My World of Neurosurgery Part 1: In the Beginning
Editor’s Note: Dr. Deborah Benzil has served as Editor of the AANS Neurosurgeon for five years. As her term concludes, she elected to use her editorial for the theme World of Neurosurgery to reflect on her own world of neurosurgery. In Part 1, she explores her roots and her residency training.
One sunny July 4th weekend, a 16-year-old waterskiing on the Chesapeake Bay encountered a submerged rock that changed the course of his (and my) life. When his skis skittered, he smacked his head against this rock. Dazed, he unhitched the skis and staggered to land. At first, he felt and seemed fine, but then he rapidly declined and became comatose. His buddies alerted 911, and soon a trauma helicopter transported him to Shock Trauma in Baltimore. As this was 1983, the stat CT scan took more than 30 minutes to complete, but the astute chief resident jumped to action when the first slice of the temporal fossa was visible, instructing me to wait for the films and then meet him in the trauma operating room. The 16-year-old had a massive epidural hematoma. That day, my new white hospital shoes became permanently stained when I drilled the burr hole that released the blood clot and ultimately saved his life. The full craniotomy that followed was amazingly quick, and by the next morning, the teenager was asking to go home. He recalled none of the drama that had unfolded, but I would never forget.
This, my first encounter with the world of neurosurgery, occurred during my very first clinical rotation in the third year of medical school. Up to that point, I knew little about neurosurgery and, frankly, had no interest in it as a specialty. But during that month, the residents took me under their wing and exposed me to the wide spectrum of neurosurgical patients – acute spinal cord injury, malignant brain tumors, degenerative spine, cerebrovascular surgery and more. I dutifully followed them from OR to clinic to ER to consults and was rewarded by their teaching and the opportunity to “get my hands dirty” with procedures both inside and outside of the operating room. I was hooked. I made the decision to enter the world of neurosurgery.
What was the world of neurosurgery in 1983? Many neurosurgeons of today would hardly recognize the neurosurgical world of 1983. Some remarkable historical reminders are:
- There were just 10 ABNS certified women; only three held faculty positions.
- Most aneurysms were surgically secured after waiting for the period of vasospasm to resolve.
- The Midas RexTM drill was not in general use.
- Microscopes were limited to rare CV and tumor cases.
- Almost no spine instrumentation was performed by neurosurgeons.
- Substantial dehydration with mannitol and Lasix was the norm for severe traumatic brain injury (TBI).
- Clinical use of the MRI was not FDA-approved nor covered by Medicare.
- The first United States Gamma Knife® was still four years in the future.
- More than 90% of all neurosurgeons were in private practice, many solo or two-man (there were no two-women groups).
Into this world I did wade – feet first and eyes open, but not fully aware of the challenges and rewards that lie ahead.
My first enormous challenge was to achieve a residency training position. Throughout my education, there had been many roadblocks (you can’t take calculus in 11th grade!) and twists, but my hard work and dedication allowed me to leave a rural community to enter Brown University, graduate with honors and gain early acceptance to medical school. It never dawned on me that I might fail at my next endeavor. Resident interviews were frankly a fright:
- My morality was questioned;
- My capacity to master the technical aspects of surgery was doubted;
- My intelligence was vociferously distrusted; and
- My pocketbook was depleted.
There were also uncomfortable moments that related specifically to being a female interacting with men in powerful positions – enough said. Eventually, I was able to break through and land a position at Brown University/Rhode Island Hospital. Returning to the location of my glorious undergraduate years was very appealing, as was the chance, finally, to pursue my dreams.
Brown was an amazing place to train and Providence a perfect host for my young family with limited resources. The volume and variety of cases were spectacular, and most of the faculty I worked with were remarkable clinicians, technicians, teachers and mentors (see Box). These were transformative times within neurosurgery with rapidly expanding technology for diagnosis and intervention paving the way for expanded practice and improved patient care. I was fortunate to catch that wave at a fortuitous time, further enhancing my education. Just a few examples:
- MRI installation facilitating intense exposure during my radiology rotation.
- Transformation to early aneurysm surgery as well as aneurysm treatment using coils.
- The opening of a spectacular children’s hospital giving me understanding of all the intricacies involved in that process as well as an optimal facility for our pediatric neurosurgery patients.
- Gamma Knife radiosurgery program initiation, the cusp of a revolution.
- Epilepsy surgical treatments.
- The dawn of molecular biology tools for neuro-oncology.
There was still very limited spinal instrumentation by neurosurgeons, so my exposure was exclusively bracing, decompressions, discectomies and tumors. Mastery of complex spine was not yet part of my neurosurgical world.
The learning curve was steep but exhilarating, and I slowly established independence in assessing patients, doing procedures and ultimately in the operating room. These were the days; however, it was before formal resident evaluations, direct supervision, duty hour restrictions and strict program requirements for education. As such, there were constant challenges, including:
- Disruptive faculty
- Feeling isolated and underprepared
- Utter exhaustion
There are huge periods of time for which I have almost no memories and my capacity to do anything after work other than sleep was nil. Placement of my first Gardner-Wells Tongs was done alone, my never having seen one positioned before. We regularly took call every other night and worked 100+ hours with incredibly low pay (I started at $15,000 with no benefits). Today’s training environments may not be perfect, but incredible progress has been made in all of these realms.
Beyond the routine stress of residency was the added strain of being the first and only female in the program. The routine world of neurosurgery in those days included pornographic images in the call room and inserted into many lectures as well as routine comments about female patients’ physical attributes. Then I announced my pregnancy, which led to another wave of scorn and derision, mostly from some of my fellow residents. Perhaps I didn’t help my cause by having two pregnancies back to back, but I had carefully chosen these to coincide with my research years and to impact the team the least. Still, it created fear and trepidation. In the world of neurosurgery, this has changed remarkably little in more than 30 years. Few programs have paid maternity leave and there remains no “good” time for a neurosurgeon to plan pregnancy/childbirth.
In those days, completing a residency was a contest of survival – getting over the finish line and becoming a good neurosurgeon because of hard work, intelligence and the small but passionate faculty who cared about teaching. I parlayed my pre-residency research into a funded fellowship and got my first taste of presenting at national meetings and getting manuscripts accepted. I slowly started to connect with residents outside my program, including a woman on rare occasions. These early connections were a critical lifeline; most remain close friends and colleagues today. Decades later, I can still recall the cases in which I clipped my first aneurysm, removed a pediatric posterior fossa tumor and completed a brachial plexus exploration. After seven years and nearly 500 cases completed in my chief year alone, I felt prepared to embark on the next stage of my career.
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