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Fireside Chat: The Making of a Master Neurosurgeon

Robert Spetzler, Roberto Heros and Jacques Morcos

September 09, 2020


- Welcome ladies and gentlemen for another session of the Virtual OR from The Neurosurgical Atlas. This evening we have a very special edition of the Virtual Operating Room. We'll be having a fire chat or a very casual discussion about the making of a cranial operative neurosurgeon in academia, and more importantly, a master neurosurgeon. What does it take to become a master neurosurgeon and ascend to the level that our guests this evening have reached. Dr. Roberto Heros from University of Miami and Dr. Roberts Spetzler from Barrow Neurological Institute have truly been role models both for me and Jacques for many years. And have been role models for many neurosurgeons. We have so much respect for them because it is upon their shoulders at that we stand and see farther. So based on that, we'd like to hear their thoughts about what was right about their era and the present, as both of them remain such a role model for both of us. And then furthermore, we're gonna touch upon what will be the future of the opportunities for mastery in neurosurgery. Jacques Morcos from University of Miami, who is also truly a master surgeon and has worked both with Doctors Spetzler and Heros extensively, we'll be starting with a discussion and as we go along while I bring up some of the more provocative talks. So with that in mind I think the focus of discussion will be what was in the past that worked to become a master neurosurgeon and to create new innovative opportunities in operative neurosurgery and will be the future most importantly for all of us and the viewers. Jacques I wanna thank you for moderating. Obviously you have been tremendous in moderating the sessions from Miami and the cerebral vascular and skull base symposium and I really appreciate your thoughts and the first set of slides you have. So with that in mind, Jacques please go ahead.

- Thanks Aaron, can you put the slides for me so it can help us kind of have a structure to the discussion?

- No problem, happy to do it.

- Thank you so much for inviting me to talk, fireside chat to two of my favorite people, with the host as we know and many people do know. So Roberto Heros and Robert Spetzler, the question of tonight is what we would like to understand from those two giants, what makes really a master surgeon? What explains a young boy like this becoming the person we know today? What explains somebody like me standing introducing him at his symposium saying "in the pyramid of elite educators "and master surgeons in neurosurgery, "Roberto Heros sits alone. "That's how you sit, when you are at the very top "at the spear of the pyramid, "there is room for only one "yet no tears need to be shed for him "since 'alone' does not mean 'lonely.' "'Alone' here means unique, "unmatched a leader of uncommon drive, "a surgeon of uncommon integrity, "a teacher of uncommon honesty, "a man of uncommon passion "and a giant of uncommon humanity." Equally, what explains a young boy from Germany like this guy here ascending to become a giant in his field, allowing somebody like me to stand where as I'm offering him the award, the Cushing Medal saying, "Robert Spetzler is an outlier "and that is self-evident. "On a frequency distribution of all neurosurgeons "plotted for skill and mastery, "all would agree he lives on the far right. "But the unsettling truth is "that he does so in so many other attributes "besides surgical mastery. "For the achievements of the mind, "there is leadership, charisma, resilience, "originality, persuasiveness, surgical innovation, "age at which became director, academic productivity..." So on and so forth. Well, this is just the glimpse of those two people and hopefully between Aaron and I tonight, we'll try to get to the little bit deeper into who they are and what advice they may have to the younger and maybe older generation as well who are listening today. So I wanted this conversation to have some structure otherwise it will go in so many different directions so that's why I made both slides to help come up with the questions I really want to ask them. So I'm gonna refer you first to this book by Robert Greene, that discusses the secrets to mastery and perhaps I can leave this slide from the book and ask both Robert and Roberto in a little bit, perhaps address some of the points, help us understand your path to mastery. How did you find your calling? Did you have an apprenticeship, mentorship? I'll tell you a little bit in a second what the so-called seven deadly realities are. I'm gonna ask you if you think you have them, what was your creative phase in your career? And when did you know you became a master? So, Aaron we can perhaps even either leave this slide and I'd like to invite maybe Roberto to start a little bit to maybe look at those points Roberto and just tell us a little bit, tell the people who don't know you about yourself.

- Okay well, first of all, I'd really like to apologize to the audience for my younger brother's poor mastery of English. Jacques Morcos had the disadvantage of having been born a foreigner.

- It's about you, it's not about me, forget me now .

- Never really mastered the English language properly. Jacques, that's outstanding my God, what a phenomenal introduction, who can master the English like you do. So, first of all, let me say that I am really humbled to be sitting here among three true masters of neurosurgery, one of my generation and the other two from the younger generation. It's really an honor and a real pleasure to be here with you to talk informally and without slides that was my condition that I would show no slides because I was afraid that what happened would happen. In fact, what happened is that my computer is not working so I'm doing this with my telephone and I can actually not even read your slides Jacques but I will do-

- Oh okay.

- That's fine no problem, no problem, I'm good.

- How did you find your calling Roberto?

- Yes, well I tell you how and I've dropped a talked bit about that. When I began my neurosurgical residency, I actually was gonna go into pediatric neurosurgery. In fact, about at the middle of my residency I had already lined up a good friend of mine Paul Chapman a fellowship in pediatric neurosurgery at London at that time was a place to go if you wanted to be a pediatric neurosurgeon. Then something happened, something came along during my residency and that was the operating microscope. That really was a breaking point where my career changed. The microscope changed everything. And how did it do that? Well, first of all, it made possible for us to do things by the time we were chief residents, senior residents, chief residents, that would not have then been by our, clearly before us, before the microscope, there were master surgeons around the country who could clip an aneurysm safely, but it took him 10, 15 to 20 years, 100 cases to be able to do that. And my mentors, people like Dr. Sweet, Dr. Rajaman just couldn't believe that we, and I don't mean just myself, Dr. Crawl who all of you know well was a couple of years ahead of me he actually was the one that brought the microscope to the Mass General where I trained. But our mentors just couldn't believe that we could clip aneurysms safely when we were senior residents, chief residents. And then the microscope may make one operation really possible that wasn't possible before get microscope and that was the microanastomosis and the bypass graft. And again, our mentors could not believe that we could put together little vessels of one millimeter or less in diameter and suture them together, they thought that we must be phenomenal surgeons already at state to be able to do that, which only the microscope made available. In my particular case one during the middle of my residency I had a period of research and that was again, a tremendous period of growth for me. I happened to go into a laboratory of , he was working on vasospasm at that time and everything I did about vasospasm failed, never did anything that amounted to anything but what I did do is kill a lot of animals, particularly ducks, imagine at that time working with ducks today that would have been impossible. So since my experiments all failed the ducks all had to be sacrificed and just before sacrifice I took the opportunity to practice microanastomosis, which I had learned to do my initial training was actually at Burlington where you had been two and a half, three years before I was there in the same laboratory taught by Ester the same technician that taught how to do microanastomosis so what I would do is that every duck that was before sacrificing, I practiced bypass and I remember practicing things like doing in ducks with large neck, doing a flavectomy and do a lingual anastomosis initially and then even doing that through the cylinder side of a toilet paper, using that cylinder to use long instruments on the cylinder and I had do bypass. So that made it possible by the time when we were chief residents to start doing bypass surgery. So that being able to clip aneurysms all that was made possible by the microscope. And that's what made me change from pediatric neurosurgery into vascular neurosurgery.

- Roberto this is a good timing for me to add add Robert to take us through his experience, what made him find his calling.

- Yeah, thanks Jacques. Pleasure to be with you guys. I don't know whether any of us ever will have really reached mastery, but I'm happy to say a few words about my journey. I was introduced to medicine from a family that were really educators and engineers when I was five years old and I got tetanus. And when I got tetanus, I was admitted to the hospital. I was so sick that they put me in a storage room with the big iron lung machines for the polio victim, because I was so sick they didn't wanna put me in the pediatric ward. And I'm sure that, that experience somehow drew me toward medicine and was also a great attention getter at the age of five to have people pay attention to me, tell my story over and over again. And I also remember very distinctly from that period as, because I was a very special case I was given penicillin at a very late stage in the disease to see whether it had any effect. I obviously made it. And so I was taken to the auditorium on a gurney placed on the stage and then the professor who rightfully felt some ownership for having saved me, took off my gown and I was a five-year old naked little boy in a stage looking out at of white coats. It was just the most humiliating event. And even to this day I cringe when I think about it. And I hope that somehow that made the better, but I knew before I entered high school, that I wanted to be a neurosurgeon. I'm not really sure why, but I'm sure that must had something to do with it. I went to Knox College and did an honors project in canine blood flow. I went to Northwestern because Dr. Buechley was there and he ran a lab and he was really my first real mentor. He sent me as a medical student to Switzerland, life-changing. And then, because he was gonna retire, he recommended that I go to San Francisco instead of staying at Northwestern. And that was for me, that was absolutely a spectacular journey to get to where I was really gonna learn this craft under the tutorship of .

- Roberto, just a very brief word. Your Bay of Pig experience at age 19, Robert just talked about, he almost died at age six with tetanus. You went through an amazing, horrific as well experience at the age of 19. Did that play a toll in you becoming a neurosurgeon or it had nothing to do with it?

- Well, that's actually where I began to do some neurosurgery. It was a very primitive no that it had nothing to do with it. It did have everything to do with, confirming in my own mind that I wanted to be a physician, particularly that I wanted to be a neurosurgeon. And therefore that I had to survive, get out of there so I could do those good things. That's all.

- Okay, well, I'm gonna take you to the next slide. I want you both. I don't know if you can read them in that book. This Greene mentions that it's very rare for a true master to have a lot or more than one of those so-called seven deadly realities. So I want you, I'm gonna read them and what I want to ask you, be very transparent and honest with us and the audience. Do you believe in yourself, you're guilty of one or more of those. Let's call them some degree of shortcoming, being envious, being too much of a conformist, being rigid, being self-obsessed, having some degree of laziness, flightiness, or being passive aggressive, any of you? Do you recognize any of those in you?

- Well, I can start-

- I think I have in every one of those I have a little bit, yeah. I think human beings, I think when you talk for example about laziness, there are many times when I've gone to bed at night and said, I really should have gotten that done, rigid, I think there are times when I've been rigid, but in general, I don't think those seven deadly realities have a big role in my life.

- Roberto.

- Yeah, no to mine either. I think envy has a bad connotation. I think jealousy would be a better word and yes, I am guilty of that. I mean, how could I not be jealous of somebody like Robert Spetzler, every time, not only he's always done everything in neurosurgery better than I have, but it's interesting in our travel club experience, we started skiing and of course Robert was always ahead of the pack, but then there were things that at travel club. One day we found a ping pong table and I had a ping pong table at home and I said, "okay, here's something I'm gonna beat Robert with." Of course he beat the heck out of me playing ping pong and so forth with almost everything else that we have done. So jealousy to some degree, if that's a better word than envy, yes. The others, no conformism. Certainly no rigidity. Absolutely no self-obsessiveness, laziness, yes of course we all have a bit of that. We all like to be a little lazy at time. Flightiness also to some degree.

- Yeah.

- Passive aggression, no.

- No, it's true and what I saw of other role models I have. It is true you cannot find a true master that has a significant component of those things. So, there is this book about "How to Think like Leonardo da Vinci." And I'm gonna again, test you on those so-called seven ways and maybe I'll start with Robert again. Now, Robert, those of you who don't know is an accomplished artist, pianist, and probably would have ended up as a professional musician, had the not thankfully been attracted to neurosurgery.

- Yeah.

- So, Robert regarding, I'm not gonna read them in Italian as they're meant to be read, but curiosity, the desire to demonstration, test knowledge via practical experience, your ability to master your senses and sharpen them, your ability to be comfortable with ambiguity, your ability to juggle art and science, your ability to balance body and mind, the so-called poise. And lastly, the ability to see forest from the tree and so forth. Could you comment, what's your self assessment of how good you are at those seven things or how poor you are at any of them?

- Yeah, thank you Jacques. First of all, my venture into becoming a professional pianist was extremely short-lived. I recognized the talent that was required is so much greater than becoming a quote "master neurosurgeon." So, but when you look at these, the list of these nouns, curiosity, I think curiosity is an absolutely essential component of everyone. And I think it has particular application in neurosurgery, this curiosity to how we can do something to make it better, to make it faster, to make it easier, to make it less lethal. Demonstration, I think there's not a master neurosurgeon or a master surgeon or a master of anything like da Vinci who doesn't have demonstration, this part of the ticket to get that title in the first place. You have to demonstrate your skills. You have to have an open mind to let people observe. Senses, yeah. And by the way, it's ambiguity, I'm absolutely delighted that I can correct your English. And I think Roberto takes great delight in the fact that I can correct your English. Out of the three of us none of us have English as our mother tongue.

- That's right.

- What I think that number five, I think is really, really critical because art and science, we try as neurosurgeons to be on the side of science, but there is so much art inherent in how we treat patients, how we treat each other. And I think art in my personal life plays an incredibly important role in balance, it along with physical exertion provides the balance so that we can spend these long, endless hours in the operating room where we have to be so focused. And so that really goes to poise as well. And I don't know what connections big picture.

- Your ability, I mean you're a master at it too. I know you very well. Your ability to interconnect things that may not be obviously connected and, your globalism, both of them.

- I think, the word I really, really love is serendipity.

- Yeah.

- Because I've been given credit for so many things that I had no conscious involvement in achieving and it was serendipitous that they happened to me and I think that's very important, but this interconnectivity, if that's what we're talking about, whether it's international, whether it is national or local and includes your interconnectivity with your family and friends, and an absolutely essential part for human beings.

- Roberto, do you want to comment on any of those seven things? I don't know if you can see them on your phone or you have la-

- No, I actually transitioned to the computer now. So I think whatever cookie the computer was lacking disappeared or something I don't even know what a cookie is, but it was anyhow. Curiosity, yes I'm curious. And I do try to sharpen my senses. Ambiguity, I'm comfortable with that. Art and science is I can tell you that my art, if I have anything to do with art, it's just medicine. This is the ability to put the whole picture of a patient together and to balance scientific knowledge. And you know what, you've heard me talk about this many times. You could call me anti-science in many ways because what I really try to myself and also teach my residents is not to become a slave of science and to be able to integrate the art of analyzing the whole of the patient and put it together without being enslaved by the details of the science, but yet having the scientific background to be able to do the right thing for the patient. Balance of body and mind, we all have it. We all are, or have been very physically active. As Robert says, I don't think that we can go through the hours of work that we do in the operating room if we weren't physically active and took care of our bodies in a variety of ways. Big picture, I think I've been doing pretty well in terms of realizing and keeping the big picture in mind, as opposed to the different parts and the details. In fact, I'm not much of a detailed man and that at times has come back to bite me. The fact that I have missed the details because I concentrate too much in the big picture.

- Okay, I'm gonna move you to something slightly different, but I want to see if your mastery, whatever way we define it actually has brought you happiness in your life. This is very important for the young people listening. So I'm going to quote you again, a book, which by the way, an older book called "Flow." And if there are any Hungarians listening to us, I cannot pronounce the last name of the author. I call him Mihaly, a psychology professor, trying to, he had tried to figure out through actually surveys and studying. So-called happy people. What was common to all those people. And we're not gonna get into the details, but here are the nine attributes he found in people who had achieved optimal performance and were genuinely happy without going into each one of them on the left. Would you say you both have a healthy dose of each of those, commitment, honesty, courage, passion, immediacy, immediacy, meaning your ability to draw pleasure from the moment, doesn't mean you don't plan the future, but that's an impo... Openness, receptivity, positivity and trust. Do either of you disagree? I submit to you, you both have all of those nine attributes, unless I'm mistaken. You agree?

- Go ahead, Roberto.

- What can I say, sure. Into lesser or larger degree, I think those all apply to both of us. I know Robert well enough to know that he, each of these applies to him in kind, and certainly to some degree to myself, I thought you were gonna ask me when you began Jacques, that you were gonna ask us whether our career had made us happy or you call it your... We call it our career. And, I was thinking about it as you began to speak I thought about that and I said wait a minute, I am a happy person, no doubt about it. I just don't stay even when I have a major complication or surgery, which is the closest that I come to happiness, it only lasts until the next case I do that goes well. And then it kind of, I don't forget it. It stays in my background informs part of who I am, but it doesn't make me unhappy anymore. So the issue is, am I happy because of my career and the way it has gone or was I happy anyhow, was I just meant to be happy? And the reality is that I've always been happy. I mean, I was happy in prison to be honest. And people got angry at me because I seem to be happy all the time and they didn't understand that. And so I think that maybe these, because I am happy that I have been successful in my career rather than vice versa, but certainly I'm a happy person and I know that Robert is too, but Robert I'd like you to comment on that, were you a happy person before you were successful.

- I must say, Roberto, your answer was absolutely on target. The thesis that mastery makes you happy, I think can never be proven. And I don't think it is a cost of satisfaction. It is a cost of being happy for the moment. But I bet everybody that was happy as a master was happy before they even considered whatever they were doing. It is an inborn fortune to have a happy outlook, to have a glass half full. And I think mastery itself is an accomplishment, but I know many masters who were unhappy before they became masters and who are unhappy when they are masters, but are still very much masters.

- Yeah, completely agree. Absolutely. We don't need to name names, but I completely agree with what you're both saying. Okay, from this book, and this is what I really would like to also hear from you. When people say I'm in my zone and that's what Mihaly talks about and what he means being in that "Flow" zone at the top right. Where your high skills match your high challenges. So, Robert, I mean, I know the answer because I know you well, but I want people to hear it. Give us some examples in your daily life, either now or before you retire what puts you in your flow zone most of the time, what kind of activities?

- Yeah. It's really a very interesting reflection. I've always had the ability, even when I was young to suddenly become interested in something, focus on it, almost exclusively with a burst of energy that I normally would not have. And I'm thinking, for example, I got a chance. No, I'm not gonna tell you, but anyway, this ability to focus and to get into a sewn, I very much understand, whether it is, when you're jogging and you suddenly happen or whether you're going down a ski slope and you're in the zone. And most importantly naturally when you're in a difficult operation and the whole world disappears in your focus where you're only concentrating on getting over this hump of the difficulty of fixing this patient.

- Yeah, absolutely. Roberto, what puts you in your happy zone, a difficult operation, reading, you love reading history of biographies. What puts you in your flow zone?

- All of it, Jacques. I think, it's always looking ahead and looking at the future and what is the next thing that is going to happen that is a challenge, or that simply that brings me happiness. Maybe a trip, maybe an operation that I'm particularly looking forward to, but just always looking at what is next that is going to, that it's gonna make me happy. What is the next happy thing that has happened to me? Lucky as we are we always have happy things coming. We don't have to wait very long for them.

- Okay, and by the way, going back to what Robert said, Robert, look you predicted what's on this slide from Mihaly, the characteristic of flow, having clarity of purpose, living the moment, the resonance between challenge and skills, focus, concentration, clarity of action, forgetting yourself, you're in the middle of surgery and time passes by, sense of time distortion. The last one is interesting one because it can be really double edge sword. When you love to do something, you may start doing it in what he calls autolytic manner, meaning you're doing it for its own purpose. I certainly hope none of us. Let's say we love doing bypasses. Hopefully we're not doing it just because we love to do it. But because obviously the indications are there. That's where I think that last one may have a double-edged sword, but otherwise you look at this list and again, that describes you, describe most happy people who have reached mastery. Let me ask you a few questions, Roberto, do you lose sleep before a major planned surgery?

- I did, I did. There were cases that were very challenging, losing sleep. I'm not sure, but I went to sleep thinking about it and frequently woke up thinking about it. And in own mind planning, thinking of the operation. But then I would get up in the morning, take a bath, shave, and then always, it was all great I have this great case coming today that is a good, day, is gonna be a good day today. In fact, just made think of the, the shaving test and I'm glad that Robert hasn't had to go through that. But at times I asked myself as all of you know, I have slowed down to the point that I'm doing very little surgery now. And I ask myself, how did I decide when it was time for me not to do something else? And I call it the shaving test. And what that meant is that when I had a challenging case, one of those crazy grief, four or five ABMS that I really should not have done, but I still, as I was shaving in the morning, I would say, oh great, I have these great case coming today. And that was, but then they came in a time, I got to be into my seventies, that as I was shaving and thinking about the case I had that day, I say, "oh damn it, this is not." And then I decided that case was a case that shouldn't be doing anymore. And of course I've been fortunately, to have Jacques Morcos around to do those cases that were "damns" for me and not do so. It was easy for me to gradually stop doing those cases. I'll tell you that the first case that I decided not to do any more was say a bypass. And as you know Jacques I haven't done a bypass now for at least seven or eight years. And I was doing an anastomosis I forgot exactly where deep anastomosis and I finished and I really had difficulties with it, both in terms of stamina, as well as technically I had issues. And when I finished it just didn't look right. It wasn't perfect. It was a little narrow and it wasn't perfect. And I remember thinking, "oh my God, "do I have to take it all down and redo it?" "Maybe not," I said, "maybe be all right. "Maybe it'll stay open" and I just struggled with that for several minutes. Finally, I did redo it and it looked good at the end. But then I said, you know what, it's time not to do this anymore when I have somebody around like Jacques who can do it so much better and easier without sweating. Anyhow, that was just a little anecdote.

- Thanks, Robert, which night is more unsettled for you, the night before a major worrisome surgery, or the night after a major complication? Or are they equally bad?

- No, they're not equally bad, but before I have a really major case, I will have trouble falling asleep, but I use that, that unsettled time to go over the case, step-by-step look at what potential complication can occur at each step and how would I react to it? And I think that has helped me face complications during surgery better. After a major complication, my night is an absolute wreck. It is the way of neurosurgery. You have these incredible highs where you feel you've really made a positive impact on a patient's life only to be brought back down to reality with a major complication that just pulls the rug out from under you. And in reply to the follow-up question of, does it become easier or harder with more experience? I think what happens with more experience is that your judgment becomes better, your complications become less, but it does not become easier.

- And yes, I agree with that. I agree. I need to finish up because I want to give the rest of the time to Aaron maybe I I'm gonna skip this if that's okay. I'll finish with legacy, which will allow Aaron to pick up from here. Roberto, if you could give one, no, let's start with this one. Three pieces of advice, actually no the second one actually Aaron will deal with that one. Let me skip the second one. Roberto, one last piece of advice to your children if you had to give it before you died, one piece of advice, what would it be? And I'll ask you the same question, Robert.

- To my children?

- Yeah your children, yeah.

- Oh, my God, do whatever makes you happy, whatever makes you happy, whatever brings you happiness, where you find your comfort zone. And don't try to be like me. That's the main thing, because each one-

- You are happy. Why would you not want them to be like you? You're a happy, you just said it. You're a happy man.

- No, no, no I want them to be happy like me, but not by doing what I'm doing. That not make them happy. They need to know what makes them happy and that's the advice I would give them.

- Okay, and Roberto also you, if by a miracle, you were outlived by a group of former trainees and they are reminiscing about you in 30 years. What would you really want them to say, boy that Roberto, nobody was better than him at what? What would you want your former trainees when they're reminiscing about you to say you were the best at what?

- I was probably the best at remembering my complications, as you all know, I can tell stories to the residents every day. And each story has a moral because the moral is that I did something that led to a complication and they remember that, if I had told them just the great cases that I did they would have forgotten about a second after I said it, but they love to hear that the professor screwed up don't they? And they remember that. And then they remember why you screwed up. So I remember, just but forget the cases that went well. I mean, there were a few, of course, but I do remember the ones that did not go well. And I think I learned from most of those.

- Robert, if AANS wanted to establish a yearly award in your name, what accomplishments would you like AANS to recognize in the young neurosurgeon? What would you like them to award the neurosurgeons for, what kind of work?

- I think for that innovation, innovation. And I also, I think I had the words that Roberto uttered for my children. It would be what makes you and those that you love, happy, everything else comes after that.

- Agreed. Agreed. Well, as you both know, I can keep going for hours, but I'm gonna shut up and hand it over to Aaron. But thank you both-

- Before you, yeah go ahead. Nobody can do this like you can, fantastic job.

- Only with the people that I love like both of you.

- Fantastic.

- Thank you. You're muted, Aaron, Aaron you're muted.

- Thank you, Jacques. Thank you to all of you guys. Obviously these are very interesting thought provoking topics that are very important. Something that is very important to all of us and the future generation is we learn from the past and the history repeats itself. However, neurosurgery is also facing significant new challenges. Every generation has to find its own way of being a master surgeon. We can't necessarily copy the past, copy of the legacy of others and claim it to be our legacy. That's just not being original. And I think when the tough questions arise such as this is that now we have people like Dr. Heros and Spetzler who have truly established a legacy and have become master surgeons. So what is upon us and the future generation to become a master surgeon? We can't just repeat their formula because just like in any other business and I'm my own MBA training and business smart a free market mentality, is that it's all depends when you wanna be successful in a project or a business, it's all about timing, environment and execution. So our time, our environment and the way we execute is going to be different because the era of neurosurgery that's ahead of us is very different. We're facing significant competition from much more decentralization of neurosurgery. In other words, building a very rich practice is much more difficult than it used to be, building those number of cases is going to be very difficult. Neurosurgeons are facing significant scrutiny in the most number of institutions than most academics institutions are a state run, occasional private practices that obviously the freedom is much more. Those scrutiny led to us to be much more conservative in terms of our innovation. The face of endovascular therapy radiosurgery have affected in open cerebrovascular neurosurgery and skull-based surgery respectively significantly, just because an aneurysm doesn't have an option and it's ruptured doesn't mean that we can take them to the operating room, there are very effective therapies endovasculary that are being proven to have significant durability. So building a large practice of clipping aneurysms or doing bypass, and unless you can get away with complications is gonna be almost impossible. So we have to face new realities, very difficult ones in terms of where we are going as cranial surgeons to become master surgeons. So this is my sort of piece of the puzzle that I like to at least have an hint of solving even though I don't have a solution tonight, I'm gonna go ahead and bring my slides up. And they're just gonna be some provocative topics about what we need to go and where we need to go. So, just hold on one second for me here. So what is truly an academic operative neurosurgery? In the face of radiosurgery and endovascular therapy where our realm of treatment is becoming more and more narrow. We have to be much better technically, we have to compete with procedures that potentially their durability is not as sustainable, but in the face of those critics, it's gonna be extremely difficult to prove a major invasive procedure is less risky than endovascular or radiosurgical therapy. There is a significant evolution in our professional. We have to be honest about it. If we don't be honest about it, we're not gonna be able to face it effectively. What does it mean? I mean, the resources for academic neurosurgery are shrinking significantly. Just a number of dollars are no longer present. It used to be that we were able to generate that much revenue. We could use some of our revenue to dedicate to research. That's no longer as possible. Most importantly, the administrators in hospitals don't have as much value for a great surgeon because the internet has changed. And in fact, sometimes surgeons with significant reputation can potentially take their patients away if they leave an institution and that's not great for the institution. So, and the ability to have those big number of large case series has significantly shocking because of the decentralization because of alternative therapies. And the freedom to innovate has very much been decreased because of the alternative modes of therapy available that are less risky. And therefore that ability to be innovative, to conform, conduct high-risk surgery as very much almost non-existent or very limited. So considering all of that, I think we're facing a significant revolution. And if we can create those big series, no matter how good we are technically, if actually technical expertise of a neurosurgeon may not be the most important factor in being an academic operative neurosurgeon, what is it in the future that as a new generation of neurosurgeons, we can introduce to make our own legacy. These are difficult questions, and I want to bring it up and let everybody discuss that. Dr. Spetzler you have been truly the most innovative neurosurgeon our time and I wanna ask that question from you. What do you think if you had to start your career at age, let's say 37 or eight, were you really, you were obviously the guest of the Congress at the youngest age ever, if you're 40 years old, you're the honored guest at Congress and you're starting the height of your career. What do you think you would do now to create the similar legacy you have created for yourself today?

- Aaron, what you have said much, I really don't agree with. I think that the tone for the future is too negative in my opinion, neurosurgery is a big tent and it has, if you think about the innovations for example, in spine surgery, they're phenomenal. Endovascular is under the same tent when they improve on what we do with an endovascular technique. That is to the benefit of neurosurgery as a whole and obviously to a specific patient. Yes, the winds are totally different than they were. I think there is still a very, very important role for the microvascular neurosurgeon. We don't need as many as we did when Roberto and I started off when microneurosurgery was just at the dawn and the complexity will be higher, but we also have brand new ways of really honing our skills. We have virtual surgery, we have robotic surgery. Today's resident can spend endless hours in the laboratory that we never had the privilege to do because we were doing a lot of menial tasks during our residency. I think overall, neurosurgery is as dynamic with a incredible future as it has ever been. And I think what we need to do is we need to recognize the reality of endovascular neurosurgery. We need to recognize where stereotactic radiosurgery has a place, but when you're talking about innovation, just think about radiosurgery alone. Every one of the tools that is out there that's being used commonly was initiated, thought of by an innovative neurosurgeon, neurosurgeons are leaders, they're innovators. I have absolutely no question that this will continue.

- And if I ask Dr. Heros the same question from you, where would you think we'll be going? I obviously, I agree we don't want the talk to me negative because the future is bright, but the limitations that are placed on a technical micro surgeon is significantly different. Go ahead.

- Well, my answer would be very similar to Robert. I think that clearly you have to look at neurosurgery globally and the opportunities that we had, that Robert and I had when we began, that were brought about by the microscope and made us become microvascular surgeons. That is no longer an innovation. That's no longer new, but there are magnificent opportunities for innovative neurosurgeons. Look at functional neurosurgery.

- Yes.

- The frontiers of functional neurosurgery are Unbelievable, unbelievable. Now is there, of course, is there a role still for people to do what all of us, the four of us have done, which is to concentrate on microsurgery, back microvascular surgery, skull-based surgery. Yes, there is still a role, but as Robert said, it's gonna be for the few, is gonna be very limited. But when I look at people like Jacques Morcos, when I look at your videos, Aaron, when I look at my colleague Mustafa Baskaya for example, and see them operate, it's doable. You still can become master surgeons, even if you didn't have the advantages that Robert and I did. And we did have major advantages when we began to talk about many of the things that you mentioned were the advantages that we had that you don't have and yet you're able to do it without those advantages. We did have the advantage of, it was very easy for us to go because we brought in a lot of money clinically, probably as much as we 30 years ago as much as we do now. And yet we were able at that time to use, as you said, Aaron, that money to do research, to have fellows in the laboratory, to have technicians, to have a lab. So it was much easier for us to do, to be in academics and do research. It was much easier to be innovative because again, we didn't have the competition. We could, if we had a challenge and I'd remember just some of the crazy things that I was able to do, just because there weren't any alternatives I can recall. For example, the challenge of aneurysms the origin of the basilar artery, there was an alternative then. Dr. Drake had done some from the front through the mouth. They all died of meningitis. So I said, well, what if we just drill more laterally along the condyle and how much I had no idea, let's do as much as necessary to be able to see the basilar origin, nowadays is much more difficult to do that. I remember having a duro fistula transfer, sigmoid sinus that had a lot of feeders, of course, as they do coming along the presigmoid region. And I remembered that had a couple of deaths because of bleeding from that. So I said, well, if I want to excise this whole area of the sigmoid and transfers, because there was no endovascular surgery, then I got to get control of those feeders coming from the presigmoid region. So let me just drill this bone until I can get control of that without really knowing what was on the other side, very much, those things that nowadays it's very much more difficult to do that. So we had some major advantages at that time because of the lack of competition, the lack of alternatives, and you don't have those and yet some of you have become truly master surgeons in spite of the difficulties. In spite of the fact that building a practice now is much harder than it used to be when Robert and I began, I think Robert, you were in Cleveland and I was in Pittsburgh, I think within the first two years to practice and you probably more had done 100 bypasses. It's not 150, is that nowadays that's difficult, but you guys have done it and you have acquired expertise, by just being and concentrating on that, can everybody do it? No, it's gonna be a select few, but it is still possible. And you guys of your generation, those that have become truly masters are examples of the fact that it is still possible.

- Jacques, what are your thoughts here? Turn your microphone on Jacques.

- Yeah, thank you. We have to adapt to change or you don't survive. And we have, I mean just take here. You're younger than me, but I mean, look at our example, I would have never thought I would become an endoscopic endonasal skull-based surgeon. I mean, to be honest, what? Took that up in 14 years ago, I was laughing at it in 2004. when I heard presentations, I was doing what Sam was doing at the time, saying what you're taking a cranial, not a cranial, meningioma or something, then you realize you have to keep up with the pace because you are not comfortable at the time of your training to do something. You have to adapt or you will not survive. And that's where the open-mindedness needs to come in and you've done it, I've done it. Many people have done it. You cannot be married to a technique. You need to be married to your desire to improve a certain disease, whatever it takes. If your skillset doesn't allow you to do it, that's okay, let somebody else do it. Focus on what your strengths are. I understand the tone of your slide. The tone of the slide is saying really well. It's not like it was in 1977 when these two gentlemen graduated from residency. Yes, that's true, but it's not supposed to be. And we're supposed to be in a constantly changing environment. And the role of microsurgery is alive and well, but it needs to be in tertiary and quaternary centers. Can you and I control this? No, but that what the word needs.

- No, I agree with you. And I think all this statesmen made this correct. I think something I always say that. I think Einstein said that if you give me an hour to think about answer you, bring you a solution to a problem, I think about the problem for 55 minutes and then I think about this solution for five minutes. And I think that was really the goal of this slide here, is that we have to focus on what are the challenges. In other words, I think as surgeons, we often take many of our background challenges for granted. Not the individuals we're talking to tonight, we always put the blindfolds on and think about ourselves and our abilities and do not consider the challenges that are haunting us. I think there's no doubt that the challenges are very different, but they have to be, our challenges are more than the challenges at the time of Dr. Spetzler, Heros. Our challenges are different. And I think it goes back to the responder Jacques or Dr. Spetzler and Heros very much responded to is that we have to be very much more adaptive for us to be able to change to the environment just like any species in the history of evolution is that for us to be much more adaptive and realize that the solutions of the past may not apply to the problems of the future. So if we have to pick up endonasal surgery, if to realize how useful it is to do radiosurgery for small residual tumor in this skull base, and don't be as aggressive as you used to be because there's limited other options if the tumor regrows. I think remembering that those new therapies are friends and not our enemies and use them to the best we can. And most important of all, just like everybody mentioned, micro neurosurgery is gonna be for very few. It's not gonna be as popular among many that were able to do it as it used to be. And those that do it are gonna do it because they love it. Not for any other reason. And I think that is more than any other time in the history of neurosurgery people have to do something because they have passion for it and not for anything else. Dr. Spetzler do you have any comments as closing comments after what I mentioned?

- Yeah, thanks Aaron, you bring up the word passion. I think any physician neurosurgeon who does not have passion for this specialty has missed the boat. It's passion that drives us, it's passion that makes us better. It's passion that lets us learn from our mistakes. There hasn't been a single resident applicant that I haven't asked how passionate they are in wanting to join this very, very special field of medicine.

- Dr. Heros, any closing thoughts you have.

- No, no question, I couldn't agree more with that, just every day I think and say, to be doing, just think about the fact that about probably 99% of people work for a living. They work because they have to work to make a living. And to think that we can do these phenomenal thing we do, neurosurgery. And actually we get paid and actually rather well for doing what we do for having, for doing what our passion is that gives us all the kicks and rewards that it gives us is a phenomenal choice of career and I think that we're very, very fortunate to have gone along this path and to have people like you on the subsequent generations who are equally passionate as we were when we started this, we're very fortunate.

- Jacques, do you have any closing statements, please?

- My closing statement is I'd like to thank these two giants for having been in my professional life or having been a beacon of neurosurgery to the rest of the world. We love you and admire you both till the end of time. Thank you very much.

- Thanks Jacques. And I wanna equal that as well. Unfortunately I was never fortunate enough to work with Dr. Spetzler or Dr. Heros, but I have to tell you that there's not a single video of theirs that has not been in the public that I've not watched. There's not been a single paper of them that has been in the public that I've not read word by word. And I can tell you that all of us truly looked at both of them as our mentors as if we have been in their operating room. And I can really think every time I get into trouble in the OR I can very much see them looking over my shoulders and thinking what they are thinking at the time and trying to do the same. And those are the qualities that all of us need to have for younger generation that continual improvement, watching your own videos and others every day. Remember that you can always do the next surgery better, no matter how good the patient does. The next surgery has to be shorter and better. So with that in mind, I wanna thank all of you for your valuable time. I wanna thank all the 400 people that at some point joined us during the session from 60 different countries and wish everyone a great week. Thank you again.

- Thank you, and thank you for the invitation.

- Bye, bye.

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