Presidential Address to the 2024 Annual Meeting of the Congress of Neurological Surgeons

It is a singular privilege to be with you today. I am grateful to Bob for his generous introduction and cataloging the steps and people who made this moment possible. It is one we all share together and will not come again. It represents a combination of many choices and sacrifices, joys and frustrations, sweat and luck. We must embrace the power of our shared purpose and experience. It is no accident, but a convergence of intent and sustained commitment. We gather at the Congress of Neurological Surgeons (CNS) Annual Meeting to reflect, consolidate, and look ahead in our own personal and professional journeys. For each of us, there was a moment of commitment to neurosurgery. Each one of you knows that point in your story. Consider the threshold feelings and aspirations of that time. Meditate on how it is been affirmed or fallen away from your daily life. Many describe our profession as a calling. I hope our time together nourishes the inspiration of that moment for each of you. What is the scale of our shared opportunity? The people in this room are in a stronger position to characterize and reverse disease than at any time in the history of our specialty. Imagine the power of that possibility over our lifetimes. Now imagine what is required. You will find the practical wisdom of stoic philosophy in Teddy Roosevelt's arena or Garcia's jungle or Edison's concept of failure. We all know that athletes do not answer to sportscasters in the crucible of human performance. As neurosurgeons, we must celebrate action and one another. We must, however, reconcile our efforts with the historic pace of change and unprecedented uncertainty. I hope three perspectives will help us meet our generational moment. First, we will explore neurosurgical exceptionalism and our shared professional commitment. Second, we will contemplate an astronaut model of neurosurgical practice. Third, we will celebrate the power of gratitude and lessons learned from those sharing in the journey. Their discussion frames our time together this morning: neurosurgical exceptionalism. No man ever steps in the same river twice, for it is not the same river, and he is not the same man. Heraclitus beautifully captured the dynamism and impermanence of our world. Like many stoics, he believed the virtues of practical wisdom, temperance, justice, and courage represented the natural response to uncertainty. Stoicism amplifies these virtues by emphasizing the dichotomy of control. In the modern era, the river moves swiftly with challenge and possibility. There are events in our power and those beyond our grasp. Our specialty stands at an inflection point, a collision of technology, ethics, and economics. How will we meet our moment? A privilege of the CNS Presidency is bearing witness to the diverse tapestry of talents, experiences, and perspectives in this room. With the convening power of the CNS, we can be clear eyed and deliberate in our actions to leave a better world for the patients and surgeons that will follow, but how to begin? For my part, I remember being a young surgeon at the river's edge. As a capstone to my residency training, I was given the opportunity to address the Society of Neurological Surgeons on how my training experience informed a view of neurosurgical education. At the time, my surgical teachers felt like impossibly distant mentors, larger than life, and confident in the face of uncertainty. Though clear eyed about risks, early neurosurgeons pushed technical limits with a responsible, steely humanism. It was an era defined by the gap between the natural history of a disease and the performance of a technically sound operation. It was the stoic dichotomy of control. Consequently, the profession took on the gruff character of a stoic priesthood. Surgeons were necessarily removed and aloof to the magnitude of uncertainty faced in the operating room. There was an imperative to reflect, codify, and move on. Doubt would be the enemy of action operating with such tools and under such constraints. One thing that never varied was the fluid economy of surgical movement and decisive action in all manner of hazardous scenarios. In a time fraught with variables beyond the surgeon's control, their performance could not be one of them. This artisanship, sustained attention to detail, and commitment to craft became my animating purpose. It led to the slow accumulation of data, and hard-won complication profiles offered to patients with practiced hands. It was my feeling at the time that we spent too little effort focused on that journey. On how to close the gap between the data tables published in our journals and the ebbs and flows of daily practice. As a chief resident, I shared the principles of peer mentorship and esprit de corps that shaped my own residency. Fishing alone could not match what we could do together. I hoped this approach would resonate with the senior surgical educators in that room, and I could better understand the path to their lived commitment. Since that time, I have spent an equal measure entrusted to lead a neurosurgical department. For the medical students, residents, and fellows here today, I promise you the doctor you become is in your control. Indeed, the history shows our collective progress relies on the proud urgency of that commitment. Our opportunity comes when enhanced capabilities empower a shift in perspective. Consider the progressive visualization of Orion Nebula in the modern era and observe the conceptual shift from mythology to the composition analysis of the James Webb Space Telescope (Figure 1). The object of attention remains essentially unchanged over the time horizon of observation. We are the ones who are different.FIGURE 1.: Images of the Orion Nebula from 1882 to 2024. All images featured are within the public domain.In the coming days, each of you will return to your respective practices and another patient will offer their most sacred trust. They will place their life, function, and very being in your hands. Over the past two decades, I have seen the miraculous become commonplace. Our ambition as surgeons has grown from no focal deficits with minimal surgical footprint to the full restoration of neurological, cognitive, and affective function. The modern era restores our patients to full, participatory lives by deconstructing the surgical event into highly reliable, segmented tasks. We engineer processes of care to minimize variance and close the gap between efficiency and efficacy. In this environment, neurosurgical exceptionalism means unapologetically celebrating that triumph. We must relish our history and how often we can now say, “I can fix your problem.” We must remain connected to our wonder and artisanship. Deconstructing the Orion nebula into component parts does not diminish its beauty. Indeed, scientific examination can bring a greater appreciation of the wonder of the achievement. Richard Feynman captured this dynamic beautifully in his “Ode to a Flower.” His artist friend believed he could see the beauty of a flower, but scientists take it apart and render it a dull thing. Though perhaps not as aesthetically refined, Feynman protested he could appreciate the beauty of the flower. At the same time, a scientific approach offered beauty across several dimensions, ranging from cellular organization to elegant molecular processes. Feynman contemplated the fact the flower's colors evolved to attract pollinating insects and the interesting implication the insects appreciated the color. This prompts the question, why is a flower beautiful? Ultimately, science only adds to the excitement and mystery and awe of a flower. It may now feel to some like we live in a world where surgery is no longer viewed with the same mysticism and that physicians are providers buffeted by larger economic and cultural forces. This friction is not our story. We understand the components of our success, the coupling of technical excellence with clinical results, and the opportunity to realize the ambition of those who founded our specialty. Like Feynman's flower, understanding the surgical techniques that made these beautiful images possible should only add to their wonder. This is neurosurgical exceptionalism, a guild-like community bound by shared commitment and professional esteem. All of you who imagine the possible and act on behalf of those suffering from neurological disease. This esteem comes from knowing exactly what each of you gave of yourselves to be in the position you are to help your patients. You leave your families on a moment's notice to meet the patient in their moment of need. You inspire trust in their loved ones managing the fear of an uncertain outcome. You rejoin your family fulfilled that in another home somewhere you have given a fellow human being that same opportunity. That, my friends, is EXCEPTIONAL. Celebrating that commitment is a central objective of our time together at the CNS. We can reconcile this celebration of one another with the humility that comes with a profession of service and the many areas of neurological disease where are progress remains slow. We can be clear eyed on the path of mountains we have left to climb. Space, the ocean depths, and the human mind remain the last extensive frontiers of scientific discovery and understanding. What a privilege to work at the boundary of human progress. The neurosurgeon is no longer the lone towering figure standing against disease but rather supported by an entire team of specialists to enhance their capability at the point of action. We are in Houston for a reason. It is the application of advances from other areas to historically neurosurgical problems that powers our success and increasingly places new diseases within a surgeon's reach. Jeremy Swan's observation of sailboats inspired the Swan Ganz catheter and an early endovascular renaissance. It is a credit to the surgeons in this room that our field has attracted such interest and partners. How will you show up to lead that team? Ultimately, these entrants do not represent threats to our primacy in the field but opportunities to broaden our collective impact. Let us lead this conversation as we always have in ethics, economics, and execution. We will not cede our experience as stewards of access to the living human nervous system. We are the only ones positioned to balance the needs of many, demands of science, and the trust of fellow human beings who place their lives in our care. In the last CNS Presidential Address from this stage, Ash Sharan concluded his address with my favorite quote from Wilder Penfield, “The brain is the organ of destiny. It holds within its humming mechanism secrets that will determine the future of the human race.” I believe we are poised to realize Penfield's promise. In preparing for this moment, I reviewed the addresses and noted the remarkable frequency with which my predecessors successfully described the future of our specialty. Although it may be the CNS has benefitted from prescient leadership, I believe there is a simpler explanation. The people in this room made the future with gratitude for those who have shared the journey. Margaret Mead underscores the point. “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” If you have the ambition to change the world, you must learn from those who blazed a trail for others to follow. For my part, I am deeply grateful for the inspiration and shared purpose offered by my professional relationships. As neurosurgery brought these individuals into my life, I knew each person could be a teacher to me. The lessons were often personal. One formative lesson preceded my commitment to neurosurgery in an era like our current disruptive moment. During my undergraduate education, Stanford was at the heart of the Silicon Valley boom that powered the commercialization of the internet. It was a seismic shift in human connectivity and information. Before med school, a quarter century ago, I discovered the emerging field of health services research. Alan Garber, now Harvard's President, urged and sponsored my masters training. This decision laid the foundation for my academic career. It exposed me to the power of logic and discipline in the face of uncertainty. Ron Howard, a foundational thinker in decision analysis, captured the paradoxical book ends of uncertainty beautifully. “You know more than you realize and less than you think you do.” His examinations were graded on a log 4 scale and involved 20 multiple choice questions of almanac trivia. “How many gallons are in Lake Michigan?” with four responses orders of magnitude apart. Instead of selecting a single answer, the student assigned each response a probability that it was the correct choice. All probabilities should sum to 1. The exercise was to use what you did know to assign the greatest weight possible to the correct answer. With a log 4 scale, the never event was assigning a zero probability to an answer. If it proved to be correct, the score of negative infinity for that question would ensure you failed that examination and the course. Why? By assigning a zero, the student had said something was impossible and it had happened. This is the worst type of failure of thinking or imagination. It is never truer than that in the operating room, scientific laboratory, or an M and M conference. It is the unconsidered outcome or variable that often proves fatal. As a relentless optimist, I framed Ron Howard's lessons differently. I am grateful he taught me anything is possible. This truism is the hope and engine of human progress. I was deeply fortunate to discover my passion for neurosurgery at the Johns Hopkins School of Medicine. I learned the power of platforms in my research at that time. Using the 9L gliosarcoma model in Henry Brem's laboratory, we empirically trialed the polymer-based delivery of various adjuvant medications to Carmustine. Quinacrine, an antimalarial medication, was my payload. Under Dr Rick North's tutelage, I was able to participate in the pioneering days of spinal neuromodulation. Leveraging Palm Pilot/Treo platforms to bring patients and the concept of battery life optimization into what had been an empiric, labor intensive process. Most importantly, honored guest Henry Brem taught me by the power of his example. He spoke authentically and personally about the balance of our neurosurgical calling and our larger lives. I remain deeply grateful for his support and wisdom that allowed me to pursue neurosurgery and stay close to my family. It was a master class in perspective and priorities. Focus without experience can create blind spots. Relationships only deepen with time. I remember well the extraordinary people I met during the neurosurgery residency interview process. It is been a privilege to witness the spectacular trajectories of their careers and socialization into our shared profession. Friends made during residency are the connective tissue of our specialty and first opportunity to be part of something larger than yourself. As a resident, I benefitted greatly from the mentorship of giants in our field. Gordon McComb demonstrated the quiet assurance that deep experience could offer a worried family and expedited the cranial vault remodeling of my infant cousin as a professional courtesy. Marty Weiss his with His a sound of and a commitment to remain of the nervous as our surgical of by examination the and perspective of a generational than us to and to the Dr is the friend and who in on your worst days or when may not your In he what it means to be there for a and were the you would imagine in that time. 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