S04E77 Mastering the Craft and Compassion of Neurosurgery - Dr. Christopher Winfree

I had no doubt back then that he would become a neurosurgeon and as I got to know him better I realized eventually that he would be a great neurosurgeon , because Chris is someone , as former University of Michigan coach Jim Harbaugh would say , attacks each day with an enthusiasm unknown to mankind .

And if Coach Harbaugh is a Michigan man , then Chris is 150% a Columbia man . Just like Dr Stephen Strange , the Marvel superhero , chris stayed at Columbia to train in neurosurgery .

But while Dr Strange is fictitious , the prestige of the Columbia neurosurgery program is certainly not Ranked number one recently by Newsweek magazine as the best neurosurgery service in the world . Dr Winfrey stayed at Columbia and is now an associate professor . I think Chris approaches life with a unique perspective and energy . He defies easy stereotyping .

Yes , eating only nine meals a week , as he talks about , is definitely something you could imagine a hyper-efficient neurosurgeon to do .

But unlike Dr Strange , he never listens to music in the OR and , as he relates in this episode , he was able to figure out not just how to be a great surgeon , but also a great doctor to his patients , which is a maturity and a growth that I would not have easily imagined to see back in our early days of training .

When Chris talks about his mentors and how he mentors others , it is heartwarming to see how important it is to him that he relays his gratitude to those who helped him and how he can help others in his life .

Becoming a neurosurgeon is no easy feat and , as one of the program directors of Columbia's residency program , chris is very blunt about outlining what you would need if you aspire to perform brain surgery , but the path to achieving success in anything meaningful is no different , and the advice he gives will work for anyone in any field .

I hope you enjoy listening to Dr Winfrey as much as I did , and thank you for watching and listening . All right , hi , welcome to another episode of Botox and Burpees , our highlights on surgeons , and I have a very special guest today .

This is actually one of the very first surgeons I ever met in my medical career , and that was because we were actually gross anatomy partners for our very first course in medical school . This is Dr Christopher Winfrey . Let me intro Dr Winfrey , or Chris , and just give you a little bit of his background .

So Dr Winfrey grew up in Jupiter , florida , attended Dartmouth College for undergrad and you finished with high honors very nice in chemistry .

And then , after completing medical school with me at Columbia University College of Physicians and Surgeons in New York , you joined the Department of Neurosurgery at Columbia as a resident and then , following residency , you completed a fellowship in peripheral nerve surgery in New Orleans and then a second fellowship in functional and stereotactic neurosurgery in Portland .

And you're currently an associate professor of neurosurgery at the College of Physicians and Surgeons in New York City , at our home institution , and you specialize in peripheral nerve surgery , peripheral nerve cancer surgery , nerve and muscle biopsies , pain neurosurgery and spasticity , and your research also covers many of those same topics and you have a million different

honors in terms of your professional organizations and what you do .

So I just want to thank you , chris , for agreeing to do this with me today .

And when you and I first met in 1987 , 1987 was 34 years after the armistice that ended US involvement in the Korean War 33 years ago I met you at Columbia . So that's the time that's passed since then . We started college , something like 12 years or 13 years after the Vietnam War .

So just to show how old you have gotten , but it's good to see you've been working out . Clearly . You've definitely put on some muscle mass . Since the last time I saw you , we operated together maybe 12 years ago , and I remember you not being quite so muscular , which is good , so you've been combating the muscle wasting that happens with the elderly .

Every other day is one meal a day and sometimes we'll do brunch on one and sometimes two days on the weekend . So I really try to keep to nine meals total per week , no snacking , just black coffee and water . What happens when you do that is your body just transforms .

All your body fat essentially goes away and you turn into this warrior where you just have tons of energy and you just during the day you just can be incredibly focused and energetic , and it's , it's actually a fantastic way to live .

It's obviously not for everybody , but um , but I've been practicing a long time and it's great how many calories do you take in ?

I don't care about carbs , I don't care about ice cream . It's all good , and when you do one meal a day , you don't really have to worry about that stuff , as long as it's a well-balanced meal . So I don't count calories or any of that stuff . None of it matters .

And it's so funny , I'll be talking with people and then a couple of years goes by and I ran into somebody I hadn't seen him for a couple of years . He's like hey , chris , I haven't seen a couple of years . I'm looking at the guy and I had no idea who he was .

Cause I also have partial face blindness , I I'm not good at recognizing people and I didn't know no idea who this person was talking to me . I've known him for years . He's like yeah , the last time we met you didn't you mentioned intermittent fasting ? I started 150 pounds . I mean it's astonishing . That's the other reason why I didn't recognize them .

But the point is , um , you know , there are people out there who are , who are interested in trying some things to make themselves healthier and better , and this is one of a million things you can do and you can influence people , not intentionally , like I'm not trying to change what people do , but just cause I talk a lot , I'm a yabber and so sometimes it

rugs off and sometimes you can make a difference in someone's life and it's nice when they tell you you know .

It's better for your teeth . The list just goes on . You just rid your life of a lot of baggage that's unnecessary .

Um , give me a memorable training experience or something you really remember , that sort of either put you on the path to neurosurgery or really confirm that for you , or something that was just really special for you during that time .

Since I was in sixth grade learning first aid and Cub Scouts or Boy Scouts , whatever it was , and I remember that exact moment that happened and then it was surgery until middle school or thereabouts I'm like okay , neurosurgery Never knew a neurosurgeon , never met a neurosurgeon , but just knew I wanted to do it and that's just that .

So you know , it's not like I made some conscious decision . I had no choice in the matter . But during training neurosurgery training is this really messed up ?

Prolonged experience where it was , just quite frankly , it was a horror show of you just just years and years of sleep deprivation and constant work and you're just immersed in tragedy and the death and destruction and all of it and um . But during that time you really figure out .

You know who , what people are made out of , um in , in , you know how people's true nature and I'm not talking about patients , I'm talking about the people you work with .

And during that process I was fortunate to work with a lot of really great people who served as mentors , both in terms of faculty co-residents and even med students you can learn from and I had a series of .

You know , every resident goes through and you're training and you're making mistakes , or you're just having bad outcomes through no fault of your own and people can either yell at you and say , yeah , you're doing a terrible job , or they can sit down and they can teach you and educate you and help form you into a competent physician and neurosurgeon .

And I had a lot of people who fall into that latter category .

And what's really neat is , as you get older , you start to figure out what's important in your life and at some point you figure out that you know gratitude is actually important because you see the people around you starting to die , right , and if you're like , oh man , I should have said something to that person .

So you start making these mental lists of all right , I'm going to when I see somebody , I'm going to tell them you know how they , they , you know what they meant to me , and all this , and not that your life is sort of obsessed with this , but when you have the opportunity , show some gratitude .

So I actually ran into one of my senior residents my chief resident , actually at a meeting in Jerusalem , because you know we're in academics and we travel around the world and give lectures no-transcript for you .

Show them gratitude , show them what they meant to you , cause people are out there living their lives , often oblivious to things and you don't know what kind of impact you have on other people .

And if you can just take a moment and share with somebody how you meant to me or what you did for me that shaped my life , I'm telling you people love that and there's not enough of that in this world , because people are so lost in what they're doing . It's all about they want and what they want to project .

But take a minute and explain to somebody , maybe today you know if you have delivery listeners can do that this weekend , maybe or this week

. Find somebody that meant something to you in your life and tell them how they meant something to you and the difference they made . And I'm telling you that makes a world of difference , far more than any social media likes or anything else . Tell them face to face what they meant to you . That would be my advice .

And instead of being like you're a horrible person why did you get that ? He sat down and said , you know , here's the imaging study that that that you looked at and misinterpreted , here's why you got it wrong . And here's , next time , how to not to get it wrong and never made the same mistake again .

And you know it happens in different things and sometimes it's not even about making a mistake , it's just here's how you could have done something a little bit different . Or here's how just to do better . And you know it's helping you become a better person physician , neurosurgeon , whatever and people that are around you that help you become better .

That's who you should be hanging out with . That's who you should be identifying as mentors and people that you should ally yourself with , not people that are saying things to make themselves look better . You know , seek out the people that do the former and your life will be much more enriched .

But make sure you tell those people , at the appropriate times , the difference they made , right ? You tell those people at the appropriate times .

I was a guy in college that would go to rock concerts and I'd crumple up the ticket stubs and stuck in my ears . I wear earplugs on airplanes and subways . I'm a huge fan of lack of noise , so I shut off the music . I learned as a resident that I can't be listening to music in the OR .

I was making mistakes and nothing catastrophic , but you get distracted and you're just sloppy . So get rid of the music , get rid of the sound . I clamp the suction . I don't have suction going in the OR . I unclamp it when I need it and I reclamp it . I hate noise . So there's that . Visualization is a huge thing . Any case . That's challenging .

Think about it . I go through it step-by-step , visualize it . So once you're in the case , you're like all right , we've already seen this 50 times . You know I visualized it . The other thing is you really I try to put myself in the patient's shoes .

Like , what would I want as a patient and so peripheral nerve surgery used to involve really really big incisions , lots of dissection , doing a lot of exposure . Soon , as I became an attending , I started limiting those exposures . There are times where you need to make big incisions , like I did last night . I had to make a big incision on somebody .

Smaller incisions hurt less . Historically , a big brachial plexus exploration is a 12-13 hour surgery . Patients stay overnight . They're often intubated overnight . I mean it's just you know you're putting patients through this , this sort of shark bite kind of thing .

So I said early on as an attending I'm going to do this in stages and I would do multiple smaller exposures , each one lasting maybe two hours , and get the patient hold and bring them in in stages . And patients tolerate that so much better and most of these are young , healthy patients . So the repeated anesthesia episodes aren't really an issue .

But that's what I would want as a patient . I don't want to have this massive you know incision that you're exposing stuff you kind of don't need to be exposing , doing the smaller chunks that are more tolerable , less painful , and I started doing that all over and it's really not a concept I came up with .

I mean , general surgeons been doing that with cholecystectomies right . Developing laparoscopic procedures . Patients are outpatient now . They don't stay in the hospital for four days . You , you know . You trained in general surgery . You know how that is . Doing that in in of my field is a thing too Minimally invasive .

Spine surgery which I , of course , am not a spine surgeon had nothing to do with , but it's really transformed the patient experience . Things hurt less , they're less time in the hospital , and that's one of the

things I did . I think to be a better surgeon is really focus on what I would want as a patient reducing pain and getting patients the same outcomes with less invasiveness , and I think that's a . It all starts with keeping the patient , you know , patient's interest in mind first .

You've , like , I just remember us as very eager first year medical students , but then , in order to become a better surgeon , it wasn't about a surgical skill which we all need as a prerequisite , you know , like great hand , eye coordination or be able to sort of see what's going on in a surgical field .

But it sounds like a lot of what made you a better surgeon was developing , like you said , emotional intelligence and knowing what someone would want and then working towards that , which is so weird if you think about what a typical surgeon quote stereotypical mentality would be right .

It's just , you know , do the most you can be as aggressive as you can , do it all at once , like . Those are the kinds of things that you would imagine what a surgical like , what a typical surgeon would do .

being judicious in the treatments you offer and not offering stuff that you probably shouldn't be doing just because you can do it and just because nobody really understands what you're doing , and I could probably offer all kinds of crazy things that patients would say , okay , I'll do it , you really shouldn't be doing , and so you know .

I see a lot of providers out there because I work in the medical legal space , and I see a lot of stuff that other providers do and I'm just left wondering what is going on .

But I will say also to your point about the emotional intelligence I was an emotional misfit , you know , growing up I didn't really have , wasn't particularly emotional , but really didn't have good EQ at all .

And that's been a work in progress and I constantly struggle with it because even you know , until pre-pandemic I mean the 2000 teens I would still get these health grade reviews where Dr Winfrey doesn't listen and he's just , you know , arrogant and all this stuff .

And I find it helpful to read that stuff because I really try to sit down and figure out what's happening . And so what's interesting is the pandemic happened and everything went to telemedicine and we also at Columbia switched to Epic , which is a electronic medical record .

And what was really neat is when I would see a patient now or during the pandemic , I would read through their chart in Epic so I knew exactly kind of what's going on , their history . And instead of having a patient sit down in front of me and kind of rigorously go through this algorithmic history and I'd interrupt them because they'd go out of order .

And it was just . I was really not being a good doctor . I was just trying to get this list of stuff done so I could get through to the imaging and then what can I do to treat , and it was really not a great way of doing it and I had no idea . I didn't realize how bad a doctor I was being .

I'm not saying I was a bad surgeon , I was a good surgeon , but a bad doctor Like it just wasn't a person you'd want to go see in the office . But I didn't really realize that until I would read the health grades and then I sat and thought about it and then once telemedicine happened , I could actually sit there and just listen to patients .

I could just hear them tell their story and I'd have to interrupt them because I have Epic . It has all the information there and , yeah , I can fill in the gaps . But I give patients 10 minutes , 15 minutes to just talk and um , which is hard for me because I talk a lot .

But once the pandemic ended , we started seeing patients in the office , Like I try to do the same thing . I just go in and , hey , what's going on ? Let them talk , cause they almost doesn't matter what they say . They can go off on tangents , doesn't matter , because I already have the story from Epic .

I already have pretty much everything I need and if there is something missing I'll ask it . I don't need to do a super rigorous physical exam like when I was training my peripheral nerve . They're like you got to strip the patients naked , you got to look everywhere they're doing all this invasive stuff .

And now we've got high resolution nerve imaging that can show us just about everything we need to see . Like it's not that I don't ever examine patients I still do exam , but a focused exams . Like I don't have to have patients take off all their clothes and do all this because patients don't really want to do .

They want you to sort of examine what needs to be examined . They don't want to be creeped out , I don't know . Just there's . The medicine has changed . We have diagnostic capabilities we didn't have before and you can practice just as great a medicine , and mostly it consists of listening to a patient .

Let them tell their story , cause a lot of patients just want to be heard , and that is a recent thing for me . I've been in practice for 20 some years , as have you and I'm still learning stuff Right , and I think I was a bad doctor five years ago and I think I'm a much better doctor now and that's you know . I'm a late learner , you know .

But I think if you , as long as you keep learning , I think that's the key .

I love that Great advice . Let me ask you this what is one of your favorite surgical procedures that you you still really enjoy doing at this time ?

These are sort of technical variations of nerve surgery , like , for example , patients who have motor neuron disease . So someone's suspected of having ALS , pls , some of these diseases that affect motor neurons .

Our neurology group at Columbia is really busy . We have a huge neuromuscular centers and I see a lot of patients who need nerve and muscle biopsies . And historically there was a motor nerve biopsy . So these are peripheral nerves that supply muscles . So normally when you do a nerve biopsy you take a sensory nerve so you don't cause weakness .

But some of the plastic surgeons actually some of your colleagues invented a motor nerve biopsy at Columbia years ago , 30 years ago or something , and I started doing it to help diagnose some of these patients and it was this hard kind of .

It's a gracilis motor nerve biopsy , so it's up in the groin area and it's sort of an awkward place and it's not a place that neurosurgeons really know how to get to . So I started thinking about ways of doing this better and I developed one that involves perineal nerve down by the knee much easier . It's a classic peripheral nerve exposure that you know .

Any hand surgeon any you know nerve surgeon knows how to do it's . You can do it in your sleep . But anyway I developed a motor nerve biopsy there . Much easier . I can do it in awake patients under local anesthetic and it's just super straightforward and that's fun . I love doing that procedure .

I invented it and you know it was published and it was kind of cool . Recently did another one , um a femoral nerve motor branch biopsy , and again , uh , in the process of publishing that and I I could do that . So doing surgeries that I've actually invented is really cool . My favorite one also involving the biopsies you know a sterile nerve biopsy .

You cut out a piece of the sterile nerve , you send it to the lab and the patient's got numbness for life in their foot . It's not a huge deal but kind of a drag . So I started doing nerve reconstructions back in the mid-2000s where I would harvest the nerve and then repair the nerve with a sterile off-the-shelf kind of conduit .

And over the years that's evolved because there's better allograft repairs now and so I did it so that patients could get sensory recovery Turns out that's not the big advantage . I've done a thousand you know almost a thousand of these it turns out one of my colleagues published .

The real advantage is that when you do a nerve biopsy , there's a 26% chance that patient's going to get a horrible nerve pain syndrome , a painful neuroma which can be debilitating . It's awful right when it happens . Patients are in agony , it's terrible . So debilitating , it's awful right when it happens , patients are in agony , it's terrible . So it turns out .

Repairing the nerve after the biopsy reduces the incidence down to 4% . It's almost an order of magnitude drop . So of all the you know , and this is the way people are doing biopsies now . So this procedure has actually saved hundreds , if not thousands , of people from getting these horrible pain syndromes . And it wasn't even the intent of the procedure .

It's just one of the sort of the happy sort of accidents , to quote Bob Ross , right the artist , it's one of these things that just happened and people are out there benefiting from it . And it wasn't like I was a smart person and kind of figured out that I'm going to save people from getting pain .

It's just coincidence or just a fortunate thing , but but I still do like a couple of these a month and I do it and and it's and it's great and it's kind of fun to yeah , I , I'm the one that figured this out and and , and we're helping people with it and it's and it's pretty cool , and so I still enjoy their simple procedures , but I enjoy doing them .

Or did you like say , go back and say , listen , let me look at these areas , let me look at the anatomy and try to figure out better , better ways of doing this ?

You're just , it's an attitude of trying to find a better way to do something like um and it's true in all aspects of life Like , like all my my wife will give me grief about this , but I'll get a piece of dive gear or something and I'll just immediately start taking it apart and rebuilding it to make it exactly , cause I cave dive and that's a real specific

type of diving and it's it can be super dangerous and you sort of have to have your gear customized for exactly what you need in whatever environment you're in . And my wife's like look , professionals are building this stuff and you're just taking it apart and redo . What makes you think you can do it better ?

I'm like , well , because I can do it better and my life depends on it , and I'm just , that's just the way it's going to be and and it's this sort of stubborn attitude that I can make something better in that people are doing in the operating room and just because they're doing it doesn't mean that's the best way to do it .

There are definitely better ways . That doesn't mean if you don't know what you're doing , you should just go reinvent all the surgeries that you're learning in a residency Not saying that at all . But there are definitely ways to improve things .

As long as you're open to that and you're open to maybe making some modifications , there's no reason why you can't push the field forward , and I don't think I'm not unique in that . I mean there are a lot of surgeons out there doing stuff and there are a lot of people pushing the envelope way beyond anything I've done .

I mean there are people inventing new ways of treating patients . Forget surgery . I mean , who came up with mRNA vaccines ? I mean that's a totally different way of thinking about vaccines . I mean this is modern medicine , this is engineering , this is you know anything .

There's people out there pushing the envelope , thinking about different ways of doing things , and I think it has nothing to do with anatomy . I think it just has to do with embracing that attitude of trying to do something better and just make it happen .

Maybe not everyone does , or maybe it's unique to you , or just something that you have to do every time you step foot doing a case .

I use it more as a teaching moment for the residents . Like a lot of cases , I do involve fluoroscopy , so I have the residents set up the fluoro and it's got to be perfectly straight every time . I can't start with it crooked . But I don't . I don't do something where I have to go scrub a certain way or it's . It's not really like that .

I don't have a thing where I make everyone do something like during the time out . I don't because I don't want to mess up other people's game . For me it's an internal thing . Um , like yesterday we were , I had a couple of complicated cases and you know the start .

We were talking about some things , but as soon as the case started I'm like I got to focus on the case and this conversation's over and I wasn't , you know , being a dick about it , but I was just like .

We'll resume this later , but right now I got to focus , and so , for me , it's not about controlling the outside environment , it's about controlling my inside environment what's in my head , reducing extraneous noise , reducing extraneous conversations and focusing on the work , and so for me , it's about that , not so much an external ritual .

There are definitely surgeons out there that , like I said , have to scrub a certain way . They have to not talk for two minutes or whatever . I'm not like that , that's okay .

I mean , I've heard it louder than some concerts sometimes , the way some people have it going in the OR .

That's just reality of it and I learned that a long time ago . And if , over the span of my career , one patient gets hurt because I'm distracted listening to music , it's not worth it All those years of entertainment for me . Not worth it . So I just abandoned it . Just not going to happen . No music in my OR . That's it , hard stop .

. And and then my chairman , sandra Connelly , has been um , a great mentor for me also . He , um , was a junior resident when I was a med student , working in the neurosurgery labs at Columbia , and then he stayed on his faculty .

He helped , I think he was pretty much instrumental in helping me get a residency spot and then he , I'm sure , was instrumental in helping me get hired as faculty and I'm still , you know , he's chairman now I'm still on his faculty . He's been an outstanding mentor just as much through his work ethic .

I mean he literally works harder than everyone else in our department and has just done an amazing job . And , you know , not just a mentor and a friend , but a role model , right , and you know there's so many people like that at Columbia . But he's probably been the one person who's been most important for my career .

Not that he's in the OR helped me do cases , it's not about that . It's a much more macro type mentorship than that , you know , cause I'm the I'm the peripheral nerve surgeon in my department . Nobody knows , nobody has any idea what I do . It's just they come in they're like what are you doing today . Oh , that's great . What is it ?

What part of the body is ? They have no idea , right , and that's fine . You know that's not their thing . But this is more . You know a structural , long term mentorship over decades , and being in a place for so long , you can take advantage of things like that . You know , if you're moving around every job every three years , you are literally on your own .

You got nothing , unless you have outside mentors , but then they're not really applicable at work . But staying at Columbia for 30 , 33 years , now you have this longitudinal relationship because Columbia keeps people right .

There are people who have been at Columbia longer than I have 50 years , 40 years and you know you can have relationships with these people for decades on end and there's something so incredibly valuable about that . It's hard to explain .

Like you , like I don't I wouldn't want to say royalty , because he doesn't seem like he's standoffish or anything but he just he was . So I mean , everyone respected that guy Like and not because of anything that he was like outlandish or anything Like it was amazing how , uh , how you just knew , um , how special that guy was .

And then the other person , sandra Collin . I remember him as a medical student , when he was a resident , and he was pretty quiet , like he . He wasn't someone who was like really like out there or had like a crazy personality or anything . I can't believe that he became head of your of Columbia Neurosurgery . Well , he's not out there .

Like I'm trying to figure out how to you know , arrange my schedule and how , to you know , manage a couple people in my office , and that's what occupies me . He's operating on a completely different chessboard , right , and I just it's astonishing and it's just amazing to watch and it's not something I could ever do . Like I never want to be a department chair .

Like I agree , you're going to ask me about where , what I want to go in nursery . It's not a department chairman . I can't stand managing people , I detest it . And Don Quest has this magnetic personality no-transcript .

He served in Vietnam , was a fighter pilot , left without a scratch , and the guy just has this personality that when you meet with him and I see this because his office is right next to mine he meets with these med students both virtually and in person .

He makes them feel like they're the center of the universe , while when they're with him and it's amazing he has this way with people and it's not something I could ever do . I just I don't have that gift .

I can entertain people right , I can talk to people and funny or sarcastic he's got the gift where people really want to be in his orbit and it's really really cool . And it's not just about that , because there are plenty of magnetic people out there that are selfish . He actually helps shape people's careers .

He makes those people not only want to be with him , but he helps them get to where they want to be in life . And that's what's so cool , because anybody can have a magnetic personality . It's what you do with that personality , like , are you helping people with it or are you just serving yourself with it ?

He's definitely the former category and it's amazing to watch and he's relentless with it . He never , he never stops . He's still in there . He was in there all day yesterday meeting with students and helping them get forward with their lives , and it's just incredible . He's such an incredible resource for Columbia .

You have to be able to work in incredibly difficult environments where you're doing your best and patients are still dying because they've got horrible diseases , and people are struggling and they're coming to you in the most desperate times of their lives and you're trying to help them .

But you're trying to balance that with with with with life things and you know your family and other things and and I I think you have to at , at , at the core . You gotta be a doctor , right , you have to be in it core . You got to be a doctor , right , you have to be in it to help people to some degree .

I know it sounds a little corny , like every college student says that in their medical school interviews and just parenthetically , I mentor a lot of people and a lot of people come to neurosurgery . They don't know why they want to be neurosurgeons and they have difficulty with that question . I say look half the neurosurgeons you're talking to when you interview .

They were born neurosurgeons . They don't know why they want to be neurosurgeons either , so don't worry about that question , that question . You tell them that you've always wanted to be a neurosurgeon , they'll say I get it , me too . Next question you got to have a good answer for why you want to be a doctor .

Right , and because being a doctor is a lot different than being a neurosurgeon . Being a doctor involves a lot of things like the sacrificing your time and ability to help people and all this other stuff . The medical thing and that's where it starts being a neurosurgeon is a totally different kind of thing .

It's not that you're not a doctor , but it's a type of medicine that has to . It has to put its claws into you somehow . I don't think you can just say , well , I think I'm going to be a nurse , or just because I like the nervous system , I don't think that's going to fly .

I think it sort of has to find you in a really fundamental way , whereas you can come up with a list of reasons and you really should have a list of reasons for why you want to be a doctor , like because you can't just casually go be a doctor .

Of course you can't casually go be a neurosurgeon either , but but being a doctor , being a neurosurgeon are different and um and I don't know if that that answers your question , but no , but you got to be a doctor first and then , for whatever path you get to , neurosurgery . Maybe you like the nervous system , maybe you like doing stuff with your hands .

That's fine , um , but I think it's something fundamental where it just it grips you and you can't you can't shake free of it Now .

What is your , what are , what are the future things you're looking forward to doing , or what do you want to do , like what is it that you have in your sights now ?

I'll put in my paperwork for formal promotion to full professor . But that's just paper . You know , that's , that's paper stuff . That that doesn't affect me day to day . It's just my original stated goal as a , as a kid was to be a professor of neurosurgery . So I'm just satisfying that . But it's really just checking a box .

I mean , it's not that professional goals maybe , you know , be an associate dean a few years down the line , that's a big time commitment and I'm not ready to give up clinical practice , do that yet . But you know , close to retirement that might be an option . But you know , maybe I'm not the person they're looking for .

So it's it's not like I can just decide to be a dean and it happened . You know , it's a process and if they think I'm a right fit or a good fit , then fine . But again , that's stuff I'm sort of looking forward to , but I spend every day thinking a little bit about retirement . Right , I teach a personal finance course to neurosurgeons .

It's not an online thing , I don't do it for money , it's just . When I'm a visiting professor I give grand rounds . I'm doing it this week , actually coming up for one of the neurosurgery programs .

I mentor a lot of residents as they are becoming attendings to sort of make sure their financial situation is in line , and you know there are a lot of doctors out there doing that and I'm not doing anything formal . I get nothing in return for it . It's just my kind of teaching thing . It's fun . It's fun for me to think about retirement .

It's fun for me to think about , you know , being prepared for that and helping get other people straight in terms of , you know , getting their financial lives squared away and making sure they have , you know , disability insurance and life insurance and the right bank accounts and the credit cards and just you know , trying to have as frictionless a life as possible

and being prepared for retirement and living beneath your means , all the basic stuff I mean . This is not complicated stuff .

I mean it may be scaling back from a lot of my administrative stuff , scaling back from a lot of the work travel , scaling back from a lot of the you know I'm an editor on the editorial board of a whole bunch of journals .

You scale back from that stuff and just focus on maybe seeing patients in the office one or two days a week , operating one or two days a week and , and , you know , having some time to do other stuff like reading , watching movies and all this stuff that I don't really have a lot of time for now . Um , but I you know my family and I travel a ton .

As it is like we're not like , oh , I have to retire so I can travel , like we're traveling all the time and it's great , um , and so I'm in a good place now . I don't have to change right now and I'm not like look into the next big thing , like if I could do this for the next five years , that'd be fantastic and then make some decisions .

You know , if I still feel like continuing , then fine , but I'm not going to be one of those neurosurgeons I still operating at 65 or 60 . It's not going to happen , like still operating at 65 or 60 , it's not going to happen . I just there's no way .

And they might be still at the peak of their careers . You know , surgically like skill wise , right ? So where do you sit on that ? You do ? You love operating so much that it would be hard to walk away from that ? No , okay there's I .

But like , for example , career development , I had a conversation with somebody recently who asked me to be on the board of directors , one of the big , you know , neurosurgery organizations , and I was like you know what ? No , I'm not going to do it . There's plenty of young , hungry people out there trying to build their careers . You got to ask one of them .

I just I appreciate it , I'm honored by the ask not doing it and I started saying no to stuff . I've been saying no to stuff for a while and saying no is a very powerful thing and I'm not in the space where I have to do everything and try to be number one and run all these things . Like I've been president of stuff before , I've run things .

It's not my thing , not interested . What I want to do is provide some content for people . Like I've organized a few courses that I teach and provide lectures for , and you can make a difference in people's lives doing that . I don't have to run organizations .

I can actually teach people face-to-face and one-on-one or in specific courses and make a difference that way .

And for me I've tried to transition to sort of mentoring the residents , med students and to the extent I do give lectures , it's more on the international circuit , Like I've got some international projects , I'm working on the World Federation and things like that and some of my European colleagues and Australian colleagues and it's great stuff , um .

But I've kind of gotten out of the the national meeting grind where it's the same national meetings every six months and it gets kind of monotonous . I've kind of pulled back from that . And same with surgery .

Like I don't feel like I have to , you know , just operate , bang my head against the wall all the time , like I I would be happy scaling back , you know , in a few years . But we'll see , maybe I won't , I don't know , maybe scaling back not an option , maybe columbia doesn't want me to do that .

I don't really have a choice and you know that's , that's fine too , but I'll worry about that later . But 59 is when I guess start thinking about and age 59 is when I start thinking about stuff . I don't have to worry about it now in I'm in a good place now , I think .

Yeah , let's finish by talking about anything else you would say for someone who was listening to you and says I want to do what that guy does , I want to be like that guy , Like you . Clearly are not the same person you were when we started medical school . Like there's a whole lot that happened between then and now .

So what do you say to someone who's in the beginning of their path , like they can't have the perspective you have , like what kind of things would you be able to say to them ? I mean , what do you say to the medical students , to the young residents , like when , when they're coming in to help them sort of get to where you are ?

it's . It's going to be a marginal utility for me to spend time telling a med student about my journey with the whole telemedicine thing . It just sort of you sort of break things down and make it easy , as easy for your mentees as you can .

And I say , look , if you want to get to where I am , focused on doing a couple of things get good grades , get good board scores and get get good letters when you do your rotations and your sub-Is , where you spend a month rotating as a fourth-year med student , because those three things will get you into the residency program you want .

Because if you have bad board scores , you're probably not going to do well in neurosurgery match . If you have bad grades probably not going to do well in neurosurgery match . If you have bad grades probably not going to do well in neurosurgery match . And , worst of all , if you have bad letters , you're not going to get matched in neurosurgery .

And so don't worry about any of the other stuff you and I talked about today . All that stuff can happen later . Focus on those three things , okay . And to get good letters , you have to be able to work with people . Like when you work on a rotation , they're going to notice if you're a med student you're kind of acting snotty to nurses and support staff .

Nobody wants to work with somebody who's like that , right , because if you're snotty to nurses , then as you rise up to the ranks , you're going to be snotty to the residents . You're probably going to do that to patients and just not going to be a good person to work with .

So you got to be somebody that people want to work with , because when they're choosing you as a resident , they're choosing you . Not only they have to work side by side with you for the next seven years , but you're going to be the face the forward facing care for their patients .

Like when my patient's in the hospital and there's an issue , they don't see me first . They see the residents in the middle of the night , right , and who do I want talking to my patients , who are incredibly important ? I want residents that are good people , right , and so on your sub eyes .

You need to make sure that everyone who's looking at you and everyone's looking at you everyone needs to see a good person , right , cares about patients , cares about working hard , cares about not being a complete weirdo around the other people . And so this is what I tell med students you want to be a neurosurgeon ? Do these three things . Start with that .

Once you're a neurosurgery resident , then you can start to make some decisions about career trajectories . Do you want to unspecialize ? Do you want to do fellowships ? Do you want to do research ? What do you want to do with your life ? But none of that matters if you don't get the first three . Okay . So I try to break it down and make it 10% .

When you and I were going through med school , okay , when I did presentations I don't know about you I had transparencies in a slide projector . Okay , I didn't know what PowerPoint was . I didn't know what the internet was . It was the stone ages .

Like we were doing these crazy , like I would type on a Microsoft word thing and then have to get special printing paper to print out . I mean , it was ridiculous . And you know , I had a couple abstracts and a couple of papers when I applied for neurosurgery residency and I was like , whoa , this guy's great .

And now we're interviewing applicants that have , you know , 20 , 30 , 50 papers oh my God , a dozen of which are first author papers . And some of these people you see their applications they've got 270 board scores . They're 99th percentile . Like I was maybe 90th percentile , you know , I was good but I wasn't 99th percentile .

And they've got papers in nature medicine . Uh , jam , you're like , how , like , how do you even do that ? Like , like these people are so astonishingly polished and qualified that it's mind blowing . And had I applied with my application this year , my application back in 1994 , whenever it was 95 , I , I , maybe I'd match .

I mean , I'm not matching at Columbia , I might , you know , match , you know overseas or something I don't know . It would be a horror show . So you're asking me if it's more competitive . Yeah , it's more competitive because the applicants as a whole are so much stronger . I mean it's amazing we ever made it to , to , to where we got .

But I guess everyone was sort of mediocre back then , so I agree .

In fact , I think generation X had a single-minded nose of the grindstone work ethic that no subsequent generation has had since . Now . That doesn't mean other subsequent generations don't have other qualities that are equally valuable collaborative , teamwork , based , more , you know , interactive .

Whereas gen x is like I'm going to get this job done , I'm going to do it by myself . Yeah , I'm not saying that's perfect or anything , but in certain fields like neurosurgery , that tends to be the personality trait that gets you through residency's ability to do that .

Someone who insists on collaboration , all this other stuff that may not get you through the horrors of residency . You need to be able to get in there and suffer for seven years and make it through intact on the other side , and so I think Gen X had a unique ability to do that .

Some of these guys that are so young and so accomplished , I really want to see how they do in terms of resiliency after encountering situations where you aren't doing your best , where the situation is impossible , where you failed multiple times , and how you bounce back from that .

But I guess that's why they have you as a mentor , because you're the one who's going to say listen , this is what you're supposed to do when these situations happen .

And that's where the Gen X teaching in terms of dealing with adversity , dealing with the grindy because those are boy especially Columbia neurosurgery that residency was one of the worst I'd ever seen in terms of training there's no doubt it wasn't the worst I mean , there are plenty out there that are , but but it was definitely .

It's probably something external that's happening to them , whether it's social media screens I'm not an expert in this but something has happened to the current generation where people are dealing with levels of anxiety they didn't have before . Maybe it's partially a pandemic , although I think it predated that .

It's almost a disease that we didn't have to confront so much . Uh , that the current generation is and it's really crippling for a lot of people , and I don't have the right answer for that .

What I will say is I spent a lot of my life essentially training for controlling fear and controlling my response to danger , and it all started while I was a little kid , surfing and you know , getting tumbled around underwater and and drown proofing and and learning not to panic , even though I was disoriented . Underwater , zero visibility , couldn't breathe .

You have to be able to find the surface and and and , not panic and then and then from there scuba diving and then cave diving and being stuck and pinned underwater and in situations where , if you panic , you're dead , you just cannot . You just don't have that option .

You have to just be able to control your response to danger in a way that gets you out of that danger , in a way where you're thinking right , your heart rate's controlled , breathing's controlled and you actively are preventing your own death . And that translates to neurosurgery , where you have to do that in the operating room .

When things go down , you've got to be able to take a step back and say I'm not going to lose my cool , everything's going to be fine , we're going to get through this , and I think that ability , which again I've worked on for decades , helps prevent anxiety . But there are certain things that you know .

Maybe it's a medical thing and you know people get anxious , and it's not something you can just will yourself out of . So so I don't know I don't have the right , I don't have the answer for everyone .

The first time I showed up at a Saturday conference and I saw those guys beat the crap out of medical students , up on the on the board and , uh , pimping the hell out of people , I was like , oh yeah , no , like yep , I don't love this like that , so for sure .

I've gone away from pimping , but what I'll do is we'll give the lecture and at the end of it I have a series of questions where , instead of you know to Neil , what did I say ? But I was like , how would you explain to a patient the concept of how an antidepressant works ?

Or you know , because you know antidepressants are important for treating chronic pain , which a lot of patients run . It Like , how do you explain this surgical procedure to a patient ? So it's not just you know having them repeat stupid stuff , but it's , these are the skills you're going to need as a doctor .

So how are you going to explain this to a patient in a way a patient can understand ? And so it's more of these integrative type things where I don't just point to a thing and say what's this anatomic structure on a film ?

But how are you going to consent a patient for this surgical procedure , which is an integrative sort of thing , where they have to process a lot of information and then communicate that to a patient ?

And I think pimping has sort of hopefully for most teachers , most educators has moved into an area where you're actually helping the person be a better doctor , because it's not about asking for stupid facts , it's can you show me you're learning how to be a doctor ? That's what I've tried to integrate into my teaching .

It's a work in progress teaching and it's a work in progress . I mean , I'm like I'm the world's best teacher , but I'm trying , and I'm really trying to to make these things better and have it not just be what we went through , but have it be something that's actually useful and it ultimately is going to help their patients in the future .

Because , remember , as medical educators , it's not just about us and teaching the residents or med students . It's about training the next generation of people who are going to actually take care of patients , right ? So again , keeping your mind , your focus on the big picture and doing what you can to enhance that process and not just do it for yourself .

I mean , you know , I think every surgeon's amazing . I think you're amazing . But when I listen and hear what you've gone through , the way you think about approaching things to what you've learned , like that just blows me away . I love that and I just want

to thank you , chris . It's been what 20 , some almost 30 years and I still feel sometimes like a medical student . 33 years yeah , that's crazy , and you look about the same . Maybe a couple lines are a little deeper but , that's about it .