Mentorship in Neurosurgery

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- Hello, ladies and gentlemen, and thank you for joining us for another session of the AANS Grand Rounds. We have a special guest tonight today, Dr. Will Couldwell from University of Utah. He's undoubtedly one of the most accomplished mentors of all times in neurosurgery. It's truly an honor to have him with us today. He's the best example of what a great mentor would be in terms of helping the future young neurosurgeons achieve their great potential. So, Will, I thank you again for accepting the request to discuss about mentoring in neurosurgery, especially young faculty and I'm very excited to hear your comments. Please, go ahead.

- Well, thank you Aaron, it's an honor to be here and it's an honor to contribute to the Grand Rounds once again. And we've got an important topic today talking about mentoring junior faculty. I'd like to just sort of let you know that this was given as a presentation to the young neurosurgeons at the WNS a year ago, but I think it has some important messages for all you junior faculty. I'd like to point out this one special person that I've been a great fan of over my career is Sir William Osler. And maybe it's because I was born in Canada and I went to McGill University where Osler started his career that developed my interest. But also one of my PhD mentors, Will Feindel was the curator of the Osler Library and all the materials there and so he really got me interested in Osler as a person and a leader. It's interesting when you look at Osler's grave and his wishes before he died, he desired no other epitaph than the statement that I taught medical students on the wards, and I regard this as by far the most important and useful work I have been called upon to do. And this sort of was emblematic for Osler because he felt that his students were as force multipliers. He started his career as a young pathologist at the Montreal General Hospital. And at that time would have mentoring sessions with medical students every Saturday morning. And they would publish an abstract out of the sessions every week. He developed, they would do autopsies together and he inspired the young students and his electric young faculty. And here's a picture when he was a very young man during his time at McGill. And ironically, even though he went on to Hopkins and then ultimately his career at Oxford, he gave all of his materials and all of his library to McGill University. And if you go to the McIntyre Medical Building, which is this sort of cylindrical building on the hill, this promontory on the first floor is the Osler Library. And he left his desk and all his books and even his ashes and his wife's ashes are sitting in the McGill Library. And it's remarkable the library that he developed there. He was a real bibliophile and he had works from all different types of literature. And of course this is his desk that he wrote all his famous textbooks is included there as well. So it's a marvelous place to spend time and you get a real insight into the person that he was. So let's talk about what some of the things that he did and some of the wild things that he did that related to neurosurgery, because I think it was a real inspiration to a lot of the young people in neurosurgery at the time. Osler was really the late 1800s, early 1900s, and he died in 1919. He did a lot of interesting studies and we actually published a number of these things from his works where he made a lot of seminal observations in neurology and neurosurgery that people didn't recognize at the time, but were really seminal observations. Like he wrote a pathological study on the brains of MS Patients when we did not recognize the pathology of MS. And one of the interesting studies that he did and incorporated the medical students at McGill was this studying on the brains of criminals. So there was a of a hypothesis put forward that the brains of criminals would be physically different than those of non-criminals. And he had done a lot of work on autopsies in his time and he didn't believe this. But Benedikt in Vienna proposed that the brains of criminals were deformed thus contributing to their aberrant behavior. And so he examined 35 normal brains from his material and found that same of the same abnormalities that were described by Benedikt have been described to normal people as well. And so what he did is he sent a young medical student, Ogden, to one of the small towns in Quebec to procure the brains of an individual that had been hanged for his crimes. And he developed his case that normal people had the same aberrations that Benedikt describing criminals. And then he got these brains of murders and other criminals and found that they were absolutely normal in configuration. So what he did was amazing. He published these papers at the time. And he inspired the students by getting them involved in the research project, and even how fascinating and crazy this one was. And so, but he continued the same pattern of incorporating young people into his research projects. He was really probably the best medical mentor in recent history. He became a great American physician of the late 19th and early 20th centuries. He was a pathologist, a clinician, a teacher, and a humanist. He made many seminal observations of neurological disease in retrospect that he wrote the first case of a CC fistula. He didn't know exactly what the pathogenesis of it was. But of his 1400 publications, nearly 200 of them related to the nervous system by the time he died. He began his career at McGill and then continued in Philadelphia and Johns Hopkins and later in Oxford in England as well. But probably most importantly to our specialty, he was a mentor to Cushing and Penfield. Now, Cushing was 20 years younger than him and was an early, real big fan of Osler's. He actually, this is a picture from the OR of one of Cushing's diagrams and sketches. And this is controversial, but you could state that the profile looks almost exactly like Osler. Other people disagree thinking this is not Ostler, but the remarkable similarity is there. But he was also a great mentor to Penfield, who was obviously the first director of the Montreal Neurological Institute and developed the money and raised the money for the Rockefeller Foundation to build the building in Montreal. And I had the opportunity to start my career there as a medical student and both as a PhD student as well. And this is a picture of Cushing at his desk and this desk is still sitting in the Osler Library at McGill. So I think he embodied the major mentoring philosophy that we'd all like to have. And I think that I've included a few quotes here that I think really differentiate great mentors. "Tell me and I forget, teach me and I may remember, involve me and I learn." And I think this was what Osler did with the medical students, and what I think the great mentors in neurosurgery have done with their own trainees and their residents and fellows. "The mediocre teacher tells, the good teacher explains, the superior teacher demonstrates, and the great teacher inspires." And I think that's very true. This is a good one, "Leaders should influence others in such a way that builds people up, encourages them and edifies them so they can duplicate this attitude in others." So I've seen leaders, many types of leaders in neurosurgery but it's been my observation that the best leaders are the ones that inspire people around them and are not insecure and not threatened by good people. As Charlie Wilson used to say, he gets people, he recruits people that are smarter than him and then gets out of their way. And I think that's very true. Some leaders can cast a sort of a toxic shadow around themselves and not help the growth of other people around them. So I think that great leaders inspire others around them. And so mentors provide the knowledge that we are missing and open doors to new connections and impart philosophies that we would otherwise have to take many years to accumulate. And then mentors are also great role models. The patterns of strengths and the weaknesses of leaders. And we're all human so we all have our faults. And then I think this is an interesting notion of mutual mentorship. So mentorship is the number one request by millennials worldwide. But mentoring younger colleagues provides also a window into them and to see what their needs and challenges are. So I think the mentor learns from the mentee as well, and they both understand and help each other in that regard. And I think this is an important one especially with the younger generation. I noticed as I get older is that you have the philosophy that everybody still thinks the way that you were when you were young, and the idea has changed and the world evolves. And so I think this is an important iterative process where people learn and people change, but we can all learn from each other. So let's talk about some of the specifics and how I look at mentoring junior faculty. You know, you have to recruit the best people and then give them the best opportunity for them to succeed. So we set out clear expectations, both academic and clinically. And it may be that academic mentorship may involve more than the chairperson, and in fact, most of the time it does. We developed an interesting program here in Utah where we have a mentorship program that involves people in the department and people beyond the department. They're allied to the interests of the younger faculty, and that could help with their career. So for their science recruits, for their science part of their career, we try to have mentorship well beyond the department in all of the allied areas in other departments, in engineering, molecular biology, neurobiology and anatomy, whatever, the leadership is determined that the individual needs to help define their expectations and then review them regularly. So I think that if we recruited a pure academic person that we expect to be a surgeon scientist, then we have clear expectations we want them to apply for a K award in the first two to three years of establishing themselves here. And then I've encouraged a lot of them to pursue R21s, which are a fairly easy application because it doesn't require a lot of preliminary data. And then obviously, we want them to become R01 funded and also DOD funded if they can as well. So we have clear expectations. And so our mentoring groups meet with them, and it's usually four or five people from different specialties that will review the progress of the individual, and then give us feedback on how we can help them ensure their success because you're taking good people. If they fail, you failed as a leadership team. And so this is something that I think that is understated in our specialty but happens quite frequently. And we call this the Dilbert dilemma of academia. So what happens is you recruit excellent people and excellent academic people are usually excellent surgeons and students as well. And it's always fun to do surgery, and we all enjoy operating and taking care of patients and the immediate gratification of how our patients do. And so it's easy to fill your time becoming busy clinically. And so what happens is the young faculty member spend their time getting increasingly busy clinically. And if they neglect their academic development, they just get busy clinically and they say, I'm not doing anything academically, I should just be in practice. And it's as somewhat a self fulfilling prophecy and it's very common, and so what happens is I think a lot of them drift off into private practice or a pure clinical practice in an academic environment without developing their full potential academically. And in some respects it's a self fulfilling prophecy, because I think it's easier to fill your time doing clinical work than it is to revise that paper or submit that grant. And so it's up to the mentor to really define parameters for success and hold the young people accountable to achieving those. And I think this is the most common one that I see. And Aaron, I think you're somebody who is really a role model because all people want to succeed, but some people want to succeed enough that they're willing to work to achieve it. And as you know, most of it is just getting down and doing the work and it's 90% perspiration and 10% inspiration. And you have to be able to get the ball across the line and deliver the product. And I think I can't emphasize that enough. That's the most important factor in achieving success. So just as some general practice wisdom comments, Charlie Wilson mentioned this to me. When I was a medical student on the service and he was in his heyday at that time, he said, "I never met a referring doctor I didn't like." And these three As of availability, affability and ability are probably the most important things for practice success, and there are just as relevant in an academic practice as they are in private practice. And so you'll see often the most talented people have these qualities and they become very successful both clinically and academically because they have those. Remember that, and I emphasize this to our residents all the time. And I think any of the seniors neurosurgeons relate to this, is that when you finish your residency, you're just learning to become a neurosurgeon. You're just beginning. And this is a lifelong learning process. I think this is one of the aspects of our field that I get humbled regularly as a senior neurosurgeon, just as I did when I was a young neurosurgeon because we're learning all the time. We're learning from our friends and mostly we're learning from our patients and the problems that we have with taking care of our patients. And so behind every successful neurosurgeon, there are a lot of unsuccessful years. It takes a long time and you need to keep humble or stumble. I will just point out these two people that have been so important to me over my career. And I will tell you, they both have the same qualities. This is Marty Weiss, who is the chairman of our residency program when I was a resident at the University of Southern California. And this is Will Feindel who is the director of the neurological Institute in Montreal, and also one of my PhD supervisors. They were both very humble people and inspiring in their own way and just a joy to spend time with. They were patient and kind, and they were so helpful in the operating room and academically as well. And I just can't tell you that they just embodied the best of mentorship. And I'm still so very indebted to both of them. Will Feindel died a couple of years ago, but Marty is still active and is still involved with the program at USC and just a wonderful joyous person. So these are principles that I've lived by and that I think they're are very important. I think, and Nick Triplett taught me this when I was a young man, be a leader at your home first. Be respected in the operating room. Be a respected physician and a surgeon in your own domain. And I've always considered neurosurgical leaders as growing out of the grassroots in that you become a foreperson like a foreman or a forewoman that you're working in the trenches with your peers, and you have the respect of your peers in your department and the residents, and then in the hospital that you work with, with administration and the community. Character influences character, very important factor. And perpetual optimism is important for the team. I think you can only lead as far as you've been. So you have to lead from the front. You can't call plays from the sidelines and you can't be a leader from behind. You have to lead the team and work as hard as anybody else or harder and demonstrate that this is the role model that you expect everybody to follow. And I think this is an important one that I've seen a lot of neurosurgeons sort of fall into this trap. Is that organized neurosurgery is not a career in of itself. That you need to focus on the core activity. You need to focus on your academic activity and your clinical activity, and your education and teaching activity. So you need to make yourself an expert in your field. You need to focus. You need to become an expert in a limited area so that you can make a difference in that field. You can't do too broad an area of practice. It's the analogy in my mind of being a decathlon specialist or a 100-meter specialist. The decathlete is great athlete, there's no question about that. But to really get the world record, you're gonna have to be a 100-meter specialist. And so that's an important aspect when you join these big departments that you really need to pick an area, make yourself an expert both academically and surgically, and then carry the field. Become a surgical expert and then become a mentor in that area. And I think it's important to develop a culture of service, both within the department, beyond the department, to your professional workplace. Serve on committees in the hospital and the medical board and to your community. And with respect to organized neurosurgery, the good people will ascend to those positions but it's not a goal in of itself. In my opinion, it's really just an aspect of your service to your specialty. And you will ascend to those positions if you respected by your peers and by the people you train and work with on a daily basis. So you wanna develop a culture of service to your partners. Be a team leader, step in and help. Help your junior faculty. Help them with their career development. Help them, you know, in their career advancement. Serve on the journals, this is the coin of the realm. It's where the truth comes in our specialty. How knowledge is advanced. Serve on peer review journals. Serve the American Board of Neurological Surgery. And in due time, serve in organized neurosurgery to the best of your capacity. If you do a good job, you'll get another job then it'll build from there and to medicine in general. I like to serve our medical students and our medical school. And be a mentor to everybody. Be a mentor to the students that come to visit you. We have high school students that come, college students, medical students, and of course, residents and fellows. It all flows. I think we've got a unique capacity in our specialty and we accept some of the most talented people in medicine to come into our specialty. And we have a very unique position and really, a special position that gives us a leg up on many other areas of specialty in that we understand and we can live in this nexus between clinical practice and basic science. And as surgeons, we're seeing disease and pathology firsthand. And we bridge this gap and we should take advantage of it. And we don't always do that. So this is a picture of what was called The Open Arms which was Osler's home in Oxford. He used to leave the door open all the time. And his students and residents would come in and visit anytime and they could knock on the door. And it was always an open house and it was called The Open Arms for that reason. And he was a mentor to everybody. To all the faculty, to his students, and he welcomed involvement. And I think the best mentors do that. You'll see that they'll have medical students, we have college students on our research projects and try to inspire them early on to go into medicine and then go into neurosurgery. This is Osler later in life. He married late. He married, his wife was actually a descendant of Paul Revere. I think she was the great granddaughter of Paul Revere and they had one son that lived till adulthood, his name was Revere. And this is a picture of Revere and his parents in their backyard and in England. There was a sort of sad twist to this story that came around full circle to Cushing in that Revere was born in 1895. He was the blessed son of Sir William Osler at that time. And when he was 21, he served in the war in Europe and was in Belgium at Ypres, the Battle of Ypres and, was hit by mortar. on August 27th, 1917, Revere was injured in the battlefield. And ironically Cushing was close by. I think he was in France at the time, but they called him over because Osler's son had been injured. And Sir George Crile wrote this that Brewer, Cushing and I were in consultation when Revere was injured. "The long marquee tent was quiet and dim, the end was fast approaching. The boy's features were serene and a faint smile illuminated his face when he was told that his father's American friends were there." So Revere Osler had grown up and knew Cushing well when he was younger. And so they operated and actually Harvey helped deliver anesthesia during the surgery. But his injuries were profound and he didn't survive. And he's actually buried in Belgium, in the Dozinghem Military Cemetery there. So this was a terrible event obviously for Cushing in his life because Osler was his mentor. And poor William Osler was never the same after this. And he died shortly after Revere was killed in battle. And he was honored in Canada by putting on the stamp. This is one of the last pictures of Osler when he was 70 years old and he died shortly after this picture. But I think it was ironic the end of, that at his son's death that Cushing delivered the anesthesia. So Cushing went on then and wrote the definitive biography of Osler in 1925 and 1926 he won the Pulitzer Prize for The Life of Osler. And it's still a good book, it's very dense and it's got a lot of detail, but I think it was a fitting tribute to probably the person that had the biggest impact on Cushing's career at the time. So enjoy your journey. It's a fascinating specialty full of wonderful people and great mentors. And I wish you all the success. Aaron, do you have any questions?

- Beautiful, and really enjoyable how you brought the whole talk around at the end and connected the dots. You know, I learned much about Cushing, as you know, and I know all about his personality and his relationship with Osler. It is very fascinating that we don't give enough credit to Osler for infancy of neurosurgery and how he made it possible. I can even somehow argue that if he wasn't because of Osler, neurosurgery may have not been born by Cushing. And one may say, how could that even be possible, it's because Harvey Cushing was a very difficult person to work with, especially as a youngster, as a resident, as a young faculty. And there were at least multiple occasions that they had the final decision to fire him from Hopkins. If it wasn't because of Osler who came in and really convinced everyone that we should give him a chance, Cushing would have not survived his behavior. And so if you also remember that Halsted was never in fact supportive of Cushing to start brain surgery as a profession. So who was really the person who contributed so much to evolution of Cushing to become more malleable, to become more successful, to get patients, to be able to do the first brain surgery was Osler. Because Osler truly believed that neurosurgery does have a future, unlike Halsted that felt brain surgery is a futile profession. Therefore, I can say that we owe a lot to Osler as neurosurgeons besides being a mentor for Harvey Cushing, because Osler not only referred a lot of patients to Cushing, not only encouraged Cushing to be passionate about establishing this specialty of neurological surgery, and at the same time understood Cushing. And that is something that I've always believed is probably one of the most important features and factors in a mentor. The mentor has to understand the mentee. You almost have to spend some time with them socially. You have to get to know them really closely. You have to understand their strength and weaknesses, and you have to respect them. I think mentorship starts beyond anything else with respect. There are many people who can be mentors but they're not necessarily a good mentor for me or you because we don't necessarily respect them. But the moment you start having a lot of respect for an individual and you feel like you wanna be like them, that is where the mentorship relationship with the mentee strengthens. And that issue of respect is so extremely important, especially among neurosurgeons because we all have very high expectations, we want our egos to be fueled and therefore we want to be a associated with people we truly respect. And that's why it's so important that unfortunately chairmans in our departments are determined by a search committee that often has nothing to do with the department itself. And then a chairman comes and that person certainly didn't build the work to gain the respect of the faculty but they expect the respect because now they are the chairman. And that's where the disconnect is. That's why I think the mentorship starts with gaining respect, building that respect, and it's all on the mentor to do that. Not the mentee, unfortunately. So being a chairman or a mentor per se is an extremely difficult job. Most people take it for granted that I'm doing some NIH grants. I know some people that have been able to work my way through the ranks in the national meeting and now I'm ready to be a chairman. Actually just being able to do research in the lab, not necessarily being a very flourishing surgeon does not make you a very good mentor because we're neurosurgeons, number one, so our mentors have to be highly-skilled expert neurosurgeons like you. And I think, Will, again, bringing everything together, you have been so successful as a good mentor and a chairman. Because you're not only an excellent technical surgeon, you're not only somebody who has a lot of respect among neurosurgeons, you also have a way to learn how people are and what are their strengths and weaknesses and how to inspire them. Because there's no single way or prescription or ingredient to inspire me versus someone else that is the same, it's actually very different. So being a mentor and a chairman takes extreme amount of work and effort, and just doesn't come about having NIH grant and having a lab and just knowing people to get you promoted. And it's unfortunate that I think in the past few decades, neurosurgery and the chairmanship and mentorship in neurosurgery has not been necessarily on the right track. We have been more and more seeking chairmans and mentors that have been people very strong as science, which is extremely important for neurosurgeon, no question about it. But departments are very clinically-oriented and therefore you wanna have a chairman who is also very technically gifted, that therefore you can look up to, you can relate to. Because as a chairman you have to know what are the problems of the every faculty and how can you relate to them to gain their respect. And if you're not in the same environment with them and you're doing lab work, that unfortunately creates a disparity. So again, I think Osler was so extremely successful because he built the trust and respect with Cushing, unlike what Halsted did. And therefore, Osler would remain forever a man of great respect amongst so many neurosurgeons most likely more than Cushing, because he was not only a great mentor, he was a great human being, he was a great family man, and he gained the respect of so many in terms of advancing the career of the younger faculty, college students, residents, et cetera. What are your thoughts there?

- Yeah, I think it's interesting. You can see our specialty is very small and you can see where there's been a legacy of great mentorship in different places across the country and nationally and internationally, of course, for that matter. You know, there's been a legacy of leadership in several places. I think in the Neurological Institute at Columbia is a good example of that just over the history. Memphis has been a great example with several different leaders of neurosurgery that have been national and international leaders and several places across the country, UCF, et cetera. But it's really just a few people. And I think what I've learned from Osler is that he had an enormous impact on so many people well beyond his own interests just because he inspired people. And I think, and he brought them along and he was patient with young people and he really developed them and developed the best of them. And I think that's what we need to learn in our careers and that's what successful mentors need to do. So it's really been an honor-

- I agree. to spend time with you, Aaron, and I think-

- Same here. Will, thanks as always, and we look forward to doing other sessions. I know we're planning to do at least two or three sessions on craniotomies and this specific approaches to complex lesions and we're also planning to do a session on resection of pituitary tumors and significant challenges we have intraoperatively regarding some of the micro adenomas, so like Cushing disease, et cetera. So I really look forward to working with you and I truly thank you for the great service you have done to neurosurgery and being such an incredible mentor for so many of the future neurosurgeons.

- Thank you, Aaron.

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