The toughest decisions spine surgeons have to make


From dealing with serious postoperative complications to choosing the right practice partners and learning when to say no, five spine surgeons detail the most difficult decisions they've had to make in their careers.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

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Editor's note: The following responses were lightly edited for style and clarity.

Question: What's the most difficult decision you've had to make in your career as a spine surgeon?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The most difficult decision I have ever made was to not cover multiple hospitals. One of my mentors bragged to me he used to cover 17 different hospitals. At one point, I was covering three to four hospitals. It is simply not sustainable. Committing to one or two locations or hospitals is hard. It is hard financially and there is the panic of not spreading out enough. But if you are working hard, following through and doing your best, in this day and age, it does not necessarily mean you have to be everything to everyone and everywhere for everyone as well. 

John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): I'm a young surgeon, so for me it was all about choosing the right group. I wanted to have support and infrastructure in place, but I didn't want to go to a practice that already had so many things figured out that my personal practice would be rigid. I wanted to have room to grow but enough structure to make that growth predictable. That's obviously quite specific, but expending a large amount of time and energy to find the right fit for me and my family ultimately resulted in what, so far, has been a very pleasant experience.

Peter Newton, MD. Rady Children's Hospital (San Diego): I think the hardest decisions are those we make after one of our patients has experienced a serious complication. We are faced with a flood of emotion: anger, frustration, guilt, shame, etc. The course correction necessary to manage a serious complication requires acknowledgement, empathy, experience and often a peer's fresh eyes on the situation. Asking for help should not be a difficult decision. 

I had a patient with cerebral palsy who became coagulopathic after a revision anterior-posterior spinal fusion. Her retroperitoneal drain output was difficult to keep up with by transfusion. Her bleeding was so substantial that, when the drain was clamped, it began impairing our intensivist's ability to ventilate her. The option of returning to the operating room to stop her sources of bleeding — presumed to be the endplates of her extremely osteoporotic bone — seemed like a long shot. Deciding to take this girl to the OR with the real possibility that she would exsanguinate and die was one of the most difficult decisions I have made as a surgeon. 

With my general/trauma surgeon colleague at my side, he helped me through that difficult but ultimately obvious decision. Deciding to go back to the OR was the right call, and her story fortunately ended well. I will never forget the parents kissing their daughter goodbye as we wheeled back into the operating room, not knowing if it would be the last. The decision making after a loss of spinal cord neurologic function is equally important and just as difficult. This is also a time-sensitive, complex problem that needs clear decision-making. Checklists can help, but if the deficits remain, don't forget to call a colleague. Get help with the next steps; discussing it will make your difficult decisions after a serious complication easier. 

Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Early in my career, I wanted to have a high-volume practice with well-established referral streams and networks. I never said no to any case, and would take on any patient who needed my care. Over time, the opportunity costs of saying yes to everything became quite high. Learning to say no seemed counterintuitive in the moment, but in hindsight, understanding the value of setting limits allowed me to establish a high standard of care, prevent burnout and focus on a better work-life balance.

Hamid Mir, MD. DISC Sports & Spine Center (Newport Beach, Calif.): When I see a patient and make recommendations ranging from nonoperative to operative treatment, the most difficult decision on a daily basis is trying to understand the patient and putting myself in the patient's shoes and — through that lens — decide the most suitable treatment option. 

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