Thursday, December 5, 2019

What Residency Looks Like LXXXIII: It's not brain surgery

I used to want to be a neurosurgeon. Growing up in Baltimore City in the 1990s, when Benjamin Carson would give inspirational talks to school children about doing well in school, I thought I wanted to grow up to replace him at Johns Hopkins. It was the hardest job I could think of, and I liked the approbation from adults when I told them this.

When I got older, a good family friend advised that I wouldn't like myself by the time I finished neurosurgery residency and that I should find a specialty that was more accommodating to women. I had always wanted to work with children, especially those with special needs, so in college I entertained the idea of going into developmental and behavioral pediatrics. In medical school I learned that DBP is more of a consult field, whereas I still cherished the idea of developing long-term relationships with patients and their families around all issues, especially those around access to resources such as community supports, education, and jobs. Very late I discovered the fields of transitional medicine, which helps teens graduate into adult clinics, and complex care, a niche for taking care of children and youth with special health care needs. These are growing fields, as more babies survive the Neonatal Intensive Care Unit (and later, the Pediatric Intensive Care Unit) to grow into young adults who carry diagnoses such as developmental delay, intellectual disability, Autism Spectrum Disorder, or cerebral palsy. They might use a feeding tube, a breathing tube at night or all the time, a walker or wheelchair, a communication device or sign language, and a variety of other technologies and accommodations seen and unseen.
Cookie Monster Clip Art -
This is an accurate representation of me
in the OR during a neurosurgery case.

One medical advance helping this population is the shunt, a plastic tube that drains excess cerebral spinal fluid from around the brain into the heart, chest cavity, or abdominal space. There's a joke in pediatrics that goes, "It's not the shunt." That's what the neurosurgeon stereotypically says when consulted about whether a headache or infection could be due to shunt malfunction or infection. In their experience, the shunt is almost never to blame. I wondered why. In order to be a good primary care doctor to patients with shunts, I signed up for an elective rotation with the neurosurgery team. In clinic or on the wards, I shadowed the other providers to hear the kinds of questions they asked, and in the operating room, I just watched at first.

Then the fellow got me a pair of official scrubs* so that I could "scrub in" to surgery to stand closer to the table. After I was scrubbed in, they let me help:

- I programmed a shunt (it involves a fancy magnet).
- I held instrument cords while the surgeons and techs got everything into place.
- I either stepped on the electrical knife pedal or pointed it out to the attending. (It was the round one.)
- I cleaned bits of brain tumor off of the fellow's instruments.
- I held my finger against a hole in the patient's skull to prevent cerebral spinal fluid from leaking out. (I felt like the little Dutch boy with his finger in the dike.)

I mean, I wasn't doing brain surgery. But I appreciated the surgeons' willingness to let me tag along to see how their perspective differs from mine. The point of electives in medical school and residency isn't to master that field, it's to get a better appreciation for it and to pick up a few tips and tricks so that I will be a better consultee. Plus, doctors and surgeons are human too, and we all prefer to work with and trust people better when we know them, so I felt like I was doing a sort of cultural exchange program to built bridges between the pediatricians and the neurosurgeons.

All in all, it was a successful elective. I can't stand the early hours of surgical and hospital work, and I wonder whether I would have ever built up the appropriate dexterity for surgery, but I will be a better doc now that I know it's not the shunt!

*A few years ago the children's hospital changed their OR scrub color to what I once overheard a surgeon describe as "Cookie-monster blue."


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