Jeffrey A. Brown, MD, FACS, FAANS

First, some basic requirements: there are a lot, but that is the point, too.

Doctors educated in the United States are granted their MD degree upon completion of (most often) four years of study and clinical preparation after college graduation. They must pass a series of three examinations to be granted a license to practice in the state(s) of their choice. The first exam covers basic medical science. The second deals with the principles of clinical conditions. The last exam is taken during the first year of clinical training (internship/residency) and covers the application of medical knowledge to diagnosis and treatment. After completion, the MD degree is a general one and approves one to practice any field of medicine.

Physicians who attended non-US medical school are granted their MD degree from that country. To be allowed to enter a United States clinical training program they must take another version of this series of three tests. It is specifically designed for foreign medical graduates.

Osteopathic physicians (DO) have a different degree program, different training programs, and take different licensing examinations. Osteopathic medicine education is said to deal with patients “holistically”.

To become a board-certified neurosurgeon in the United States requires at least five to six years of training after medical school at one of about one hundred carefully evaluated and approved programs, and sometimes includes one or two years of elective additional focused (fellowship) training in a subspecialty of neurosurgery. These areas of training might include spine, pediatric, vascular, tumor, or pain neurosurgery. Fellowship training is not required.

The final board certification occurs after several years of practice, submission of all operations performed during those years for independent review and successful completion of an oral examination. In recent years certification by the board must be renewed by further examination every decade.

To maintain any state-granted medical license, physicians must complete 50-200 hours of approved continuing medical education biannually. More often now, some states are mandating reeducation in areas such as infection control.

Finally, to maintain privileges to work at hospitals, neurosurgeons must complete annually scheduled education in hospital policies and practices.

So how does a neurosurgeon stand out amongst colleagues as an expert after all this education?

Education is important. What comes next is what makes one an expert. Experience, dedication, passion, personal contribution to the advancement of the field, team development, the capacity for humanity, and empathy for others make the difference.

Let’s take experience first:

A seminal paper reviewed data from a database representing 1/5th of non-federal hospitals from 19 states for 1,590 microvascular decompression operations (MVD) for trigeminal and glossopharyngeal neuralgia, and hemifacial spasm. The authors learned that there were significantly fewer complications from MVD surgery by neurosurgeons who had performed at least 29 MVDs per year. Low-volume neurosurgeons’ cases had a significantly higher incidence of brain hemorrhages after surgery and a need to drain spinal fluid after surgery (a sign of greater intraoperative bleeding). 29% of all MVDs at these hospitals were being done by a neurosurgeon doing only one MVD a year.

The hospital in which the surgery was done was also an important consideration, especially in patients older than 65 years. Hospitals in which at least 20 MVDs were done yearly discharged significantly more patients to their homes than to another facility, such as a nursing home or rehabilitation center (1.6% vs 5.1%). For neurosurgeons, the corresponding percentages were 6.1% vs. 0.5% (only 1/208 patients) for surgeons doing more than 29 MVDs a year. Complications were twice as frequent at low-volume hospitals and 12 times higher for low-volume neurosurgeons.

It’s not just the neurosurgeon that needs the experience. It’s also the team built around that physician in all aspects-the hospital and the team recruited by it.

What about those other aspects of what makes a physician stand out amongst other colleagues?

The ability to communicate is essential. Does the doctor sit at your eye level when meeting with you, summarize the essentials of your health situation, then elaborate, in understandable language, what he or she believes is your diagnosis and his or her recommendations for its treatment? Does the doctor then discuss the risks of any surgery recommended, the likelihood of each complication occurring, ideally the likelihood in his or her personal experience, and even the risk of not proceeding with surgery? This is the beginning of the informed consent process. Note that it is an interactive process, not only a piece of paper slipped to you on the morning of surgery. Does the doctor provide an opportunity for you to pose questions and respond? All this takes time. Does the doctor allow for it? An expert technician must be matched by his expertise in the elements of being human, the essence of professionalism.

What does that mean?

Integrity
Eye contact
Use of power words- helping phrases

Does the doctor exhibit the elements of compassion/personal engagement?

ESP
(E) The doctor reflects back his or her behavioral/emotional observation of you, the patient.
(S) The doctor stops to listen without interruption.
(P) The doctor provides a plan and summarizes.

And when the doctor is leaving the room does he or she ask an open-ended question, such as, “Is there anything we missed?”

A key to what makes an expert is how he or she handles an unexpected complication. Is the complication rapidly identified and are all efforts made to limit the injury from it?

What if the physician believes that the best treatment is not something in his expertise? The ability to understand the limits of one’s knowledge is also essential. Does the doctor provide assistance in finding a doctor and the facility that do have that expertise?

What is done after surgery can also be critical. There may be more to do. The problem may be
ongoing.

An expert should not be an “expert” in only one thing. He should have other options to offer, other answers to the question, “What if this doesn’t work?”

We all hope that it did.

So.

Anything I missed?