I remember a meeting in Columbia I attended some years ago when speakers presented their talks to the audience. Each speaker talked about the fantastic operations they were doing and the technology they were using. The neurosurgeons in the audience, who could not afford this technology, were made to feel inferior and inadequate. I was so angry that I tore up my planned lecture and compared the behavior of the visiting speakers to a rich person who opens his home for 1 day to the poor people in the surrounding area inviting them to see his luxurious home and eat foods they could never have. Then, they were sent home to live their daily lives. To me this behavior shows a total lack of understanding of the needs of the people and the community.
In the first place, what is the proof that all of this technology is of any value? A recent article in JAMA (July 8, 2009; 302:149-158) compared the outcome of minimally invasive spine surgery to standard microsurgery and found that there was no difference in the outcome of the patients in the 2 groups. So what is the message? Learn to do an operation well with no complications and keep doing it until you find a good reason to change.
Intraoperative MRs that cost millions of dollars are now being abandoned by neurosurgeons in the United States and elsewhere because they are not practical or useful. There is no proof that resection of tumors using cortical EEG at surgery prolongs survival. In my 50 years doing research on brain tumors and taking care of patients with brain tumors, it is obvious that surgery will not cure malignant brain tumors. Radiation therapy will add a few months to survival but is not curative. Until the introduction of Temodar, chemotherapy was not much more effective. Trauma surgery has not changed over the years. The value of hypothermia is questionable, if of any value at all. However, the development of intensive care units has been very helpful in improving outcomes of patients.
Some technology has been useful: microsurgery is a clear asset to provide better outcomes. Bipolar coagulation is very valuable. These are the technologies that are beneficial in neurosurgery. Those are the tools neurosurgeons need worldwide. The others await detailed evaluation before they can be adopted widely.
What is more important than all of this technology is good judgment. Good judgment can be found in neurosurgeons regardless of where they live, whether they are in a rich or poor country and, in most cases, regardless of what technology they have. I have seen people with very expensive technology who have no judgment in how to use it or when to use it. I see neuronavigation systems used routinely when a simple understanding of the relationship of the brain anatomy to surface anatomy would be sufficient. In addition, the neuronavigation systems only work two-thirds of the time in my experience, so the surgeon is left without this technology anyway. Is all the instrumentation necessary in spine surgery? Many times I have been told that a patient needs a fusion after a cervical laminectomy because 20% of them will develop a kyphosis. So, the logic I am supposed to accept is that if 20% of the people need it, 100% should get it whether they need it or not. This increases the cost of health care unnecessarily. And does it make sense, or does it make cents?
Using their detailed examinations that take 1 hour, neurologists are able to localize the site of lesions that we now find with MR technology. What happened to the history and physical examination that provides such essential information on the patient besides allowing the physician to become familiar with the patient as a person? Yes, good judgment comes from intelligence, the thoughtful use of information, and the understanding of people and the circumstances. It comes from thinking human beings and not from machines that are allowed to take the place of thinking.
Perhaps surprisingly, this good judgment is a quality that any person in the world can have. It cannot be purchased. It is between one's ears and must be used.
My father always told me that when you speak, tell the audience something that they can use the next hour when they are seeing patients. Make the information useful. The reason we are invited to lecture is to help those who asked us to come. We are not there to make them feel inferior or inadequate or to advertise for patients. We are there to help others with the problem they face.
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