Nothing is impossibleBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7561.s46 (Published 29 July 2006) Cite this as: BMJ 2006;333:s46
- Keyoumars Ashkan, senior lecturer and consultant neurosurgeon
Keyoumars Ashkan retraces his route from Iranian teenager to consultant neurosurgeon
Box 1: A typical week
Tuesday—Clinical and multidisciplinary team meetings; ward round; administration
Wednesday—Research; teaching; audit
Thursday—Theatre; subspecialty (functional) multidisciplinary outpatient clinic
Friday—General neurosurgery outpatient clinic; ward round
For most people, including medical students and doctors in training, a career in neurosurgery is a dream or a joke rather than a serious consideration. This view of neurosurgery is doubly detrimental because it not only discourages young doctors from exploring a potentially fulfilling career but it also undermines the specialty by losing the new talents needed for its advancement in terms of patient care and research. I hope to shatter some of the myths, legends, and stereotypes around neurosurgery and re-present it as a real and achievable career.
An alternative neurosurgeon's tale
I arrived in London from Iran aged 16 in the winter of 1984. The most immediate issue was my limited language, but what I lacked in English, I had in determination and ambition. I chose not to spend time in language schools and, instead, immersed myself in English dictionaries, grammar, and phrase books. One month later, I was lucky enough to be accepted by the local comprehensive school where with the help of my teachers, I succeeded in securing O levels in five months. I spent the next two years studying for A levels in a London further education college. What struck me most during this time was that although the standard of teaching was high and there were many promising students at the college, there was always an aura of pessimism when it came to career advice. It was as if the students of a further education college were not supposed to contemplate a career in medicine. This only helped to strengthen my resolve. I subsequently left college with four top grade A levels and three S levels to study medicine in Cardiff.
Like most medical students, I thoroughly enjoyed university. I worked particularly hard in the preclinical years, which I am sure provided me with the discipline and foundation for later development. From early on, I had a particular affinity for neurosciences. I was fascinated by the way the brain, this mushy mesh of cells, controlled nearly every aspect of the human body, had the ability to construct or accommodate “the mind” and yet still maintained vast areas of seemingly spare (although probably just so far unknown) capacity. I further developed my interest by doing a neuroscience project for my intercalated BSc. Luck was again on my side when I was allocated to neurology for my first clinical attachment. My keenness combined with the tolerance and enthusiasm of the professor of neurology resulted in a series of successful research projects, which further fuelled my interest in the subject. Although I had good opportunity to learn about the medical management of neurological disease, the curriculum offered little exposure to its surgical treatment. This encouraged me to spend my elective in neurosurgery, which I took in Toronto, Canada. I found the experience challenging and stimulating, an endeavour that no doubt had a direct influence on my later career.
A year later I finished medical school with multiple distinctions, 20 prizes, and two publications, but as yet undecided between medical or surgical neurology. I decided to try a bit of both. I managed to get on the medical senior house officer (SHO) rotation for Hammersmith-Brompton-National Hospital for Neurology and Neurosurgery. This was a great experience and helped get me the MRCP (Membership of the Royal College of Physicians). I followed my neurology SHO post with a standalone neurosurgery SHO job. After much contemplation I decided that my future was in neurosurgery. So I guess you could say I am among that rare breed of neurosurgeons who are primarily neuroscientists but who have a major interest in surgery, rather than principally a surgeon who happens to prefer operating on the brain instead of any other parts of the body. To this end, I went on to a series of other SHO posts in surgical specialties to secure the FRCS (Fellowship of the Royal College of Surgeons).
I bridged the gap between being an SHO and a specialist registrar (SpR) in neurosurgery via a locum registrar post. I completed my SpR training on the South Thames London rotation but included subspecialty training and research in functional neurosurgery in Grenoble, France. I found the training and the specialty every bit as rewarding as demanding, as stimulating as exhausting and as invigorating as disheartening. After successful completion of the intercollegiate FRCS exam, I was appointed as a senior lecturer and consultant neurosurgeon at the Institute of Neurology and National Hospital for Neurology and Neurosurgery in 2004, exactly 20 years after my arrival in the United Kingdom (box 1).
What qualities are expected from a neurosurgeon?
We must not forget that neurosurgeons are doctors, so they must always place patients first and be caring, compassionate, considerate, honest, and respectful. In today's society, effective communication skills are as important as excellent technical ability and spatial coordination; and teamwork is as essential as decisiveness and assertiveness. Stamina remains a must; not just during training but also after becoming a consultant. You need it to cope with all those phone calls after midnight whether you are on call or not.
Box 2: Keys for successful entry into basic neurosciences training
Undergraduate achievements, prizes, intercalated degree
Competency and skill records from foundation years
Audit and research
Publications and presentations
Attendance at relevant courses
Structured interview and references
What are the pros and cons of the job?
The job has many attractions. Most of our patients suffer from acute and life threatening diseases, which in many cases, contrary to the general presumption, can be significantly and positively improved by neurosurgical intervention. Only recently I had a letter from a patient informing me of her return back to work less than a year after surgery for a coma-producing subarachnoid haemorrhage. The case mix of our patients is particularly interesting and the cliché that neurosurgery has a wider repertoire of operations than any other surgical specialty is probably not far from the truth. Although like all branches of medicine, subspecialisation is becoming increasingly necessary, most of us maintain an active general neurosurgical practice. It is therefore not unusual for me to see new and follow-up patients with a whole range of conditions, such as lumbar and cervical spine disease, hydrocephalus, brain tumours, and peripheral nerve disorders all in one clinic. For the technically minded, neurosurgery is the Mecca because of its intricate, often microsurgical, nature and the exponentially increasing operative tools, from spinal instruments to neuronavigational and stereotactic equipment and deep brain electrodes, which I regularly use when doing functional neurosurgery. In research, neuroscience is one of the fastest growing areas in medicine and despite our busy clinical commitments, neurosurgery provides great opportunities for active participation and clinical translation.
But every rose has its thorns: there are also downsides to this specialty. By its nature, when things go wrong in neurosurgery, they really do go wrong, and often have catastrophic consequences. It is important for a neurosurgeon to be able to cope with these issues emotionally and learn from every adversity. Resource shortages and limitations hit small and expensive disciplines such as neurosurgery particularly hard and it is very disheartening to have to cancel an operation because of lack of beds, theatre equipment, or intensive care facilities. It remains our duty as doctors to struggle with these shortcomings for the sake of our patients.
In recent years, the commonest route of entry into the specialty has been through basic surgical training (box 2), usually incorporating at least six months of neurosurgery at SHO level. After the MRCS exam, to improve competitiveness for the very limited number of SpR posts, most trainees either take up locum appointments (for training or service) or spend time in research, ideally leading to a higher degree such as an MD or a PhD. Once appointed, SpRs undergo training for at least six years although most take further time for subspecialty training or research. On successful completion of this programme and the intercollegiate exam, the certificate of completion of specialty training is awarded, enabling the candidate to apply for a consultant post.
Modernising Medical Careers (www.mmc.nhs.uk) is about to change this. Although the exact details still need to be worked out, the current plan is that after completion of a two year post-medical school foundation programme, neurosurgery candidates will enter a seven year training scheme. The first two years of this will be in broad basic neurosciences training. After this and further assessment and selection procedures, successful candidates will enter into a specific neurosurgical training stage leading to the award of a certificate of completion of training (CCT). Further post-CCT specialisation will almost certainly be required for more senior positions.
The preconception of neurosurgeons as technical and intellectual supreme beings of public school background with little concern for the consequences of their actions or their colleague-patient interactions is a fallacy. Neurosurgery is a fulfilling and exciting career for the committed and the passionate in whose hands, ultimately, the future of this specialty lies. ■