspecialization and six have complex spine specialism, so we do not feel we need separate on call rotations for subspecialties. My particular subspecialties are complex spine and functional neurosurgery. I am lucky to be working at a Level 1 trauma center that is also a tertiary referral center for metastatic spinal cord compression. Much of my practice is degenerative, ‘simple’ spinal surgery, a lot of it complex instrumented spinal surgery, open, percutaneous and minimally invasive, and the rest is general and functional. I enjoy occasionally wielding an endoscope to treat hydrocephalus or doing an image-guided craniotomy to remove a benign brain lesion. I set up a DBS for movement disorders service in my hospital last year and am doing increasing amounts of spinal cord and dorsal root ganglion stimulation for pain.
JV: What attracted you to a neurosurgical practice?
EP: I grew up near lots of chemical engineering plants and studied natural sciences at Cambridge for my undergraduate degree, initially studying physical sciences like chemistry and geology with a plan to switch to chemical engineering in my second year. The Oxbridge college system facilitated a lot of mixing between students studying different subjects and I soon realized I was far more interested in the science of how the human body worked. I switched in my second year to studying physiology, pharmacology and experimental psychology and enjoyed the psychology the most. I majored in experimental psychology and had an inspirational tutor at Trinity College in Simon Baron-Cohen. I also had a great research project supervisor in Trevor Robbins, overseeing work involving microdialysis to measure dopamine and serotonin in rodents performing an attentional task to evaluate aspects of executive function.
I became excited and interested in how the mind and its substrate, the brain, worked. I realized I did not want to be a laboratory scientist but preferred to apply my knowledge to treating patients. As a graduate-entry medical student in Oxford, I preferred surgery to medicine and psychiatry and found an inspirational mentor in Tipu Aziz. He encouraged me to pursue my interests in brain mechanisms and how the basal ganglia worked. Later, he inspired me to pursue chronic pain as a neglected area of neurosurgery, and I did a doctoral degree and functional fellowship with him enfolded into my residency. I guess I am not unusual in wanting to do neurosurgery from just before medical school, but perhaps unusual among neurosurgeons in not wanting to do neurosurgery from school or college.
JV: Describe what you believe is the typical practice of neurosurgery in your country. Is neurosurgery all cranial? Is all spine being done by neurosurgery, or is orthopaedics involved?
EP: There is no typical practice in UK neurosurgery, but commonly, all neurosurgeons do simple elective degenerative spinal neurosurgery (i.e. decompressions), general cranial and spinal on-call and trauma. Increasingly, pediatric neurosurgeons just treat children with their own on-call and their own wing or hospital. In a few larger centers, complex spinal neurosurgeons do not do cranial on call. There are few truly integrated orthopaedic and neurosurgical spinal units. I am lucky to work in one where both specialists get on well, work together and may soon be integrated, leading to a superb spinal surgery exposure for our residents and fellows. Recently in the UK, oncology became a subspecialty in that neurosurgeons operating on malignant brain tumors must do so for more than 50 percent of their practice. Skull-base and vascular neurosurgery are also relatively specialized, as are functional and pituitary surgery. Most neurosurgeons in the UK have completed a formal subspecialty fellowship or two after residency and have one or two subspecialties.
JV: How profitable is neurosurgery as a profession compared to other professions in your country?
EP: Neurosurgery is reasonably paid in the UK compared to mainland Europe but is much less profitable on average than other professions of similar status, such as being a barrister or a partner in an accountancy firm. Neurosurgeons in training earn £40,000-60,000 per year. UK junior doctors recently held protracted strikes opposing the government’s stealth pay cuts for out of hours work pushed through by propaganda claiming excess mortality at weekends existed due to worse junior doctor staffing. Full-time NHS consultant neurosurgeons earn about £80,000 ($100,000) per year. It is possible to spend one to two days a week treating privately insured patients while a full-time NHS consultant, and this might double or triple a neurosurgeon’s income if they are lucky, but insurance premiums are high and UK neurosurgeons who earn more than half a million dollars per year are few and far between. A handful of UK neurosurgeons who work purely in the private sector exist, and they work hard with good salaries and high indemnity insurance premiums.
JV: What is a typical day in practice for you?
EP: I arrive at work at about a quarter to eight in the morning and may check some results and scans before attending the morning handover meeting. At St. George’s, we have a great tradition of teaching morning meetings where the registrar (resident) presents three to five cases in an hour and faculty ask the interns and junior residents questions about the imaging and cases. Sometimes the senior residents who have passed their FRCS(SN) board examinations lead and ask the questions. I am lucky to have Henry Marsh as a colleague, author of the bestseller “Do No Harm” and one of the main outspoken advocates of this morning teaching. I always enjoy his anecdotes from his vast experience of life and neurosurgery at home and abroad. We have a year six US resident rotating through our service (currently from Houston Methodist) and often enjoy learning their perspective on management. They get a great experience, learning to instrument a lot of spine with only X-rays to guide them and clipping double figures of aneurysms in six months.
By 9 a.m., I may have faculty meetings, a ward round or a theatre list. Typically, I will do one big and one to two smaller cases on a list (for example a bilateral DBS including battery implantation then a percutaneous spinal fixation for trauma). My operating list will finish around 5 p.m. If I leave the registrar to close the incision then I will do a post-operative ward round before heading home. I have 1.5-2 operating theatres a week, and when I am not operating, I may have faculty or management meetings, multi-disciplinary team meetings in DBS, pain neuromodulation or complex spine and once a week I will have a clinic from 9 a.m.-1 p.m. when I will see 12-20 patients with my resident in a parallel room. I try to spend half a day to a full day a week doing academic work, but it does not always work out like that.
One week in 10, I serve as consultant of the week, trouble-shooting problems, seeing sick patients for colleagues who are away and attending board rounds to ensure patients are well looked after. One night in 10, I am on-call. As faculty, we are non-resident on call, but I often stay late to go through the referrals and admissions. That evening, I might catch up on paperwork, emails and perhaps even write a blog post – see www.londonbrainsurgery.com.
JV: Describe how you believe your practice differs from neurosurgery in the US.
EP: I perceive that American neurosurgical practice can be categorized as ”Academic” which is highly subspecialized or as “community” which happens in smaller centers or partnerships of a few neurosurgeons and is more general. My practice is somewhere in between with 10 faculty and two subspecialties. As a registrar, my starts were later and I probably operated slightly less days of the week than a U.S. resident, but my UK training took longer (two intern years, eight-year residency, one-year fellowship). As an academic, I have little support from large institutional grants or staff to write or illustrate papers as a U.S. academic might. Almost all my St George’s Hospital practice is free for the patient and my private practice is largely undertaken one day of the week in a different hospital elsewhere in London ( The London Clinic on Harley Street). If I have a particularly complex private or international patient, such as revision DBS for severe dystonia, then I prefer to undertake it in St George’s where I have a fantastic, dedicated neurointensive care unit.
There is often a clear separation of public and private in UK neurosurgery. Most UK neurosurgeons create their private referrals by networking and word of mouth, rather than having any hospital marketing help. Another difference is that my residents triage and handle all on-call referrals and call me only if they are unsure or want to admit or operate on someone. This comes from the great British tradition that a consultant is there to be consulted! I rarely run parallel theatres, again in contrast to the U.S., although we do let our registrars do a lot of operating.
JV: Describe the biggest issue you see challenging your practice.
EP: Like many UK hospitals, my hospital is facing financial challenges and these are dealt with in different ways. Until recently, faculty neurosurgeons were able to keep waiting lists for operations down by doing some operations on Saturdays or on other extra lists in return for reasonable payment, but the hospital now feels unable to remunerate the operating lists so well. Consequently we have stopped the extra Saturday operating. The waiting lists are growing beyond a few weeks and these patients may need to be operated on elsewhere or in the private sector if they breach beyond certain times or become unwell. Such market forces are beyond my control but add a further interesting dynamic element to managing one’s practice. In general, my neurosurgical department has not suffered many of the problems other UK departments have, including cancelled operations due to lack of ward or intensive care beds, lack of theatre operating space or poor junior staffing. We have benefited from strong clinical and managerial leadership to expand our services and faculty appropriately in a supported fashion. Key to all of this is that as wehave weekly faculty meetings, a respect for each other’s strengths and subspecialties, and can have a laugh and resolve any territorial difficulties we might have in a positive and amicable fashion.
JV: Describe the biggest issue you see challenging neurosurgery in your country.
EP: Increasingly, expensive and complex therapies are becoming centrally funded rather than by regions based on a patient’s zip code. Surgical specialties are coming under scrutiny from health bodies such as the National Institute of Health and Care Excellence (NICE) to follow guidelines based on high levels of evidence. Neurosurgery treats some rare disorders with irreversible therapies that are not always amenable to high quality randomized controlled trials and difficult to study for cost-effectiveness. Consequently, some therapies become forbidden in the NHS. Trainees, therefore, lose exposure to them as few residents rotate to the private sector. Cervical disc replacement and lumbar fusion surgery for back pain are good examples of this.
Closer to home, merely balancing the books is a challenge for any NHS neurosurgical unit performing expensive high-risk treatments with occasional morbidity and outlier patients. These may have longer lengths of stay in a culture of ‘efficiency,’ resulting in poorer tariff payments for surgeries. Tick box competency rather than experiential junior doctor training and the loss of the firm system where one intern, one resident and one consultant work together for four to six months are other bugbears of mine. I am lucky that my department is outstanding for neurosurgical training, its residents having won the Norman Dott medal four years out of five and being awarded the prize of a couple of months fellowship in the Barrow Neurological Institute (BNI), strengthening our U.S. exposure and links. We have also written a few neurosurgical books between us, like my recently published “Neurosurgery Self-Assessment” published by Elsevier and Case Histories in Neurosurgery by my consultant colleagues Matthew Crocker and Pawan Minhas, published by Oxford University Press – so we tend to attract good residents and fellows. We have kept the firm-based resident structure largely preserved, although we occasionally struggle for interns and are exploring increasing our numbers of physicians’ assistants.
JV: What is the biggest opportunity for neurosurgery in your country moving forward?
EP: The UK NHS is a great resource for conducting multi-center trials. The free at point of access health care system inculcates a convivial spirit among a small church of neurosurgeons (close to 400 consultants and 300 trainees), which can be channeled into collaborative studies. The British Neurosurgical Trainees’ Research Network is one such example, having conducted rapid and excellent outcomes analysis of chronic subdural haematomas and much of the trauma research coming out of Cambridge, like Rescue-ICP and Rescue-ASDH, exemplify how powerful this resource is. I contribute to a British Spine Registry of surgical outcomes, a UK DBS Network and a national Neuromodulation registry, all of which we could ask interesting clinical and research questions of.
JV: Please share with us a unique aspect of neurosurgery in your country that may not be practiced in the Americas (i.e. there is no instrumented fusions, all aneurysms are clipped or coiled, a surgical procedure we do not commonly do, etc.).
EP: Most functional neurosurgeons in the UK do bilateral subthalamic nucleus DBS implantations during the same awake surgery rather than staged unilateral implantations and do not use microelectrode recording. A single pulse generator is implanted and connected to both brain leads, usually in the same operation. This approach arises from current consultants in the UK having mostly been trained by a handful of professors of neurosurgery (mainly Aziz, Eldridge, Hariz and Gill) who believe that microelectrode recording increases hemorrhage risk, prolongs the procedure increasing infection and pulmonary embolism risk and does not improve accuracy significantly. Just as significantly, one cannot bill much extra for staging the surgery, microelectrode recording or inserting two pulse generators in the UK NHS. Brain lesions are also occasionally done in the UK (e.g. cingulotomy for cancer pain, pallidotomy for palliative control of movement disorders), perhaps more frequently than in the U.S.
JV: You have a particular interest in DBS and pain surgery, where do you believe this practice is headed in the future?
EP: I think DBS will continue to see an expansion in its indications with establishment of some more non-movement disorders indications, such as obsessive compulsive disorder (OCD), pain, cluster headache and epilepsy. Imaging, electrode and pacemaker technological advances will drive other developments such as individualized targeting of tracts rather than nuclei, shaping of fields to minimize side-effects, smart, adaptive stimulation, and batteries that last a lifetime and can be implanted in the skull rather than tunneled to the chest. DBS will ultimately be replaced by a successful molecular, genetic or cellular therapy that will be restorative and alter the natural history of the disease and hopefully still require a stereotactic neurosurgeon for insertion. I do not think frameless functional neurosurgery confers much advantage over a frame, but robots will continue to improve accuracy and become increasingly used. Cancer pain lesional treatments, such as cordotomy, cingulotomy and various other tractotomies, will see a resurgence with a push to cost-effectiveness and analysis of the complications and expense of morphine pumps in this population.
JV: What challenges do you see in DBS and pain surgery in the future?
EP: The main challenge to my socialized health care system is cost. DBS is cost-effective without doubt but it has a high cost at the point of surgery and I am not convinced it will continue to be offered on the NHS within my next 30 years of consultant career. Thus, its wide availability is under threat from decreasing government health budgets. Similarly, rules for spinal cord stimulator IPG implantation are very strict in some European countries (Belgium for example, requires a four-week externalized lead trial), but are more liberal in the UK. These are likely to be tightened. If we lose neuromodulation from the NHS, then we may see a return to the largely lost art of brain and spine lesional surgeries for movement disorders and pain.
Other challenges come in the scientific realm. Finding objective biomarkers for pain that improve patient selection and outcomes and improving non-motor symptoms of Parkinson’s disease and difficult motor signs, such as postural instability, freezing and falling are particular interests of mine. Another great challenge is using brain computer interfaces and neuromodulation to improve outcomes in spinal cord injury, be they motor, pain or autonomic. I am lucky to have as an academic faculty colleague at St George’s, Marios Papadopoulos. He has done some amazing work on mechanisms of spinal cord injury, including intraspinal pressure monitoring and expansion duroplasty to improve motor outcomes. As a neurosurgeon treating acute spinal cord injury in a pioneering academic neurosurgical unit, it is therefore a population of patients I have access to for early intervention with neuromodulation, making for some exciting research opportunities.
JV: In terms of pain functional procedures, what do you consider the most promising therapy for the future that is not mainstream treatment as of yet?
EP: I recently started performing dorsal root ganglion stimulation for pure dermatomal pain. Its effects and outcomes are quite remarkable compared to conventional spinal cord stimulation. A variety of etiologies from knee replacement to phantom limb to CRPS to diabetes are all effectively treated, and I am a big fan. I may do research to identify novel etiologies and learn more about its mechanisms. It marks a shift in the neurosurgeon’s armamentarium from the open to the more percutaneous, but I would encourage functional and pain surgeons to learn percutaneous techniques as they have less morbidity and quicker recoveries than traditional laminotomies and paddle leads, for example.
2017 AANS/CNS Section on Pediatric Neurological Surgery
Nov. 28-Dec. 1, 2017; Houston
2nd Homburg ICP and Hydrocephalus Workshop
Nov. 28-30, 2017; Germany
22nd Instructional Course and 45th Annual Meeting of the Cervical Spine Research Society
Nov. 29, 2017 - Dec. 2, 2017; Hollywood, Fla.
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