Neurosurgery takes steady hands and nerves of steel. It can be triumph or trouble. Neurosurgeon Dr Andrew Miles says the third ‘T’, training, is the key.
“What’s the difference between God and a neurosurgeon?
God doesn’t think he’s a neurosurgeon.”
One suspects that neurosurgeon Dr Andrew Miles wants to get that joke out early in the conversation – partly to show his self-deprecating side and partly as an acknowledgement that it does indeed run through neurosurgeons’ minds (and others) from time to time.
“It’s one of those very demanding specialties. When things go right, operating on someone’s brain, and they come out of it better than when they went in, patients do treat you almost godlike,” he told Medical Forum.
“When things go wrong, particularly with brain tumours, they can go very wrong. So, you have to have a pretty tough skin. It’s horrible having to tell a patient or their family that they’ve woken up with a stroke, or they are paralysed down one side of their body, or they can’t speak. So, I think, the job does create an individual with certain personality traits.”
“Sometimes it’s hard to live with – for the surgeon and people around them. It does take a toll, personally, and not everyone’s cut out for the lifestyle. I’ve certainly come home pretty upset but, fortunately, that’s uncommon.”
“I’m finding now that it’s not only when something bad happens, I’m brought up short. At 52, I’m getting to an age where I’m operating on people who are the same age as me. I share common experiences, same age, children the same age. To tell them they’ve got a brain tumour that will probably take their life within a year or two or three, it’s sobering.”
“It’s certainly made me spend as much time as I can with my teenage girls.”
Andrew, one of three children, was two when his English parents immigrated to Western Australia in 1969.
“I come from a what might be best described as a working-class background. My parents were part of the ‘£10 Pom’ migrations,” he said.
“My father was a carpet layer and, in the school holidays he’d take me to work with him. I realised early on how hard he worked and how dragging carpets around with all the bending and stooping was tough on his body. I told him that I didn’t want to do that the rest of my life. His reply was, ‘well, you better study hard and get yourself out of this’.”
“So, I did! I studied hard and thought I might be able to get into medicine. What pushed me over the line was my maths teacher at Greenwood High School, Mr Deering, in Year 11, who told me I’d be lucky to get into university, let alone medicine.”
“I think I’d feel a certain satisfaction if he ever came to me as a patient.”
While Mr Deering put the fuel in the tank, Andrew’s art teacher inspired his creative side, especially his lifelong interest in photography, and his work ethic.
“He told me that if I worked hard, I’d get the success I deserved. In hindsight, that’s been a double-edged sword.”
All medicine is exacting but it is probably fair to say that focusing on the bits we can’t do without is living on the edge. So how did Andrew decide that neurosurgery was the medicine for him?
“Pure chance,” he said, grinning.
“My very first job as an intern was on the neurosurgery ward, which was pretty tough. I didn’t really know what I was doing, but it was a ward where there was an intern, a junior resident and a senior resident plus two registrars. So, there was a lot of support. Wayne Thomas was a wonderfully supportive mentor as was Bryant Stokes.”
“The following year, I joined the ward as a junior resident and then went onto the training program.”
“What I liked best about surgery and neurosurgery was the quick satisfaction. There’s a patient with a problem. You have to use your intellect to work out what that problem is, then use your hands to fix it. That’s exciting.”
“One of my fascinations is handmade Swiss watches. People question the cost of watches like that, but take a look at the mechanisms inside, it’s astounding. There are some similarities between watchmaking and surgery. We both work under high magnification doing intricate and difficult work with not a lot of margin for error.”
Of course, fall over that margin in neurosurgery and the consequences are dire. Andrew thinks that’s where the neurosurgical crankiness is born.
“Training was great but that first year of two as independent neurosurgical consultant, you know, I spent much of my working day scared. I readily admit that. While training there is someone watching over you, then suddenly your name is at the top of the list. You’re the one who takes all of the responsibility,” he said.
“I think that is why junior neurosurgeons get a bit of a negative reputation around the place. You’re so intense and focused, and try to make what you do as perfect as it can be. When you perceive that people around you are not doing the same thing, you tend to let the stress fly.”
“It’s a difficult balance because sooner or later, you’ve got to get those feelings under control. You can’t be screaming at the people around you for the rest of your working life. So, it really does take a good couple of years to get that fear under control.”
At this juncture, Andrew pauses and laughs.
“Of course, once you’ve got the fear under control, that’s when the ego kicks in and that’s when you start to develop a God complex. Young neurosurgeons have to be to be conscious of that and I’m not excluding myself from this.”
“There’s a middle ground between being fearful and overconfident and arrogant – it’s the moment when you just get on with the job and appreciate the fantastic group of people we work with. I have a fantastic team around me – from anaesthetists and surgical assistants and most importantly, a fantastic group of nurses in both theatres I work at – St John of God in Subiaco and Murdoch. I couldn’t do the job that I do, to the standard I want, without them.”
Andrew did his surgical training at SCGH and RPH before heading to Seattle in the United States.
“I chose Seattle because I had an interest in epilepsy surgery and RPH had a comprehensive epilepsy service that I had planned to return to. I went to work with Professor George Ojemann, who had a phenomenal reputation as an epilepsy surgeon. It was privileged to work with him.”
While the work was stimulating, given the exposure of a quantity of cases not often seen in Australia, it was arduous.
“My wife was unable to work, which was isolating, and the hours in the hospital were extraordinary. If you think we work long hours here, the neurosurgery units over there clock in at 5am and operate until 10pm. The chief residents on their one year of training actually don’t leave the hospital. They get about one week out of the hospital every three months and hardly ever see their partners. I lived in the hospital for three months,” he said.
“It was pretty tough.”
“But I ultimately got back to Royal Perth and with the Comprehensive Epilepsy Service. And then while I was there, I also did a spinal surgery fellowship.”
While the experience in the US was special, Andrew believes Australia produces better, more rounded surgeons.
“There is a lot of peer pressure early on and the hours are long, though I think things are a lot better now, But, it’s still a balance because Australia prides itself on the quality of surgeons who come off the conveyor belt. They are well trained and that doesn’t happen in a lot of countries, even the US,” he said.
“The US centres of excellence are the best in the world, but the vast majority of the population doesn’t have access to them. They go to community hospitals where a neurosurgeon might only do one brain tumour every month.”
“If you’re only doing an operation once a month compared to someone who is doing the same thing five times a week, the skill levels will be vastly different. In Australia, the most of us get to the end of our training with a very good, broad experience so the public can be assured that 99% of the time their surgeon will be skilled and well trained. However, how we get there is through experience. It’s an apprenticeship.”
Andrew said he resigned from the public system four years after he returned from the US.
“I got very disillusioned, for a variety of reasons. The work at the Comprehensive Epilepsy Centre was all very stimulating and interesting. But I took on too much. We had just had a baby, I started a private practice and I was working at Charlie’s, Royal Perth, the Mount, Joondalup, so I was running everywhere,” he said. “I had no time.”
“And I was seeing patients in the clinics with spinal pain, more than anything else. I knew they would probably never get operated on just because the waiting list was so long. That was back it 2003, it was bad. These people would be in agony because of pinched nerve pain and you just knew they’d be put on narcotics.”
“Some of them would get better by Mother Nature, eventually. But a lot of them would be in a lot of trouble, and that was quite disheartening. And then I had the misfortune of being involved in a legal case, about three years into my training.”
“An epilepsy patient needed very complicated surgery where I had to remove fairly large areas of brain. I did cure his epilepsy, but his personality changed and his wife ended up suing on his behalf for failure to warn sufficiently about the side effects. It was a very protracted case – it went on for years and that was hugely stressful.”
“I just decided that I didn’t want to do it anymore. However, I still use the techniques I learnt from George Ojemann for brain tumours in my private practice.”
Andrew’s precision equipment for a large proportion of his career has been his hands, but technology is making a play. He is particularly enthusiastic about neuro-navigation for spinal and brain surgery.
“It’s a fancy GPS really. It’s based on the same technology. We can now triangulate the exact location of a tumour which means we can now do brain surgery though a small hole in exactly the right spot. And similarly, in spine surgery, you know to guide the screws into the bone on exactly the right path,” he said.
“That’s a big change. I’ve been doing this minimally invasive spine surgery for about five years and patient feedback is less pain for less time, and the hospital stay is shorter.”
Robots are also creeping into spine surgery, but Andrew is cautious about being a “too early” adopter of new technology.
AI and IT
“I’ve been to a couple of robot courses for spinal surgery and I certainly consider myself open to new technologies. I was one of probably 10 to 15 surgeons across Australia who got involved in artificial disc surgery from the start.”
“Obviously you have to realise there is a fine line between pushing the technology boundaries and using your patients like guinea pigs.”
However, he welcomes computer-based decision making.
“If a computer can help me sift through the massive amounts of data that I couldn’t hope to take in, it will be very, very useful for medicine and amazing for my specialty. But I don’t think that’s truly artificial intelligence, that very powerful computing,”
Does it replace the skills he has worked so hard and so long for?
“No, I don’t think so. It’s an adjunct. It’s not possible for anyone to know everything. AI will happen in the future but probably not in my lifetime, but I think it would be a horrible society if it were led by a sentient machine.”
“I take heart from Star Trek, you know. They still had an onboard physician!”
More practically, Andrew believes the more immediate future will see all branches of medicine work from a multidisciplinary perspective. He and his partners, Dr Michael Kern and Dr Paul Taylor, have pulled together a team including a general physician, a pain specialist, physiotherapists and an exercise physiologist, with a clinical psychologist also available.
“I think it will become standard of care. The days of doctors, and surgeons in particular, being solo practitioners doing their own thing and then discharging their patients to their own devices will slowly end. Payers – governments and insurers – won’t allow that to happen much longer. They’ll want value for their money. And value for their money comes from using every resource we have to get the patient back to function,” he said.
“It’s ultimately for the benefit of the patient and its good for the teams as well. It’s very useful to have colleagues on hand to support and discuss difficult cases.”
Andrew is also dedicated to research through his own practice. He is a strong believer in the need for a national spinal surgery registry.
“We bought the licence for the same software being used by the British Spine Registry. In the UK, it is an NHS requirement for funding that all patients who undergo spine surgery be put on the registry detailing their outcomes,” he said.
“We are doing this for our patients now. They are sent post-operative questionnaires at three months to 12 months. The orthopaedic fraternity are doing it and I hope the Australian Spine Society will mandate a registry in the same way.”
“It’s important to identify good outcomes, but also to identify outliers. We have set up a research foundation and hope to attract some industry support. In a year or two, we’ll have a large amount of data that can really support good practice.”