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AANS Neurosurgeon | Volume 28, Number 1, 2019

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Changing Gears: Mid-Career Relocation as a Catalyst for Better Patient Care

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My uncle, and master thoracic surgeon, Mark Orringer, MD, had an indelible impact on the lives of his patients and on the culture of the University of Michigan operating room (OR) during his 40+ year career. His excellence stemmed, in part, from his methodical approach to esophageal surgery. Those who worked with him invariably heard his favorite dogma: We do it the same way, every day.” He refined a series of operative steps, from skin-to-skin, that lead to unparalleled outcomes for his patients. As a resident and junior faculty at the University of Michigan, I aimed to emulate my uncle in many ways, including the development of my own routine for brain tumor resection. More recently, family considerations and an exceptional opportunity for career development in the department of neurosurgery at New York University (NYU) lead to an institutional change, adapting my clinical and academic practice to an entirely new environment. This posed a major challenge to my ability to do it the same way, every day.

As top tier academic health systems, Michigan and NYU have many similarities:

  • Inspirational leadership;
  • State-of-the-art facilities;
  • A cumbersome electronic medical record;
  • Affiliation with a top-notch medical school; and
  • A culture and history of excellence.

That said, the institutions have unique character and nuances. Changing gears mid-career has presented an opportunity to re-evaluate my routine for clinical practice, leveraging similarities and differences between institutions to arrive at the most effective and streamlined approach to brain tumor surgery. 

Navigating Geographic Change

In Ann Arbor, Mich., I would ride my bike one mile to and from the hospital. Now, in New York City, I commute to midtown Manhattan from Brooklyn on a 35-minute ferry ride on the East River, dictating a new standard for efficiency during working hours. Developing a practice on the island of Manhattan, which is home to several world-class centers for neurosurgery, necessitates a frank assessment of how to communicate one’s value to patients.

Navigating Institutional Change

Both the Michigan and NYU have state-of-the-art operating rooms with access to the latest technologies. That said, much of the equipment varies between institutions. From the type of Kerrison punches on a craniotomy tray to the hemostatic agents used to the MR-compatible head-holder, things vary considerably. Two other notables:

  • Shunts at NYU never involve a Rickham reservoir; at Michigan, shunts are not complete without one.
  • The NYU residents looked at me with skepticism when I used a Kocher as a means of ensuring safe handling of a bone flap or chose to use a small piece of telfa affixed with staples instead of a headwrap for craniotomy patients.

Changing institutions has afforded me the opportunity to evaluate the essential components of my routine adopted over 15 years at Michigan. Areas where the institutional practice patterns overlap probably coincide with what is best for patients – areas where they do not leave room for doubt and refinement.

(Part of) the Brain Tumor Team at the University of Michigan on my last day in the OR.

A New Team

Without question, ensuring a uniform and predictably high-quality routine for the care of brain tumor patients requires a talented team of individuals and my team at Michigan was among the best. Executing my uncle’s vision for being able to do things the same way, every day is predicated on effective teamwork. Reseeding and molding the well-oiled machine of a brain tumor team is certainly one of the more formidable hurdles inherent in my transition.

One of the most valuable lessons Karin Muraszko, MD, FAANS, taught us at Michigan was that neurosurgeons are viewed as leaders. We need to know how to rally our team in the best interest of patients. She also taught us that practice makes perfect. Building an effective and well-functioning patient care team, from administrative assistants to mid-level providers to OR and bedside nurses as well as from surgical techs to senior faculty across disciplines is an essential part of an effective mid-career relocation. Without question, the lessons in leadership my Michigan team taught me have made it easier to start anew.

The personal and professional risks of disassembling a well-established brain tumor practice in one location and putting a new one together in one of the most competitive practice environments on the planet are obvious. The benefit of changing gears mid-career, however, lies in the potential to build on past experience to create something better. While the advantages of doing things the same way, every day are clear, transitions can serve as an opportunity to develop an even higher standard of care for patients.

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