What It’s Really Like to Be a Brain Surgeon

Early in his career, brain surgeon Theodore Schwartz, MD ’93, met with a patient experiencing vision loss, weight gain, and other symptoms caused by a brain tumor that was pushing against her optic nerves and hypothalamus.

The patient had already consulted two other surgeons. One recommended an invasive but well-established procedure that would require removing part of the skull to access the tumor. Another thought that surgery was too risky and recommended using radioactive liquid or radiation to control the growth of the tumor. Schwartz, who was still trying to establish himself in a crowded New York City medical community, told the patient that she was a good candidate for a newer, minimally invasive technique that he was helping to pioneer. He would access the brain through the patient’s nostrils and remove the entire tumor with no need for additional radiation.

“Very few people in the world were doing this type of surgery at the time, and if anything went wrong, my choice of surgical approach would be harshly criticized by the more senior neurosurgeons in the department,” Schwartz writes in his new book, Gray Matters: A Biography of Brain Surgery. “My reputation and my confidence were at stake, not to mention my patient’s life and career.”

This story is one of many Schwartz tells in Gray Matters to illustrate the evolution of the field and the rewards and challenges of life as a brain surgeon. Part memoir, part historical exploration, the book examines the innovations, ethical dilemmas, and discoveries that have shaped brain surgery over the past 120 years. Schwartz delves into famous cases such as the assassination of John F. Kennedy, as well as contemporary debates over issues like shaken baby syndrome and the neurological effects of football injuries, to explain how the field has changed our understanding of the brain. Drawing on his background in both philosophy and medicine, Schwartz also reflects on how recent advances in brain-computer interfaces and other technologies may challenge our concepts of identity, consciousness, and free will.

He spoke with Harvard Medicine editor Amos Esty. The interview has been edited for length and clarity.

One theme that came up over and over again in the book is competition, whether you’re describing a tumor as your opponent or writing about competition among surgeons. Do you think of yourself as a particularly competitive person?

Yes, I do. What’s interesting about something like neurosurgery is, on the one hand, you are a caregiver whose first priority is to suppress your own interests and put another person’s interests above your own. At our base, we surgeons are all extremely compassionate. But on the other hand, you’re trying to master a technical skill and the physical world around you. Traditionally, if you’re trying to become a master at anything, you have to push yourself — you’re competing with the people around you, and you’re also competing against nature.

When athletes train, they are trying to make their physical bodies do things at a very high level and compete to be the very best that they can. Neurosurgery is very similar to that. It’s a contact sport where we’re constantly trying to better ourselves. The goal, obviously, is to help other people. But when we fail, the negative emotional feedback of hurting another person or not performing at the level you want is so powerful. That acts as a motivating factor, which pushes us into a type of competition. So we’re in competition with ourselves, we’re in competition with our partners, we’re in competition with disease.

You were a musician growing up. Do you find some of that same sort of physical satisfaction in surgery that you did in music?

Very much so. There are a couple of aspects of music that I find similar to surgery. The first has to do with practicing. Anyone who’s become good at an instrument knows that you have to sit by yourself in a room for hours, just repeating your scales, getting your fingers to do what you need them to do. There’s this repetitive physicality of music that’s very much like surgery in learning how to do these fine, technical operations.

At the same time, a surgical procedure is like a performance. The piece that you’re playing has a beginning, a middle, and an end. It has crescendos, it has denouements. It has moments where you move fast and moments where you move slow. You often have an audience. When I’m in the operating room, I often will have six or seven people just watching the operation. You are performing for them. And while there are virtuosos at what we do, there are others who sometimes might miss a note.

You write that most patients will never acquire enough information or experience to make a truly informed judgment about something as complex as a brain tumor. How do you approach decision-making with patients when there is this inherent limitation?

It’s a great question, and it’s one that baffles us all the time because we’re sitting across the table from another human who’s coming to us for help. We have this vast amount of information about what the different treatment options are, which ones are more or less likely to work, where exactly their tumor is, how easy or difficult it will be to remove that tumor, and what the possible complications and morbidities are of that operation. There are also alternatives. Sometimes we can do radiation, we can observe, we can do surgery, and we want to present the pros and cons of each choice, which often involves a detailed knowledge of things that take us decades to learn. And it’s sometimes very difficult to impart all of that during a short office visit. Often what it boils down to is: What would I want done if it were me, or what would I recommend to my brother or my sister?

On the other hand, when there are multiple alternatives, we can’t just say, “You should do this,” right? We have to say, “You could do this.” These are the risks and benefits. We have to give them the alternatives. God forbid, something goes wrong. We wouldn’t want someone coming back and saying, “You never told me there was another option.” Also, it’s not a bad idea to recommend second opinions, particularly when we’re in these gray zones where we could do it one way or another.

Ultimately, we have to let patients decide for themselves. We can definitely nudge them one way or another based on what we think the right thing will be for them to do. And there’s a very careful balance between nudging and coercing. We have to strike that balance to try to get them to make the decision that we think they should make but have them make it in an informed way and feel that it was their decision.

Another complicating factor you write about is that when you actually get into a surgery, there’s often something unexpected and then you have to make decisions based on what you find. Do you think there’s a lot of variation among surgeons in the decisions they make in those scenarios?

There’s an enormous amount of variation, and I think that people don’t appreciate how much variation there is. The public wants to think that neurosurgical procedures are somewhat codified — that if you’re going in, it’s going to be done a particular way. But the truth is, every neurosurgical operation involves hundreds if not thousands of different decisions. Each decision is going to impact the next one, and every individual is going to make that decision differently. Which surgeon you see is incredibly important, because you’re going to get dramatically different outcomes based on who you see, what their experience is, and how they make decisions.

Every brain tumor is different. There are some brain tumors that are very difficult for us to reach and others that are very simple for us to reach. As a patient, how do you know which you have? Do you have a routine operation or a difficult operation? And if you have a difficult operation, is the surgeon across the table from you someone who’s done that difficult operation many times or someone who only saw it done once during their residency? You have no idea. And so that’s why seeking other opinions, going to tertiary care medical centers, seeking people who clearly have been doing this for decades and have a certain reputation is very important. Don’t just accept the first opinion that you get.

Like other physicians, you had to make decisions pretty early on in your training about the field you wanted to go into. Once you became a neurosurgeon, did your expectations of what it would be like turn out to be accurate?

Yes and no. I think when you make a decision at such a young age to go into a field like brain surgery, you have no idea what it’s really like. You’ve watched a couple of operations; you sort of know what you’re getting yourself into. But I don’t think I really understood. I don’t think I realized the emotional toll it would take on me to have another person’s life in my hands.

When you watch these operations, even as a resident, there’s always someone else who’s responsible, and you don’t really know the patients as well when you’re training. You don’t know who the person is. They haven’t entrusted you with their lives or their speech or their vision. And when you’re finally in the driver’s seat, you realize the weight of what you’re doing. And that brings us back to the occasional times where things don’t go the way you plan, which is not common, but it does happen, obviously. The weight of that is enormous. I don’t think a med student appreciates that.

Your description of neurosurgery is that it’s an incredibly demanding field. What’s your take on the ongoing discussion about trying to find work-life balance in medicine?

I don’t think you can be a great brain surgeon if you’re not willing to sacrifice some degree of work-life balance, at least for a period of time, if not forever. It is not a nine-to-five job. It will never be a nine-to-five job. That is the nature of going into a field like brain surgery. And I’ve been very encouraged by the students who go into it. I think they know that. They realize that. They appreciate it, and they’re willing to make that sacrifice for the greater good.

Do I think that training needs to be and has become kinder and gentler and not as brutal and abusive? That is for sure. It should never be abusive. It should never be demeaning. But that’s different than saying we want to make it less rigorous, because you don’t want to end up with neurosurgeons who are not adequately trained. They have to be. What we do is so complex, and there are some situations that occur rarely. You’re in your residency for six or seven years, which is a long time, but there are some types of surgeries that surgeons encounter only once every year or two, and you could completely miss them as a resident if you’re not working a lot of hours.

You’ve been in this field for decades now. What are you most excited about at the moment?

With my philosophical background, what excites me the most is the concept of neurons in the brain that seem to be active before we make decisions as to what we want to do, which indicates that we may not have as much free will, if any, as we think that we do. There’s clearly an enormous amount of calculation and decision-making that goes on below our conscious awareness. And with the upcoming revolution in brain-computer interfaces, where we’re putting electrodes in the brain and enabling people to control computers and robots with their thoughts, it creates the possibility that some of the modules in your brain that work below the level of your conscious awareness might be able to communicate with the outside world in a way that might be unexpected even to yourself.

To give an example, we know there are neurons that fire in the brain a few hundred milliseconds before I know what words are going to come out of my mouth. So imagine creating a robot that takes information out of my brain and everything the robot says comes out a fraction of a second before I actually say it. That’s sort of a scary thought, because it means that you’re not actually creating the words that are coming out of your mouth in the way you think you are. And that can be true of every single behavior that human beings do. So that kind of excites me about the future. It’s going to give us the ability to learn and understand so much more about how the brain works.

You write about medical challenges involving both of your parents. What was it like to be on the patient and family side of neurosurgery?

It’s more difficult than you’d imagine, because you’re playing two roles, right? On the one hand, you’re playing the role of the expert who knows what’s happening, and your family is looking to you for guidance, and you want to be a professional in giving that guidance. On the other hand, you’re also a child, a son, who wants to just tell your loved one, “I love you so much. This is what you mean to me.”

It’s very hard to be a doctor and a vulnerable child at the same time. Those two are almost mutually incompatible, and yet you have to play both those roles when one of your parents gets sick. It’s a push-pull situation where you’re trying to figure out at different moments in time who you need to be for them at that moment. And I write about it with my dad, how I never really said goodbye to him because I was too busy trying to take care of him, which was a very difficult situation.

Did those experiences change anything about the way you work with patients as a physician?

I’d like to think so. I’d like to think that every experience we have as a human being informs our doctor-patient relationship personalities. I think the older I get and the more people around me I have helped, the more sympathetic and understanding I am and the more I see my patients as human beings and not just conundrums or enigmas that need to be solved. I think that is extremely important.

Have the things that you get a lot of satisfaction out of in your work changed over time?

I get more satisfaction now in training junior faculty members and fellows. I have become technically much better as a surgeon, and I’ve also become much safer as a surgeon. My complications and the risks of surgery in my hands have gone down dramatically. That is very satisfying. And I do enjoy the idea of performing a technically perfect surgery from beginning to end, where no move is wasted — every move brings the surgery forward to the ultimate goal in as few moves as possible because you’re so efficient at what you’re doing.

Images: Brian Marcus (Schwartz); courtesy of Dutton (book cover)