Reflections on the past, present and future of neurosurgery:An interview with Edward R. Laws Jr., MDtime：2007 AANS[Ed.] A native of New Y
Reflections on the past, present and future of neurosurgery: An interview with Edward R. Laws Jr., MD time：2007 AANS [Ed.] A native of New York City, Dr. Laws completed his medical education and residency training at the Johns Hopkins University School of Medicine. During his illustrious career, he has served on the faculty at Johns Hopkins, the Mayo Clinic, the University of Virginia, and most recently as professor and vice-chair of Neurosurgery at Stanford. Dr. Laws has exemplified commitment to neurosurgical training and education, having served as editor of the journal, Neurosurgery, (1987-1992) and as a member of the editorial boards of the Journal of the American College of Surgeons, Journal of Neurosurgery, Cancer, and the Journal of Clinical Endocrinology and Metabolism. Among his many publications include seminal work on the biology of gliomas, pituitary adenomas and epilepsy. He also has trained numerous neurosurgery residents and fellows, many of whom hold prominent positions within neurosurgery in the United States and internationally. Dr. Laws has held many leadership positions within organized surgery, including president of the Congress of Neurological Surgeons (1983-1984), president of the American Association of Neurological Surgeons (1997-1998), and most recently president of the World Federation of Neurosurgical Societies (WFNS) and the American College of Surgeons (ACS) (2004-2005), only the fifth neurosurgeon to hold the latter honor. Recently, Dr. Laws shared some of his valuable time with Young Neurosurgeons’ News, reflecting on his experiences. JJ: Who would you say were your most influential mentors in neurosurgery? ERL: I was incredibly fortunate in acquiring a galaxy of important mentors in a variety of areas. I knew I wanted to do neurosurgery as soon as I started working in the neurosurgical laboratories the summer after my first year of medical school at Johns Hopkins. As students we had a wonderful grounding in neuroanatomy (David Bodian, MD, PhD), neurophysiology (Philip Bard, PhD, Vernon Mountcastle, MD, and Gian Poggio, MD), and biochemistry (Al Lehninger, MD). We had surgery in the dog lab that Harvey Cushing, MD, started, staffed by Vivien Thomas. That first year of research, Thomas Langfitt, MD, was chief resident and I wanted to be just like him! George Udvarhelyi, MD, and a neurologist, John O'Connor, MD, were my mentors in the lab. We actually built an ultramicrogasometer Cartesian diver apparatus to measure the metabolism of single neurons – I worked in the lab every summer and throughout my residency. The neurosurgical faculty all became mentors over the nine years I spent with them. A. Earl Walker, MD, stimulated my interest in epilepsy. Dr. Udvarhelyi got me involved with pituitary surgery and pediatric neurosurgery, and taught me the scholarly way of dealing with neurosurgical problems that he learned from working with Wilhelm Tonnis, Norman Dott, MD, and Dr. Walker, and that fired my own interest in neurosurgical history. Dr. Udvarhelvi also taught me the importance of the cultural aspects of our life and work. Patient care and technical neurosurgery were taught by two trainees working with Walter Dandy, MD – Frank Otenasek, MD, and John Chambers, MD, who were in private practice at Hopkins. John had also worked with James Poppen, MD, and they both carried on the Dandy spirit of bold and incisive, inspired neurosurgery. Neal Aronson, MD, was also on the faculty – he was the youngest neurosurgeon to have passed the board at that time and brought the best of the traditions of the New York Neurological Institute, and was my first teacher of stereotactic neurosurgery. Ted Hodges taught me neuroradiology at a time when the neurosurgical residents were doing all the angiograms and myelograms. I learned EEG from a real master, Ernst Niedermeyer, MD, and psychiatry from Dietrich Blumer, MD, both during my residency years. Frank Walsh, MD, taught us neuro-ophthalmology in a marvelous session every Saturday, with Frank Ford, MD, ("the judge") of neurology often in attendance. Monday nights we had neuropathology and brain cutting at the city morgue taught by Richard Lindenberg, MD. Spine surgery was flourishing and I was privileged to work with Robert Robinson, MD (of the Smith-Robinson ACDF). "Robbie" actually scrubbed in to help me as chief resident with an anterior approach to a T-12 burst fracture. His protégées Lee Riley III, MD, and Jack Ivins, MD, at Mayo were important mentors in spinal surgery as well. In 1968, at the beginning of the microsurgical era, Dr. Walker allowed me to go to New York for the first microsurgery courses taught by Gazi Yasargil, MD, Leonard Malis, MD, and Albert Rhoton Jr., MD. Those individuals set the stage for a new chapter in the history of neurosurgery. At Mayo, even though I was on the faculty, I had important mentors, including Collin MacCarty, MD, who knew everything about meningioma surgery, Ross Miller, MD, who was cool and calm and versatile, and Thoralf Sundt, MD, who showed me all I did not know about vascular disease. At Mayo my career in pituitary surgery took off under the mentorship of two superb endocrinologists, Ray Randall, MD, and Charles Abboud, MD, who had confidence in me and were fine colleagues. This fabric of wonderful teachers, colleagues and friends has sustained me over the years, with new inspiration and new challenges constantly appearing. JJ: Many young neurosurgeons are looking for ways to get involved with organized neurosurgical groups (AANS and CNS), but have difficulty getting their 'foot in the door.' What are the best ways to get involved? ERL: Good ways of getting involved include presenting posters and papers at major meetings, joining the Sections where often there are many opportunities for young surgeons to get involved, and actively volunteering for committee work. Networking is the key and the YNC can help. The ACS has a young surgeons group and the American Medical Association has a residents’ group – these are other avenues that can be explored. JJ: You have always managed to balance an extremely busy clinical practice and prolific academic career. New faculty members often feel intense pressure to operate, compromising their research time. Any advice on how to balance the two? ERL: It is never an easy task. Clinical neurosurgery has such an allure and technical excellence demands experience, so there are competing priorities. Always try to take a scholarly approach to the clinical work – as Miller Fisher, MD, said, "They are all interesting patients." Good neuroscience is so much of a collaborative effort these days: a good strategy is to seek out the right scientists as collaborators, provide them with challenges and insights, and with research material, and utilize their areas of expertise as windows to solve problems. JJ: The new Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions have changed neurosurgical residency education. There is a fear that surgical training may suffer in years to come because of limited operative time. Do you think this is true? Have you found any specific model of the 80-hour week to be particularly effective? ERL: We will never be able to change the current limitation on duty hours, and our response in maintaining the integrity of the educational enterprise has been suboptimal. Perhaps we need to rethink the goals of neurosurgical education and provide more versatile pathways to ultimate career choices. I do not know of a model that does this at present. My experience with the "night-float" solution is not encouraging for it creates a servant mentality that is inimical to the educational process. JJ: What areas of evolving technology do you find particularly exciting? ERL: Endoscopic neurosurgery is more than a gimmick and is leading to new and better concepts and outcomes. Radiosurgery has acquired a definite role in many areas of neurosurgery. Deep Brain Stimulation (DBS) involves a set of methodologies and concepts that may have very wide applications in the future. Neuro-imaging, image guidance and endovascular neurosurgery continue to evolve. JJ: As one of the few neurosurgeons who has been president of the ACS, what are your thoughts about the idea of an 'acute care surgeon', as proposed by some in the ACS? Do you see this happening in the future? ERL: The trauma care system drives manpower in this country in a significant fashion, and most hospitals desperately want recognition as trauma centers. This requires neurosurgeons and we are suffering a neurosurgical manpower crisis that needs to be solved. Regional systems have been proven to work, but this concept threatens the status of individual hospitals. The acute care surgeon will not be capable of dealing with head and spine trauma in an effective fashion, and it is appropriate for us to resist this idea while we educate the public regarding effective systematic solutions. JJ: What are the most important things to look for when deciding on a first job? What would you consider to be 'red flags'? ERL: Offer to fill any perceived subspecialty area, but try to maintain the prerogative to do a full spectrum of clinical neurosurgery, at least for a while. Evaluate the collaborative opportunities clinically and scientifically. It is important to feel comfortable working with the residents and fellows. The overall ambience is key. Make sure you have the opportunity to attend the important national meetings. The biggest red flag is discord among members of the faculty and among the residents. JJ: As president of the WFNS, you had a unique perspective of seeing neurosurgery around the globe. How do you find neurosurgical training outside the United States? ERL: There was a time that everyone who ended up being a neurosurgical chair abroad had spent at least some time in the United States. That is no longer the case, for a variety of reasons, and this has limited the opportunities for international exchange and dialogue. Neurosurgical education continues to develop all over the world, but is still not close to our model, which remains the envy of many. JJ: Anyone who has worked with you knows how important your family is to you. Any advice on balancing family life and a successful career (particularly when starting in the field)? ERL: It is not a good idea to neglect the family for work, even if they appear to be (and are) understanding. No matter how busy I was, I always tried to spend some time with my wife and children each day. You have to take the time to help around the house as a partner, to help the kids with their homework, to get to some of their sports events and school activities. It goes by so quickly, and you will not usually have the chance to catch up later. JJ: Recently the Internet and online 'chat rooms' have become a forum for residency applicants interested in neurosurgery. There has been concern about the validity of information that is distributed through this media. Do you think that organized neurosurgery should moderate these types of discussion areas? ERL: This activity will have some good aspects and some that are not so good. There is no way that organized neurosurgery could or should control this. Hopefully the same principles that drive evidenced-based medicine will ultimately prevail in this arena – practically speaking, however, that is unlikely.