Chapter 15: The Neurosurgeon: Making Decisions about Course of Treatment
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Description
Dr. Sawaya says that it is easy for a neurosurgeon to take a conservative, timid approach to a patient’s course of treatment, but that is a losing proposition. He explains how the mindset at MD Anderson is to “shift the risk from the patient to the surgeon” and go after the tumor in the most aggressive way. He emphasizes that the development of new technologies have to accompany this approach, as neurosurgeons need tools to help them preserve the function centers in the brain. He explains that the Department routinely images every patient before and after surgery and takes tissue samples for volumetric analysis of tumors.
Dr. Sawaya explains how he works with patients to advise them of the risks and benefits of surgery. He notes how important it is to spend time to build trust. He concludes that “This is the best form of leadership I know,” where a surgeon distills and transmits knowledge to help a patient.
Identifier
SawayaR_03_20130625_C15
Publication Date
7-16-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - Overview:The Clinician; Professional Practice; The Professional at Work; Professional Values, Ethics, Purpose; This is MD Anderson; Institutional Mission and Values; MD Anderson Culture; Character, Values, Beliefs, Talents; Leadership; On Leadership; Patients; Offering Care, Compassion, Help; Discovery and Success; Patients; Patients, Treatment, Survivors
Transcript
Tacey Ann Rosolowski, PhD:
I wanted to ask you too about the decision-making that a surgeon has to go through when working with a patient. This is kind of a different sort of question than we’ve talked about before. As I was doing the background research, I was reading any number of articles which talked about how when you’re assessing how to create a treatment plan for a patient, you often have to take a certain amount of calculated risk. I was wondering if you could talk to me about what the nature of those risks are and how, for example, skill and data and technology influence it. But then also how there may be some philosophical approaches that influence it as well. CLIP A: The Clinician C: Professional Practice C: The Professional at Work A: Professional Values, Ethics, Purpose C: This is MD Anderson B: Institutional Mission and Values B: MD Anderson Culture A: Character, Values, Beliefs, Talents C: Leadership D: On Leadership C: Patients C: Offering Care, Compassion, Help C: Discovery and Success The Philosophy of MD Anderson Neurosurgeons: Shift the Risk from the Patient to the Surgeon
Raymond Sawaya, MD:
It’s very true what you said. Because it’s easy to say, “You have a tumor—” We’re dealing with the brain here obviously— “You have a tumor in a difficult location. I’m going to just do a biopsy so that we know exactly what we’re dealing with. Then I’m going to back off.” It’s very easy to do. In fact, that is the easy solution.
Tacey Ann Rosolowski, PhD:
You mean take a very conservative, timid kind of approach?
Raymond Sawaya, MD:
Exactly. Very early on, we have taken the approach that this is a losing proposition. And so we have shifted the risk—if I can put it that way—from the patient to the surgeon.
Tacey Ann Rosolowski, PhD:
And what does that mean exactly?
Raymond Sawaya, MD:
It means that as a surgeon, by going after the tumor in a comprehensive way—surgically speaking—we are taking the risk, because if we fail then we’ve caused the failure. So we are taking the risk. I’m not talking about getting sued, although that could be part of it. But it is a failure. Now why are we doing this? Because we know what happens if we don’t do that. If we don’t do that, we’re going to fail. The patient is going to fail. Because the tumor is going to cause the problem. Now there is a delay between the time the intervention takes place and then the tumor causes the problem. So it’s delayed, it’s not seen, and the surgeon takes no blame that they didn’t take the tumor out. Shifting this problem up front, and saying, “This is when the patient is presenting. This is when we’re going to fix the problem,” so that once we get it done, the patients can go and have longer lives, hopefully better quality of life, and overall better survival. But that requires that the surgeon takes ownership and pushes the envelope. This comes with a specific frame of mind. If your frame of mind is, “Well, these are tough tumors. We may be able to remove a little more, maybe or maybe not it will help the patient, because it’s a malignant tumor.” The frame of mind that we came up with that we have applied now for twenty years is, “No. It does make a difference.” Sometimes it makes a huge difference to go after the tumor in the most aggressive way while at the same time doing everything possible to protect the surrounding brain. And we have done that. We have done that research. We have published that. And it’s one of the most quoted papers in the literature—certainly neurosurgical literature.
Tacey Ann Rosolowski, PhD:
We talked, I think in our first session, about the tissue studies that showed the margins—yes.
Raymond Sawaya, MD:
Yes, so I’ve done that and I’ve published it, so we are sharing that information with the rest of the world. And it has gotten a lot of attention. That’s why it’s being quoted and cited so often. Now, along with that comes the need to develop technology. That was your other question. They are really tied hand in hand, because this tumor is growing in the brain and the brain has zones of function and has cables that connect these zones of function. So it’s not enough to preserve the centers, if you cut the cable that is in between the centers, then you’ve caused the same damage. So we continuously during surgery are employing tools that would allow us to recognize where those zones of functions are and where those cables are. The intraoperative MRI is one of them, the mapping of the brain, the stimulation of specific centers to the patient, the patient during surgery being awake. We are able to identify areas that we will have to work hard to preserve. So the preoperative functional MRI is adding information, tractography, where we image the tracks inside the brain. All these are enhancements that have occurred over the last mostly decade. Although there were some precursors to these developments that we started here in the early ‘90s. So again, the emphasis being on doing better surgery, complete surgery with doing an MRI either during surgery or right after surgery to really document what we did. For a long time, neurosurgeons would say, “I got the whole tumor out.” Then they would close, they wouldn’t even do a scan. But if you do a scan, the majority of these patients have tumor left behind. But the surgeon couldn’t tell, because you don’t have x-ray vision. So very early on, we decided that’s not the approach we’re going to take. We’re going to image every patient before surgery and after surgery. And we’re going to document volumetrically—in other words, you measure the volume of the tumor before and how much residual after. Then you express the percent of removal, which is a very precise number. It’s not terms like subtotal, gross total, whatever—what does that mean? What’s partial resection? What’s subtotal resection? Different people might interpret that differently. But when you say ninety-eight percent volumetric resection of this tumor, that’s ninety-eight percent.
Tacey Ann Rosolowski, PhD:
You’ve got something to hang on to. Absolutely.
Raymond Sawaya, MD:
So we did that. That’s why that paper that we published got so much attention and interest. CLIP A: The Clinician C: Professional Practice C: The Professional at Work A: Character, Values, Beliefs, Talents B: Institutional Mission and Values C: Leadership D: On Leadership C: Patients C: Offering Care, Compassion, Help Building Trust and Educating Patients: “The Best Form of Leadership”
Tacey Ann Rosolowski, PhD:
To what extent is a patient involved in making any kinds of decisions about their own treatment?
Raymond Sawaya, MD:
Very much. They are part of it. But keep in mind, they don’t know. And so information is key and spending a lot of time with patients to tell them about the different perspective, the risks of the surgery versus the risks of not doing surgery. And it’s amazing—by the time they come to MD Anderson, they obviously know that they have a difficult problem, and they know that this is a trustworthy place. Then on top of that, if you spend the time to share with them your understanding, your knowledge, what can go wrong and why—they know they can trust you. So it’s interesting that we used the word trust before to describe leadership, and now we’re talking about it again. Well, guess what? That’s leadership. Being a physician trying to guide a patient to the best options, that’s the best form of leadership that I know of. Because you are helping this individual navigate through very, very complex issues. I spent my entire career studying this problem, and here they are hit by a brain tumor. They never knew they existed. So it’s a brand new issue for them and for their families. And how can they comprehend that, something that I’ve been dealing with for thirty years? So transmitting this knowledge and this experience, and distilling it in a way that they can navigate that problem is a major form of leadership.
Tacey Ann Rosolowski, PhD:
I like that connection. That’s a really nice connection.
Raymond Sawaya, MD:
It is.
Recommended Citation
Sawaya, Raymond MD and Rosolowski, Tacey A. PhD, "Chapter 15: The Neurosurgeon: Making Decisions about Course of Treatment" (2013). Interview Chapters. 1551.
https://openworks.mdanderson.org/mchv_interviewchapters/1551
Conditions Governing Access
Open
