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AANS Neurosurgeon | Volume 28, Number 2, 2019


Alternative Mind: How Non-traditional Experiences Enrich Neurosurgical Training Part 2

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In part 1, the authors introduce the concept of why individuals with varying backgrounds have advantages for all of neurosurgery for the good of communication, training and analysis. The most advantageous workplace includes individuals with diverse strengths and backgrounds. Part 2 further explores how these differences lead to the creation of the alternative mind.

Let’s Talk: Communication as a Cornerstone

Communication influences outcomes. Skilled leaders leverage a range of communication techniques and strategies to mobilize and inspire every member of their team to optimize treatment and motivate patients to be engaged and responsible with their care. In contrast, poor communicators alienate colleagues and confuse or even anger patients, preventing the delivery of high-quality health care. Advanced communication skills have traditionally been cited as an area of weakness for medical students and residents across all specialties, with little offered in the way of formal instruction. Correspondingly, medical schools and residency programs have recently began to integrate explicit educational curricula and testing protocols for physician-patient communication, including the addition of a neurosurgery residency milestone specifically focused on effective communication.1 This is a critical advance within medical education; however, among niche teams such as neurosurgery training programs, non-traditional applicants with a background in business, administration or other leadership-oriented positions can provide a healthily disruptive perspective, potentially shortening the communications learning curve for co-residents and colleagues alike.

Although all trainees seek to build rapport with patients and participate in shared decision-making, a neurosurgeon with a background in business has a series of formal models for negotiation, such as setting the goal of finding a Win-Win solution with a noncompliant or aggressive patient; by describing the common ground of treating disease and alleviating suffering; and soliciting feedback regarding the patient’s goals. The discussion could proceed to the Zone of Possible Agreement, with the identification of items that both parties could agree to before proceeding to Value Creation, in which both would identify acceptable concessions. By engaging with patients using this more structured mindset, the neurosurgical trainee empowers patients to take a more active role in their recovery. Meanwhile, the tacit companion boundary setting would aid them in establishing explicit thresholds for undesirable negotiation outcomes, keeping also at the ready their Plan B, better conceptualized as the Best Alternative to a Negotiated Agreement.

Not for the Self, but the Patient: Insights from the Military Mindset

Military metaphors are often misapplied to medical training – hospital hallways are not “trenches.” Yet, the reliance on teamwork and service to a higher purpose are shared. Explicit value systems, such as our own institution’s famous mantra, “The needs of the patient come first,” provide a critical framework, yet the alternative mindset provided by military training is the difference between learned and lived experience. Indeed, while the core values of honor, courage and commitment motivate servicemen/women to overcome discomfort and focus on the mission, true resolve is galvanized by need, such as:

  • Guarding a warship on a frigid winter night; or
  • Operating an outpost in the sweltering Persian Gulf summer.

This confers the discipline required to prioritize mission first, team next and the self last. Parallel logic applies to innumerable training modules used routinely in military education in which all scenarios lead to failure and frustration. As compared to an OSCE, oral exam or many other trainee assessments, this de-emphasizes the “right answer” and promotes resilience, endurance, resourcefulness and teamwork. Failure is experienced and witnessed by all, which tempers fear and anxiety, empowering trainees to embrace and learn from their shortfalls as a team.

Integrating these concepts, military training also routinized the debriefing, or structured review of missions to allow for both positive and negative lessons to be codified and transmitted to the team at large. Although M&M provides a partial surrogate experience for neurosurgery trainees, these conferences are scattered, the case sample small and the treatment more pageantry than pragmatism. By contrast, members of every military unit, from foot soldiers to elite fighter pilots, have learned the value of dressing-down the day’s error and can site several “near misses” that were saves only by virtue of regular and regimented review of their missions. This practiced introspection is carried to the extreme within the intelligence community, where reviewing today’s errors seems trite when compared to anticipating tomorrow’s vulnerabilities. Where medical logic is frequently linear, teaching trainees to identify the most likely mechanism or pathophysiology, the alternative mindset honed within the intelligence community is one of probabilities and parallel possibilities, equipping trainees to anticipate multiple clinical unknowns as well as creatively and dynamically adapt their diagnostic or therapeutic plans.

The Roads to Rome

Business, engineering, liberal arts and military service are but a few of the less-travelled pathways that may deliver trainees to neurosurgery, each of which has the potential to:

  • Improve communication;
  • Diversify the collective skillset;
  • Demonstrate servant leadership-by-example; and
  • Maintain the collective focus on the truly essential – the needs of the patient.

Though our neurosurgical core is shared and unshakeable – anatomy, neuroscience and clinical excellence – as the world and the workplace become increasingly diverse and interconnected, we look forward to the future alternative minds that will open and expand our own.


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1. Kim, D. H., Dacey, R. G., Zipfel, G. J., Berger, M. S., Mcdermott, M., Barbaro, N. M., … Day, A. L. (2017). Neurosurgical Education in a Changing Healthcare and Regulatory Environment: A Consensus Statement from 6 Programs. Neurosurgery80(4S). doi: 10.1093/neuros/nyw146

2. Whelan, E., Dacy, M. D., & Rownd, J. E. (2017). The little book of Mayo Clinic values: a field guide for your journey. Rochester, MN: Mayo Foundation for Medical Education and Research.


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