12 July 2010

Two residency biographies

Frank Vertosick. When The Air Hits Your Brain: Parables of Neurosurgery. Fawcett, 1988.

Katrina Firlik. Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside. Random House, 2006.

Drs. Vertosick and Firlik wrote remarkably different books about the same subject: their neurosurgery residency. Both trained in the same system: the University of Pittsburgh Medical Center, separated by 14 years. Vertosick finished in 1988, whereas Firlik finished in 2002.

Vertosick's book is a series of case anecdotes from his training, interspersed with some reflections on the profession. Firlik's book includes a handful of case anecdotes, but the bulk of the text is expository rather than narrative. Item: Firlik discusses the dangers of misdiagnosing dementia as Alzheimer's or old age when it could be a tumor or normal-pressure hydrocephalus. Vertosick describes a case of "rolling out" a "big, juicy" meningioma in a patient most everyone but her surgeons thought was hopelessly demented. She made a full recovery. Item: Firlik describes the sophisticated skull-drills that stop running as soon as the bone is drilled through. Vertosick relates the first neurosurgical case he observed, where the junior resident cheerfully explained that the clutch that stops the drill before it hits brain tissue -- then screamed curses and hustled Vertosick out of the room as the drill unexpectedly pierced straight through the skull and into the patient's brain.

For would-be patients, Firlik's book is undoubtedly the better of the two. The worst of the fratboy joshing that Firlik mentions is a pinup poster. In Vertosick's book, the high-water mark comes when Fred, the chief resident, "steals" a case from Gary, a senior resident: he performs the entire operation himself, then leaves Gary the ignominious task of closing the wound. Gary contents himself by carving "Fred Sucks" on the inside of the patient's skull---where he expected no-one would ever see it. Unfortunately for all parties, the patient developed an infection and the bone flap had to be removed, leaving Fred red-faced and screaming as he saw the "skull-o-gram." It's not the book one would give grandpa before spine surgery.

I preferred Vertosick's "case anecdotes with minimal filler" approach. Vertosick never discusses his childhood. Firlik confesses to being a bit of a neat freak. As a child, her belongings were meticulously organized; she even fantasized about being a cleaning lady. She describes a first-date with her over Indian food, her desire for an outdoor lifestyle, her pity for those with desk jobs. Vertosick never mentions what he does outside the hospital. Firlik relates her interests in Japanese language, food, culture, packaging, and architecture.

Item: Dr. Firlik shares a pizza with her husband in a tony Italian restaurant, then being paged and rushing off to see a patient with a stroke and skyrocketing intercranial pressure. Her husband, also a neurosurgeon (but one who left the practice to be a venture capitalist) calmly boxes up the food as she rushes to the hospital. Vertosick shares a pizza with Gary the senior resident in a cheap dive by the medical center (the latter takes half the pizza, folds it on itself, and begins chewing), then is interrupted by a car crash and spinal trauma.

Significant others do not enter into Vertosick's memoir except in passing. Firlik met her husband in college and had been married to him for over ten years. Perhaps Firlik's story is the more unusual of the two: a friend told me that one of his neurosurgery-residency interviewers advised him to pick his residency carefully, "since it will last longer than your first marriage."

While Vertosick may have omitted the details of his life, he describes the psychological hardening effect of surgical training. The lengthiest introspective segment in Vertosick's memoir is one such instance: operating to clip an aneurysm, he slips, punctures the vessel, leaving the patient a vegetable. He calls Gary, now long-since departed for to another hospital, who chain-smokes and tells him that if he's going to feel sorry for himself, he should hang up his mask, sit by a phone, and hand off patients to other brain surgeons. Firlik doesn't relate such a mistake (perhaps she, via luck or skill, avoided them), but does describe the emotional anguish of telling a young patient he had terminal cancer.

Firlik's book would be most appropriate for reassuring patients about the basics of neurosurgery or reassuring prospective physicians about the possibility of being a brain surgeon yet still having a life. Vertosick's book would likely disabuse prospective physicians of any such notion and would probably move all but the most desperate patients to stick with medical therapy. (As Gary tells Vertosick, "If the patient isn't dead, you can always make him worse.") For the interested non-patient/non-physician, the Vertosick's book comes with my highest recommendation.

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