In preparation for delivering the 10th annual Olga M. Jonasson, MD, Lecture, I reviewed previous Jonasson lecturers and immediately noticed that my career intersected with the first three presenters: Nancy L. Ascher, MD, PhD, FACS; Anna M. Ledgerwood, MD, FACS; and Karin M. Muraszko, MD, FACS.1
Dr. Ascher is chief of surgery, University of California, San Francisco (UCSF), and a major contributor to organ transplantation research. Nancy and I shared time together at the University of Minnesota, Minneapolis, where she was senior to me by a few years. Due to the fact there were only six women in all the programs, I got to know her and recognized, even as a resident, that she would go on to a distinguished career.
Dr. Ledgerwood was a legend at Wayne State University, Detroit, MI, where I spent most of my career. Everyone knew that Dr. Ledgerwood and her longtime colleague Charles E. Lucas, MD, FACS, were the heart and soul of DMC [Detroit Medical Center] Detroit Receiving Hospital.
The third Jonasson lecturer, Dr. Muraszko, is chairman of neurosurgery, University of Michigan, Ann Arbor, 45 miles down the road from the Children’s Hospital of Michigan where I practiced, and we have been friends and colleagues for years.
So, now, I would like to talk about my journey in neurosurgery. I am going to talk about neurosurgery because that is what I know, but it applies to journeys in general surgery, orthopaedics, and other surgical specialties, as well.
The journey to neurosurgery
How does one decide to become a neurosurgeon? I went to medical school expecting to become a family practice physician or an internist, but I didn’t enjoy studying the physiology of the gastrointestinal tract and the lungs, so that pretty much eliminated the medical specialties. Fortunately, the University of Michigan had started a new two-year course, neurobehavioral science, with a combination of neuroanatomy, psychiatry, neurology, and neurosurgery. This mix of clinical and basic sciences was well-taught and exciting, and it was something I found I could study for fun.
The summer after my second year in medical school, I shadowed a pediatric neurologist as well as a neurosurgeon. Needless to say, I liked neurosurgery better. It has an inherent honesty. You make a diagnosis, and at the end of the day, you are right or wrong. The possibility of being wrong sometimes brings fear.
When I was in practice, an eight-year-old boy was transferred to us for what appeared to be a stroke. But as I looked at the images, something did not seem right, so I asked for an angiogram, which also was equivocal. I talked with my associate and asked him to keep me from doing something crazy. When I told him about the clinical history that wasn’t quite right and the imaging that wasn’t quite right, he said, “You may be wrong, but not crazy.” So, I took the boy to the operating room (OR). As I stood there making the brain incision I was extremely anxious but relieved when a small, discrete, dark burgundy mass was exposed, which turned out to be lymphoma. These are the moments for which we read and study. We are right, or we are wrong, but in surgery there is a final answer.
After my preceptorships, I essentially became a neurosurgery groupie. I was at every neurosurgery conference my schedule allowed, including those on Saturday mornings. I soon knew most of the faculty and all the residents; occasionally, I even got called on during the conference. I was all in for neurosurgery.
Surprisingly, my parents, who had supported me in all my ventures, for the first time actively discouraged me from neurosurgery. They thought I wouldn’t get in a program, and if I did, patients wouldn’t come see me. There comes a time, however, when you realize your parents no longer know what is best for you. The world they grew up in is not your world, and you must have the courage to hope your world will be different.
Finding a community
It is estimated that there are only 5,000 neurosurgeons for a patient population of 60,000, and that they comprise only 1.7 percent of all practicing physicians. Of these neurosurgeons, 7 percent are women. In addition, more than 40 percent of all practicing neurosurgeons are age 55 or older.2 These statistics suggest that there is a need to attract students with both the technical and cognitive skill to handle a demanding profession.2 The pool of interested students is small, and neurosurgery may not appear attractive to medical students, who are the lifeblood of this profession. As a result, a number of surgical specialties, including neurosurgery, have created programs that provide early exposure and mentoring for medical students. One Canadian study found that early exposure to a neurosurgery program increased interest in neurosurgery.3 The main drawbacks that students may associate with neurosurgery include lack of time to devote to outside interests, residency competition, and busy workload. On the other end of the spectrum, neurosurgery offers great opportunities to have a meaningful impact on patients and the promise of intellectual stimulation for the practitioner.3
The sense of community is very important in ensuring the success of women and minorities in health care professions. A community of supportive peers ensures that you don’t have to fight all the time to prove you belong when you are already exhausted trying to learn the specialty. It has been my experience that women residents in general surgery do better when more women are present in their training program. I was lucky that, when choosing my residency at the University of Michigan, I was exposed to a practicing woman neurosurgeon. She made the dream seem possible.
When I went on to Yale University, New Haven, CT, for my internship, I met another successful woman neurosurgeon. But in the end, her career was a cautionary tale of the cost to the individual who takes on a pioneering role. Years later, at a Women in Neurosurgery Annual Meeting, a colleague said that she had met this distinguished neurosurgeon from Yale but that she was so bitter it was unpleasant to speak with her. I tried to explain to my colleague what had happened. The Yale surgeon had been a nurse who wanted to be a neurosurgeon. She was offered a position at Yale but was forced to wait a year or so to see “if she was really interested.” Finally, she was allowed to finish her residency and stayed on as faculty for many years. Despite the fact that she was a full professor in neurosurgery and a past-president of the American Association of Neurological Surgeons section on Neurological Surgery, the OR staff asked her to share a locker rather than give her one of her own. It was the last straw and she left. Later as other people interviewed for her job, we learned that she was grossly underpaid, and it took multiples of her old salary to attract a replacement.
She moved to Dallas, TX, where she was again isolated, then on to the University of Michigan where something that is, in my experience, unprecedented occurred. When the chairman sent her credentials to the tenure committee asking for an associate professorship, they sent them back, asking if it wouldn’t make sense to make her a full professor. He said no. Just before her retirement, she was finally made a full professor, which irritated more than pleased her because it was an exit gesture. So when this woman, who persevered through all this, is blamed for her temperament, I suggest that she was the victim, and when we encounter people who have experienced tremendous struggles, we should recognize that any bitterness is the cost of that struggle.
The role of a diverse neurosurgical community cannot be overstated in attracting the best students to our specialty. I did not appreciate how important community was until after I finished my residency and would speak to student groups. Women and black students now see neurosurgery as a world that they can enter.
This same sense of community is important at the attending level. The Neurosurgical Society of America had difficulty with relatively poor engagement among the women membership and wanted to understand why. The reason was clear to the women members, however: the society was run like a men’s club, complete with bonding at late-night poker games. Neurosurgery is, by its very nature, attractive to a small number of students, and we better pay attention to and court all who express interest.
After choosing neurosurgery, I was terrified I wouldn’t get a residency position. There are about 102 neurosurgery programs with 1,600 residents.4 I tried to present myself as a risk-free candidate who fit in and could handle the work, so I did clinical rotations at Yale, UCSF, and Columbia, and I completed surgical subspecialty rotations in neurosurgery at Michigan—one at the university hospital and one at St. Joseph’s. My interviews went unremarkably, except for two. The one at Duke University, Durham, NC, was complicated by my having acute tonsillitis with a fever of 103 degrees. When the professor invited me to make rounds and I declined, I assumed Duke would not select me. Michigan, my medical school, was also problematic. They asked me to interview twice. The second time I had to come back on Christmas Eve for an interview that consisted of a recitation of how many people had been fired from the program. I think the chair was getting some pressure to take me since everybody knew I wanted to be a neurosurgeon, and I was a member of Alpha Omega Alpha. Nonetheless, he succeeded in making me feel that I would not be welcome at Michigan, and I put them fourth on my list.
My first few months at Yale were interesting. In the 1970s, you were selected for an internship, and residency was separate, although the neurosurgery department got to pick one of the interns. Within the first few months, the University of Minnesota called and invited me to do my residency there, but they needed an answer in two to three days. I thought I was the chosen intern at Yale but was not certain, so I went to the chair and asked him to tell me if I had the neurosurgery residency and explained my offer from Minnesota. The chairman told me if I really wanted the position at Yale, I would wait until October. This was cultural dissonance at its best. I was a black woman trying to enter neurosurgery at an institution with no women neurosurgeons. I had an offer in hand, and he asked me to pass it up for a possible offer two months later. I took the Minnesota position. The people at Yale said I should have known I was their choice. I told them I would have known if they had told me. But it turned out well for me. I did more neurosurgical procedures than any other intern because when I went to Minnesota, they wanted me to tell them how I learned it at Yale.
My first day at Minnesota was even more interesting. I was the floor resident. The provost of the medical school, who was the previous chair of neurosurgery, ran into me on the floor that day and said, “You must be our new equal opportunity package.” I said, “Yes, I am,” and went back to work. Minnesota was a new world to me but one that still has a place in my heart.
As I approached the end of my residency I realized that I had not really left behind that girl who wondered if she could be a neurosurgeon. When I met with the chairman to plan my future, my parents’ voice echoed inside me, and I decided to go to Henry Ford Hospital, Detroit, where the patients came to the institution, not the physician. I was shocked that despite how much I had accomplished, those feelings of not being good enough were still there. But first, I took a fellowship at Children’s Hospital of Philadelphia in July 1981. My world contracted to just pediatric neurosurgery, but the joy expanded. The experience there was magical, with Luis Schut, MD, dispensing philosophy and career management advice at the morning meeting, along with a world of interesting surgical cases that came to us during my tenure there. The year passed quickly, and then I was off to Henry Ford Hospital. Unfortunately, there simply was not enough pediatric neurosurgery there, and I moved to the Children’s Hospital of Michigan. Within the first month at Children’s Hospital of Michigan, I did more operations than I had done in the entire eight months at the Henry Ford Hospital. I had, again, found my home.
The journey back
I practiced at Children’s Hospital of Michigan for 20 years and absolutely loved it. It was a wonderful place. I had a supportive partner who would get up in the middle of the night to see a patient no matter the circumstances. I could not have asked for a better collaboration. We also viewed each patient as our patient, and whoever was on call advanced the patient’s care. It was a dream practice.
The most important decision I made early in my career was to adopt a comfortable, but not extravagant, standard of living. If I got raises, I would live a little bit better and bank most of it. I bought a very nice house but not a showplace, and I drove nice cars but not head-turning cars. So when the day came that I began to think I might one day not be a neurosurgeon, I had the financial resources to make those choices. When we talk about burned-out physicians, and we all know them, their problem is sometimes related to the fact that they cannot afford to do what they want to do.
Neurosurgery can demand more and more of your energies. At first, you are the new guy with patients gifted from the other surgeons, as well as a lot of time to contemplate your navel and study for your boards. But slowly your reputation builds, and you care for your own patients. The committee assignments come along with teaching responsibilities, and if you are an academic, the need to develop a research program and/or studies. You begin to drop some of the other interests you had due to a lack of time. Ultimately, more and more of your life is only neurosurgery and, if you are lucky, your family. The more insidious change is your attitude at work.
We had an almost insufferable surgeon on our staff. One day while I was waiting for a result with the intensivist, he remembered that when this particular surgeon first came to the hospital he was as nice as he could be—accommodating and positive in his interactions with the staff. As he became busier, he got less tolerant and acted as if every question or phone call was an intrusion.
For me, the breaking point occurred one day when I had a monthly bridge game scheduled, and something came up at the last minute. The idea that I could not even plan something once a month and actually do it made me look at the arc of my career and see how one by one I had dropped all of my outside interests. My life was now limited to work and my husband, and for a number of years that had been enough. Slowly but surely, in crept the idea that I had once been a more interesting person and maybe I could be again.
Because we had been careful to save, I was financially able to choose what I did next. I promised my husband when he moved to Detroit that when I retired we would move wherever he wanted, so we began planning to move to Pensacola, FL, in a year, with time to make a smooth transition for the next surgeon who would take on this leadership role.
In Florida I just sat for a year and thought about what I wanted to do with the rest of my life. Slowly, I began to engage with my new town. Moving to a new town without a job makes it much more difficult to meet new people, but gradually I did, joining a couple of book clubs that introduced me to interesting people. I became involved in mentoring middle school girls and participated in the board for Belmont-Devilliers, the historic black entertainment district in Pensacola. Because I had always gone to the Tuesday pediatric conference at home, I continued to go to the similar conference at the Sacred Heart Children’s Hospital in town. When the pediatricians found out I was a pediatric neurosurgeon and they were sending their pediatric neurosurgery cases to either the University of Florida, Gainesville, or the University of Alabama, Birmingham—both located four to five hours away—they begged me to consider practicing again. And so, I did. But now I could set the conditions and I worked only Monday through Friday. Trauma patients were managed at night by the on-call neurosurgeon, and I took them over in the morning. This arrangement renewed my love of neurosurgery—no one to manage but myself, no committees, just pure pediatric neurosurgery. I loved it and practiced another eight years in a setting that allowed room for my new interest, competitive bridge, and my quest to become a Life Master bridge player—which I finally did in December 2015, the year after my second retirement.
Retirement takes different forms for different people. For me, I re-engaged with the community via mentoring opportunities, an appointment to the West Regional Library Board, and a lot of competitive bridge and book clubs. I closed the book on the neurosurgery portion of my life. Others wish to remain involved in medicine. Some move to medical administration, and others find entirely new careers in medical law or business.
Whatever you choose in the future depends on setting up your finances so when the day comes that you don’t want to practice neurosurgery, you can leave. You don’t have to be that curmudgeon darkening everybody’s day at the hospital because it wasn’t financially feasible to leave when the desire to practice was no longer there.
My neurosurgical career was a joy. I chose it freely and would choose it again. I was lucky to train in good places with supportive faculty and to practice at a dream children’s hospital with my best friends. I know I have been lucky professionally, and I hope you plan well enough to be lucky, too.
- American College of Surgeons. Women in Surgery Committee. The Olga M. Jonasson Lecture. Available at: www.facs.org/about-acs/governance/acs-committees/women-in-surgery-committee/jonasson. Accessed December 12, 2016.
- Association of American Medical Colleges, Center for Workforce Studies. 2014 Physician Specialty Data Book. Available at: www.aamc.org/download/473260/data/2014physicianspecialtydatabook.pdf. Accessed January 3, 2017.
- Zuccato JA, Kulkarni AV. The impact of early medical school surgical exposure on interest in neurosurgery. Can J Neurol Sci. 2016;43(3):410-416.
- Statement of the American Association of Neurological Surgeons, American Board of Neurological Surgery, Congress of Neurological Surgeons, and the Society of Neurological Surgeons before the Institute of Medicine on the Subject of Ensuring an Adequate Neurosurgical Workforce for the 21st Century. December 19, 2012. Available at: www.cns.org/sites/default/files/legislative/NeurosurgeryIOMGMEPaper121912.pdf. Accessed January 3, 2017.