AANS Neurosurgeon | Volume 28, Number 4, 2019


Interview With Clarence B. Watridge, MD, FAANS(L)

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“There is no sadder picture than the professor who has outgrown his usefulness, and, the only one unconscious of the fact, insists with a praiseworthy zeal, upon performance of duties for which the circumstances of the time have rendered him unfit.”

                                                                                -William Osler, 1982

Adam S. Arthur, MD, MPH, FAANS (AA): Can you share your background in neurosurgery and where you are now?
Clarence B. Watridge, MD, FAANS(L) (CW): As a medical student, I was inspired by one of the people who later became one of my professors. I decided to pursue neurosurgery and was allowed to do my training in Memphis with an internship in straight surgery at the Baptist Hospital and Neurosurgery with Semmes-Murphey Clinic/University of Tennessee. During my training, I did an exchange in Bristol, England, at Frenchay Hospital, and my chief there was Mr. Hugh Griffith after which I came back and finished my training in Memphis. Since I had been on a medical school health professions scholarship, I entered the Air Force and served my three years at Keesler Medical Center in Biloxi, Miss. I met Donald F. Dohn, MD, FAANS(L), and John J. McCloskey, MD, FAANS(L), in Pascagoula, and they invited me to work with them for a year. That year was a great year for me, much like a fellowship year. Then I returned to Memphis and stayed 30 years as a member of the Semmes-Murphey Clinic and The University of Tennessee Neurosurgery faculty from which I retired in 2015. Some friends invited me to hang out at the Mayo Clinic (Jacksonville, Fla.) and do outpatient evaluations, resident education and conference participation. I now live in Ponte Vedra Beach, Fla., and I am on staff at Mayo Clinic Florida. My wife and I are enjoying this time.

AA: You recently gave a presentation at the Southern Neurosurgery Society titled “Senior Neurosurgery: Transition of the Fourth Quarter.” Why is this an important topic?
CW: While I was the hospital’s chief of staff, some of the issues that came before the medical staff leadership involved aging physicians. In addition, a matter of concern at Semmes-Murphey involved manpower, specifically keeping a balance of young, mid-career and senior members. There are socioeconomic issues for neurosurgeons who become senior and don’t work at the same pace as when they were younger. If you Google “senior surgeon,” the first thing that pops up is not how great the senior surgeons are, it is that “the senior surgeon is a problem.” These articles note that most people who have been in place for quite some time have established themselves, are respected and have been “the rainmakers.” Challenging them about what they are doing is difficult so they are in a free fall with no real supervision of their practice.

Optimally, surgeons must think about and plan ahead for this. We must be prepared to get out of the way and let the next generation do many of the things that we did. This also means stepping aside to let new thought, new leadership and new plans come forward. We must be willing to take a reduction in compensation. But, I think there is still a significant need for the experience and skills that the senior neurosurgeon has acquired over time.

AA: You have also pointed out there are some characteristics of neurosurgery, in particular, that make this an important issue. Can you talk about that a little bit?
CW: Frequently you hear “Well, it’s not brain surgery,” or brain surgeons being compared to rocket scientists in their intellect, their skill, their position and the pecking order of respected professions and individuals. Neurosurgery is a very jealous mistress; it requires 100 percent dedication. It requires that you give of yourself in a way that engenders single mindedness. Neurosurgery can occupy 100 percent of your thought and your time. Neurosurgeons really do have a tendency to invest themselves in their profession and often do not cultivate outside interests, becoming a person’s whole existence. Neurosurgery can become “what we are” rather than “what we do.” If the field defines you, it can be difficult to find an identity when you are no longer a neurosurgeon.

AA: Neurosurgery is also a team sport – we must work closely together. What kind of things can we do to help neurosurgeons as they age?  
CW: The individual neurosurgeon has to realize that there is a cycle. When we are 65, we cannot run like we could when we were 25. Some of us used to have some hair; now we don’t because of our age. Invariably, skill sets and dexterity will begin to deteriorate. Now, this happens differently for every individual, so I think the individual surgeon has to take ownership to realize that it is a part of the neurosurgical life cycle. At some point, one needs to acknowledge that they should begin to give up some of the things they have done technically.

Partners of the senior neurosurgeon may decide that they want to keep the richness of that surgeon’s experience, but to do so, that surgeon cannot be required to be just like everyone else. We can use their talents for mentoring, teaching, counseling, management and other aspects of group practices, and allow their clinical activities to begin to reduce.

It is also important for the individual and the group to have a financial understanding with compensation commensurate with what the group values. The senior partner has to understand that this is not the same as doing multiple cases a week, taking night call and all of those things that make neurosurgery so demanding. Quality metrics and performance assessment are important measures senior surgeons need to participate in willingly, particularly if there is an issue with the work product. Such metrics as surgery time, returns to surgery, infections and outcomes remain acceptable when compared to peers. Performance assessment needs to be part of the group environment to be sure that patients are getting the level of care that they need and deserve.

AA: As you have gone into this “fourth quarter” of your career, what changes have you noticed in yourself and your approach to neurosurgery?
CW: Interesting. As young surgeons, we are all about doing the procedures being energized because of the technical and skills challenges. As you gain some maturity, the importance of doing the procedures decreases and people become more focused on the whole patient. Are we really helping people? Consider the patient with a glioblastoma recurrence for possible reoperation or with a patient with chronic back pain for potential fusion. Are we able to make those judgements and sit down with patients to help them make the right decisions? 

As you get down the road and you have had a few folks that you thought you would help but it did not work out too well – those scars remind you that maybe sometimes we should say no to performing aggressive surgeries and be a little more conservative in what we do. I find that in the last 15 years, I have gotten more joy and pleasure out of coaching younger neurosurgeons, students and residents; seeing them flower into those men and women that are the fighter pilots. Now, I feel more like a navigator than a fighter pilot, and I think that is the way it ought to be. It’s OK to say and believe, “I don’t have that on-the-edge fighter pilot mentality that I used to have.” Back away and let someone else be the pilot while you excel at teaching, advice and mentoring.

AA: That is good advice. As you look forward, what changes do you see coming that you would identify as most important to the future of our field and for our patients?
CW: The evolution of technology is both exciting and scary. It concerns me that we have begun to screen which patients we will see.. This changes us from hearing their stories and figuring out whether or not we can help them. Now, if the images do not match a set pattern, the patients are not allowed to see us. Often, people may not need you to do anything to them; they may need to hear what you have to offer, what your perspective is about their problem and how you would advise them.

However, we can do things now that we could not do in the past because of technology. I remember when we began stereotactic surgical navigation. I had done so many tumors without navigation so I understood the anatomy, how to read the images and get to the right place. The value of navigation has proven itself many times over, even to me. It seemed it would be good for selective cases, but its routine use has improved surgical approaches but technology continues to evolve to meet these needs.

I am also fearful of the costs. When a patient has a short 4-5 days in the hospital, even a policy that pays 80 percent of their charges leaves 20 percent which is still a big number. This creates an environment where the insurance market is going to be problematic. Medicare is already problematic, and for those without insurance, it is even tougher. The socioeconomics of how we deliver care has to change. We can no longer do everything without consideration of the cost, also of the necessity of each scan and special tool or technique. I am concerned that the small specialty of neurosurgery, representing about 1 percent of Medicare expenditures, could potentially be squeezed out because we cannot afford it. I also fear the legal environment, not only from a professional liability standpoint but the aspect of group and physician practice governance.

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