Episode 30 - The Anatomy of a Neurosurgeon

Well, you know, those synapses in your brain should be working all the time. You shouldn't be just at the mercy of your senses and just receiving passively the information. So I watch something even today. I mean, in my stage now, I go to a conference, I listen to somebody who has a brilliant idea, I reflect on it, I compare it to my experience. It's a constant self-criticism, constant analysis. Welcome to the Nursery Podcast. I'm Mike Wang, and I'm here with my co-host, J.P. Colson. We are here to discuss all things, nursery school. Hi, this is J.P. Colson, a resident in neurosurgery at Rush University. Please note that this is not a CME event, and the opinions and statements made in this podcast do not reflect those of any institution or professional organization. Now, let's get started. So today our guest is Jacques Marcos. Jacques is an internationally renowned neurosurgeon specializing in vascular tumor and skull-based surgery at University of Miami. I'm honored to say he's one of my partners. Jacques, welcome to the Nursery Podcast. Hi, Mike. Pleasure to be here. Thank you. So I know that many of our listeners already know who you are, but for those who might not, let us know a little bit more about who you are, where you came from, your family origins. Sure. Well, I'm half Syrian and half Lebanese. I was born in Syria, but really grew up in Beirut, Lebanon. Mostly during the war there, from 75 to 90, I always wanted to come to the US to become a neurosurgeon. And I tried, but I really failed on my first attempt and I ended up in England as a kind of, I hate to say it with my wife being British, but as a second best choice and I spent four years there, but tried again. I was absolutely. My mind was said that I must train in the US and come and train in what I consider the best medical expertise in the world and eventually I made it here. So how many fellowships did you do? I heard different stories at number. No, I did two official fellowships, one in Gainesville and one in Phoenix. Okay, but the time in England that was really more like residency training. You know, in England they call it, yes, it's senior house officer and registrar is their official terms for the training there. So I understand the desire to be an America, but what got you started an interested neurosurgery? You know how they say that if you have the right teacher, they guide you the right way. I must say the middle school biology teacher, I remember him today, I'm issued a three-o-lay with his thick black beard. We would dissect small animals and he's the passion he had in teaching. So that got me going. I think at age 16, I said that's it, I'm going to be a neurosurgeon with dissected brain and spinal cord in high school. Wow, yeah, that's great. I know that you're half Lebanese, but I've always felt that for some reason there's been a Lebanese diaspora. There's so many amazing surgeons in America that are of Lebanese origin. It's true, it's a large number. Now of course, it's a biased view. You're seeing the people who actually made it through the hurdles. And of course, I don't want to be so elitist to say, the Lebanese are particularly gifted or anything like that. No, many of us are driven. Partly because what other options did we have in Lebanon? You grow up with two universities versus what? 4,400 in the US. So the choices are limited. Well, so now I must find spinal neurosurgeon. And I know that for some people listening to us, maybe they don't understand exactly what a neurosurgeon is and what we do. But I think of you as kind of the ultimate brain surgeon. And I know that that's what most young people at least think about when they think of a neurosurgeon, right? And so I'm going to ask you this question because I'm so far in the spine now that it's a little different from me. Do you think that being a brain surgeon in some way makes us, makes us special? You know, what's a chicken and what's the egg? I must say, it's a very good question, Mike. I must say, because you were special, some of us became neurosurgeon or the other way around, you may be familiar with that study that was published few years ago, looked comparing neurosurgeons to other sub-specialties when they tried to compare the degree to which they were dissatisfied with their job and to the degree they had burnout. Neurosurgeons were way below that curve, meaning to the degree that some of them were dissatisfied with their jobs. They did not burn out. So there is, yes, so a quick answer to your question, I think we become very resilient or we started being resilient. That's why we become successful neurosurgeons. So yes, there is a certain something in somebody who becomes a neurosurgeon that takes them and makes them apart from, I must say, very most other sub-specialties. I mean, I think it makes us special and that's why we have a podcast dedicated to this topic and this group of people because I think about the lineage of Harvey Cushing and now look at the popular media, there is a single medical soap opera that doesn't have a neurosurgeon at its very center. And every movie was Dr. Strange, "Bounce Between Us." It's all about neurosurgery and it's really captured the imagination. But I think with that comes a lot of responsibility too, right? Sure. And so you also seem to embody this concept that J.P. got me started on with Jocco Willink and his podcast, which is we call it "Stream Ownership." "Extreme Ownership in Surgery," right? And I know you do that because I mean, I've seen you do the most amazing physical feats, whether it's the issue of the complexity or the detail or the dexterity or the sheer stamina in surgery. So how do you maintain that kind of energy enthusiasm? Well, you know what they say, if it's not work, if you love what you're doing, correct? It's not work. So yeah, I can very easily say I have not worked day in my life. It's, you know, you do what you do out of a drive. You have it. I'm going to turn the table at you. I've seen you do amazing things in your innovations and your stamina and your energy. You know, you're driven. It comes from somewhere deep in you that you don't feel tired and you just keep going and you maintain your focus. Nobody's born like that, of course. It comes with practice and those 10,000 hour meth, yeah, there is something to it. You just develop that resilience over time when I think back at my early years as a resident, sure, I had the passion. Certainly didn't have the stamina I developed later. So it was conscious. It was an effort. Yes, for sure. You just, you focus. When I was a resident, I would do what actually there was a John Green in his book when he talked about mastery, you talk about the deep observation. When you watch your mentor, you know, I can tell from the residents today, some of them have that ability to deeply observe and analyze what they're observing. Some passively observe. Well, it's a deep observer that's going to reach great heights versus a passive observer. I think I was very good at deeply observing early on, analyzing. I didn't have to ask too many questions, maybe at the end. And yes, I've always been patient. I'd like to think, to think paradoxically, the Lebanese war for a lot of that. You know, we lived through hell. I lived 11 years of the 15 year war in Lebanon. So, you know, today anything is almost very small compared to the risking losing your life growing up as a teenager. So that helped for sure. When you look back now, thinking about becoming the surgeon that you are today, can you think of specific moments or specific milestones when you realized you had reached a new level, or did you just patiently work through and one day realize, oh, I can operate for 24 hours now. Do you remember specific cases where you hit you that I'm at a new level now? Well, no, there was not one epic moment. I say, oh, I'm a different person today. No, it is clearly gradual, but there are the unforgettable cases. I'll never forget a 14-year-old boy with a really complicated AVM that took me, I don't know, 15, 16 hours. And he eventually did well after not doing well for several days. And when he did well, I said, gee, you know, you'd think to yourself, you don't want to talk to other people, but you think to yourself, you know, I did a great job here. I could have quite a good, I've screwed up many times in surgery. I have another patient with a very complicated, he mentioned Paris-Saitama more than 30 hours. I remember sleeping on the floor for about 20 minutes. I should have staged it. It was foolish of me to keep going. I should have done done it over two stages, but I kept going. You know, that's not the right way to do it, but those are the moments you remember you say I'm really capable of in intense focus and still maintain whatever the high quality skill level I need to do to do the case. So you get trained over time. So I'm just starting my training now. When you were coming up, did you see this level and see this life ahead for yourself? Or did you even in pursuing what you would end up doing? Did you just keep going? Just keep going and not stopping? Yeah, I love your question because the answer is very easy. Absolutely not. Would you have asked me in my late teens early 20s, mid 20s? Am I going to be whatever? And I am today absolutely not. I would have been very happy to be just part of the whole experience of being a neurosurgeon. I think I've been lucky to whatever rise in organized neurosurgery. But you know again, it comes to mentorship. I have several mentors to thank. And those are the people who open up the doors. And this is I think that's a big part. People who don't think back to think those who have opened the doors for them are showing great ingratitudes. So I have several to thank, including Roberto Heros and Robert Spetzler and Arde and Alan Crocaherd and several others for Adhad. From Lebanon, you pick the best you can from each. They're giants. Yeah. So kind of moving from that, the idea that the person young in their career doesn't know where they're going. I think for myself, when I first decided, oh, one day I'm going to be a neurosurgeon, I had no idea with that man. I think many people who pursue it or who at least early on have interest in neurosurgery have no idea what it means to be a neurosurgeon. And so many people fall off. Some people like myself are lucky and it actually sticks. But thinking about just the idea, you were young and you said I'm going to be a neurosurgeon. Thinking about your idea of what that meant then versus where you've reached your career now, you know, we call this episode the anatomy of a neurosurgeon. So it's perhaps the most cliché question there is, but who better to answer it? To you, what does it mean to be a neurosurgeon? Yeah, that definition and that meaning changed completely over time. And it keeps changing. The world isn't, you know, I'm not elderly yet, but you know, I'm a mature neurosurgeon, let's say. The field has completely changed from when I started. You know, we can certainly go into specifics of the diseases we treat that has changed completely. We just have to stay with the flow, stay fresh, stay, keep an open mind. Those are the lessons I keep learning every day. I never thought I'll be removing tumors of the skull base through the nose. I actually laughed at the idea in the early 2000s. And here I am now doing endoniesel endoscopic skull base surgery. And I can give you many other examples with vascular things. You don't want to be, yes, it'll be great if you are a pioneer, but you certainly don't want to be somebody who's lagging behind and at the end of that, what they call Scots Parabola. You just need to be, to keep a fresh mind and an open mind. But the field is completely different from when I was in my early 20s for sure. So you bring up this issue of deep observation. I want to come back to that. Yeah. Because it's, to me, I'm trying to get my hand, my head around it for the young people listening. Is that concentration? Is it reflection? Is it attention? What's actually, I mean, is it conscious? Is it subconscious? Tell me about that because when I see the microvascular surgeries you do, which is totally different from spine, by the way. Spine is a very different type of rubric. What does that really mean for you? You mean in the training stages or now in my stage, you know, in my life now? I imagine it's a continuum, right? It's a continuum. It's a comfort. Yeah, you're right. I mean, in my stage now, I go to a conference, I listen to somebody who has a brilliant idea. I reflect on it. I compare it to my experience. It was very magnified when we trained. When you trained, I watched Roberto Heros the way he would clip an aneurysm. Why did he hold the supplier this way? How come some other person held it the other way? You go, you analyze it. You go read about it. You reflect. You just can't, you know, unless you analyze things, whoever said, a life not well analyzed isn't worth living. You know, you've got to keep analyzing every action, every event. That's what I think I'm pretty good at because I'm quite cerebral about things and probably too much. That's why I'm neglected for most of my life athletic pursuits because I'm kind of too cerebral in that sense. And that's certainly I regret that. I'm going to change gears a little bit and ask you about something I've kind of wanted to ask you when I'm doing this in a public venue. But to me, it's important. So, you know, we're going to do some episodes on the children of neurosurgeons, some of whom are neurosurgeons, some of whom aren't. You have to reach children. They're wonderful. I remember you Skyping with your daughter to do her math homework. Like how the quintessential neurosurgeon is almost, is first of all busy, a little bit narcissistic preoccupied. I think I'm sort of quintessential neurosurgeon in that sense. And maybe a little neglectful. Right? How does, what, what do you tell neurosurgeons nowadays? Like, you know, everybody's got a family and they're trying to balance these things, right? Yeah. Oh no, it's critical. I mean, I, yeah, my kids wear and remain a huge part of my life. You're absolutely right. When I come home, as I, even with my wife, I come home. The minute I enter the house, the home, I'm not talking about any neurosurgery, not talking about anything medical. The kids are there when they were younger. I'll share in their lives, you know, you and I, and most neurosurgeons work hard enough to bring work home is unconscionable, I would say. And you're right. I remember going to the senior society meetings there, always around May or June, which is the time of the final exams in school. And actually, many of my colleagues remember me sitting on a couch usually at these meetings and skyping or calling my kids and helping them whatever they wanted help with. Of course, it's an intense pleasure to feel, you know, you need to be a dad. And if you're purely a neurosurgeon and you neglect your family, that's a failure. And I'm not going to name a very famous neurosurgeon who's long dead now, who's, you know, who's family at his funeral said, well, thank you all for saying such lovely things about him. But we never knew our dad. If my kids say that about me when I'm dead, then I would have been an absolute complete failure regardless of everything else I've done. Yeah, it's interesting. And we had this conversation with one of our other guests. And I was saying that I always felt like I did the opposite, which was I tried to make neurosurgery in my personal life indistinguishable. It's almost like I just barced greens a little bit like this. I sort of modeled myself up. Yeah, that's interesting. That's a very interesting perspective. What do you think, Joe? What do you think about this issue? You're working crazy hours now. You're getting, you're getting, how do they say, baptized by fire now, right? So you're getting the taste of what do you think? Well, it's, it's hard because at this stage for me, I still have some of that fire and some of that passion where, you know, we come into this in an earlier conversation you talked about medicine and neurosurgery being almost a priestly class. We come in, we want to be baptized by fire brought into this, this role that defines you. And so I don't know if there's a right answer or a wrong answer or just different neurosurgeons to cope with that level of responsibility, that level of training and how it changes you as a person, whether you just live at 24/7 or whether you need to take a break from the intensity you come home and just put it all behind you. Yeah, no, I, I would feel my life would be very incomplete if it's very unidimensional in neurosurgery in as much as neurosurgery was, was my first love, of course, in love, but you need, you need variety in your, in your brain, in your thinking, in your heart. And yes, of course, neurosurgery takes the biggest chunk of our lives, but those other moments are, are because of that are even more precious. Well, then let's do the interview questions right. Do you have any hobbies? Hobbies, love traveling, I like cycling when I get the chance. I'm loving my peloton bike, which I've had for a couple of years. Again, I'm not a natural athlete and I, you know, and I don't jump to exercise, but that's very interesting. I love that the music reminds me of my disco days and the music of the 80s. and has a ton feel free to sponsor the podcast Peloton Vice. Oh yeah I should have been careful I'm sorry And I love you know math and physics very nerdy in that way I actually read them after hours You know why because if I wasn't gonna be a neurosurgeon I probably have been a mathematician. I love the purity and the beauty of those exact sciences that really obviously don't have In neurosurgery, but that's a totally different domain. So Jack what keeps you up at night? I sleep well at night. I don't I don't stay up nothing keeps you nothing keeps me Well if if if there was anything wrong with my kids or my wife or my mother or you know things like that Of course would keep and do keep me up if there is an issue But nothing professionally nothing keeps me up at night. It's interesting my wife always tells me that The night before surgery, which is most nights of the week. I don't sleep the same as when I don't have surgery the next day and I don't think I've quite mastered maybe the art form of what you do which is very unique and precious I always thought that the move away from scolvay surgery and microsurgery was gonna be a real detriment to our field You know even though I don't do as much of it, you know. Yes. No, no It becomes part of you Mike as you know you develop that second sense it You know you know what they say about the difference between the novice and the expert the expert they say Yeah, well, you know expert has that extra dimension of intuitive knowledge versus rational knowledge and you know it in the OR You I know I know perfectly that you know it like the rest of us who've been in the field for a while that Metacognition your our ability to leave our body and look at ourselves Operating and analyzing our analyzing. I don't know if I'm being clear But that does that definitely comes with experience. I never had that as a young Faculty met a metacognition. Yeah, and when you think you started to appreciate some element of that Yeah, I would I would think six or seven years into Being a faculty so that would take me back to the early 2000 I don't know 2002 something like that you just develop you know You just need some experience and then Repetition of similar cases and then you know, I guess that's what experiences, you know Steven Giannara used to talk about that He said he just knew he could sense when he was gonna get in trouble Yes, and that's what you're talking about almost like a Jedi type of correct right and you're absolutely right another friend of mine a very famous neurosurgeon He puts it this way. He said he feels it's gonna sound weird and spiritual Presence above his right shoulder when he operates that tells him you're doing a good job Or you're doing a bad job now. It's I mean, it's not quite literal for me as that but anyway Wow, that's that's I've never heard that before have you JP? Yeah, I'd like to get one You were you were you simply need to age gracefully and you'll get it Okay, well anyone who has spent any time with you and Miami knows that you are a legendary for your riddles Brain teasers and I don't mean anatomical problems like standing on the insulin looking down to only the layers I mean a real old-fashioned riddle so for our listeners If you like to leave us with a brain teaser and listeners you can email us at neurosurgery podcast at gmail.com With your answers. Yeah, don't give us the answer right right? Yeah, absolutely JP And I'm delighted you remember the riddle on the insula and the layers. Yes, it is one of my favorite anatomical questions So JP you are on a highway Somewhere in Florida and you're interested in going to Miami and the road the highway splits into two One of them goes to Miami one goes to Orlando Unfortunate there was a recent hurricane and the sign that Points the way is all destroyed so you don't know which road goes to Miami There is a house there with two identical twins one always lies and one always tells the truth You knock on the door one of them answers and you can only ask him one question They know actually which road goes to Miami. What is the question? You should ask to know for certain which road goes to Miami That's a riddle for today. Wow, and so how now how do our listeners get the answer to be sure they're correct? So when this episode airs everyone email us your answers within one week We will share with you via another episode the correct answer and you can all know whether you got it right or not We're not gonna email them back. We won't email back. We'll announce it on a subsequent episode Okay, so that but I'll let you know as a Florida native. I don't need help from any twins I know how to go south so just so everybody knows the email is gonna be neurosurgery podcast those spaces neurosurgery podcast at gmail.com All right, we look forward to your answers fantastic. Please don't Google the answer. It's a fun. Yes Thank you. Jacques. Thank you guys. This was great fun