What matters? Many things matter in this profession: Dedication, honesty, compassion, ability, tenacity, humility, support and so on. When I began my neurosurgical practice after residency 27 years ago, what mattered most was becoming the best neurosurgeon I could be. I was well trained and had seen enough of Dr. Spetzler’s challenging cases to be ready for my own journey to technical excellence. Case volume mattered because it seemed like the fast track to proficiency. I don’t remember my starting salary at the University of California at San Francisco, and though I loved the city, it didn’t matter to me where I was as long as my vascular practice was thriving. My chairman, Mitch Berger, built an environment of subspecialization within the department that channeled open vascular cases my way and my partners indulged my appetite for aneurysms. There were countless other benefits, including large surgical series, robust clinical databases, extraordinary interdisciplinary collaborators and opportunities for research, but case volume is what mattered.
Today, what matters has changed. My passion for microneurosurgery is undiminished, I am no less busy clinically and I reached the technical milestones I set for myself. I am no longer striving to become. Instead, what matters is innovation. Creative insight, original ideas and novel techniques are my sparks. After performing more than 11,000 operations for the most challenging of pathologies, what matters more than the stats is that something new, interesting or transformative comes from all those cases, that the grist from the mill turns into something valuable. Those 5,300 aneurysms led to unusual bypasses like the double reimplantation bypass, the middle communicating artery bypass and the azygos bypass. Those 1,100 brain AVMs inspired the box concept and supplementary grading system to guide selection of patients for AVM resection. Those 1,200 cavernous malformations spawned a taxonomy for all brain cavernomas and the triangle concept, which guide approach selection and subarachnoid dissection.
The byproducts of clinical activity stand out as what matters. Innovative bypasses, enlightening classification systems and novel instruments or devices represent a capacity to envision that which cannot be seen and usher it into existence for others to see. These inventions help other neurosurgeons make better clinical decisions for their patients and thereby achieve better outcomes. These contributions help residents understand a spectrum of pathology that might previously have been confusing. These creative expressions might answer a challenge that nobody wanted to treat or solve. The impact of innovation multiplies with adoption and application, like ripples radiating from a stone thrown into a pond. Meetings like this one in Chicago are important because they highlight innovation.
Picasso once said, “every child is an artist, and the problem is to remain an artist once he grows up.” Preserving imagination and creativity over time is a challenge, but innovators somehow overcome them. Innovation requires a spark of vision, a commitment to making it real and the courage and audacity to see it through to completion. A dream without realization will not become an innovation, which makes grit quintessential. Sifting through the blood, sweat and tears of neurosurgical practice, distilling the cases and experience into something meaningful and lasting — innovation is what matters to me now.
