‘The greater you are, the more you must humble yourself;
so you will find favor in the sight of the Lord.
For great is the might of the Lord; he is glorified by the humble.
Seek not what is too difficult for you,
nor investigate what is beyond your power.
For their hasty judgment has led many astray,
and wrong opinion has caused their thoughts to slip.’
Sirach 3:18-21, 24
Just yesterday I saw a patient, Susan Curry, in the office who had been recently diagnosed with breast cancer. Following her surgery she began experiencing a number of neurological symptoms which led her doctor to order an MRI of the brain. This scan revealed she had a small tumor on the surface of her right temporal lobe, which had the appearance of a benign meningioma, which was unrelated to her cancer and her ongoing symptoms. But because her surgical oncologist could not be certain of this he sent her to see me.
As it turned out she had an MRI, 7 years earlier which in retrospect showed the tumor, although it was smaller; so my conclusion was that it was indeed a benign tumor and because of its current size I told Susan we could simply follow it with serial or future MRI scans. I did tell her and her husband Jim I wanted to run some additional tests because of her symptoms but for now we would just keep an eye on the tumor to make sure it was not going to continue to grow.
Susan, however looked at me and with an insistent tone asked me, ‘Are you sure you don’t want to take this tumor out? After all, in your blog you said how excited you get when you have a patient with a brain tumor.’ I told her, ‘Well that is true, but only if the tumor needs to be removed.’ Seemingly, she was not completely satisfied with that answer, as if to imply she wanted me to take the tumor out anyway. She went on to say that she was fine with knowing the truth but it was not knowing that upset her so I assumed she just wanted to be absolutely certain it was not cancer, but in the end, said ‘OK’.
In many ways the decision-making of when to operate is more difficult than actually performing the surgery. And in some cases it is not whether surgery should be performed but whether I should be the one doing it. There may be many reasons for this; perhaps I don’t have all the equipment that I may deem necessary to take care of the problem at hand or perhaps it may be that it is a procedure that I don’t perform regularly and so I should refer that patient to a neurosurgeon that is more experienced.
To be a brain surgeon one cannot be short on ego or confidence and so admitting that I may not be the best one for the job can be a difficult pill to swallow!
Of course no patient wants someone to operate on their brain if that surgeon doesn’t believe he is the ‘best and most talented neurosurgeon in the world’! And so for me it is a delicate balancing act between confidence and honesty. Although there have been many times in my life when in the middle of a surgical procedure I have literally said to myself, ‘What am I doing here?’, only to deftly navigate myself through the procedure without complication.
Once I operated on a patient with a ruptured aneurysm and for reasons beyond my control I went into the surgery not having a complete picture of the surgical anatomy. As it turned out it was an extremely difficult surgery and an aneurysm I had never clipped before but I performed the surgery flawlessly. Had I known going in where that aneurysm was located I might never have agreed to do the case but as it turned out I was indeed the best man for the job.
So in practically all instances my skill, talent and knowledge is more than enough to get the job done. And having operated my way out of seemingly impossible situations many times before it is easy to understand how I would come to believe that I am indeed the ‘most talented neurosurgeon in the world’. But this is exactly why I must always turn to God, and ask for guidance.
Such was the case with Maria Papadakis. Maria, 22 years of age was involved in a car accident. For some unknown reason she became dizzy while driving one day, passed out and drove her car off the road and hit a telephone pole. On arrival to the emergency room she had a headache but otherwise was perfectly fine that is until she had a CT scan done of her brain. In the left frontal lobe was a tumor, just above the speech area and right up against the motor area controlling the right side of her body. Later, the neurologist would conclude she likely had a seizure which caused the accident.
She was admitted to the hospital that evening and I saw her in consultation the following morning. As it turned out I had operated on her mother Helena for a ruptured disc in her cervical spine a couple of years earlier. I then ordered an MRI scan to be done. After reviewing it with the neuroradiologist we concluded that the tumor likely was a low-grade astrocytoma, or perhaps it might even be a relatively benign tumor. Nonetheless, it would have to be biopsied so I could determine what would need to be done surgically. I discussed this with Maria and her mother and told them I would perform the biopsy the following Monday and depending upon the results I would tentatively plan on the actual craniotomy for Thursday of that week.
On Saturday as I operated on Michael Dubois who had spread of his lung cancer to his brain, I thought of Maria and the difficulty I might encounter operating on her brain tumor. It was fairly large and although it’s location was above her speech area it extended right up to the motor area controlling the right side of her brain. Since it was likely to be a low-grade tumor the visual and tactile difference between it and the surrounding brain might not be that great. Thus, I could have trouble knowing if I had adequately removed the entire tumor; conversely I might not realize if I had also removed normal brain tissue in my attempt to resect the tumor.
So my dilemma was should I be the one to remove her tumor as I knew I could, probably doing a better job than most neurosurgeons. Or refer her to be treated at the University of South Florida where they had an intra-operative MRI and more experience performing an awake surgery where they could accurately map out the speech and motor areas of her brain.
On Sunday making my rounds at the hospital I stopped by Maria’s room first and sat down to talk to her. I explained to her my concerns and that I decided she would receive better care if I referred her to Dr. van Loveren. As I spoke with her she finally comprehended the seriousness of her condition, as her face changed from her usual bright and carefree look to one of apprehension, although she thanked me for doing what I believed was best for her.
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