Every spine surgeon eventually confronts the same moment: a decision that cannot be deferred, delegated or softened by consensus.
Operate or don’t. Decompress or fuse. Act now or wait, knowing the consequences of waiting may be irreversible.
Mark McLaughlin, MD, has spent decades making those calls. As a neurosurgeon and founder and partner of Princeton (N.J.) Brain and Spine, he has learned that what most often disrupts sound judgment in those moments is not lack of skill or knowledge. It is fear.
Over the course of a career, Dr. McLaughlin estimates, a spine surgeon may make 30,000 or more life-and-death decisions, whether a patient will walk again, whether damage is reversible or whether intervention comes too late.
In those moments, pressure is inevitable. What matters, he said, is how surgeons respond to it.
“The first thing I do is identify what’s happening,” Dr. McLaughlin said. “Fear, in some way, shape or form, is interfering with my thinking.”
Fear, he explained, is not always dramatic or obvious. It often masquerades as discomfort, anxiety or unease, all of which quietly erode focus.
“Fear is the anticipation of a future event where you’re afraid of how you’re going to feel,” he said. “And that’s incredibly corrosive.”
Reframing fear in the operating room
Early in his career, Dr. McLaughlin followed a strict rule: never operate on friends or family. The concern was not technical ability, but judgment.
“If something goes wrong, it affects your judgment and ability to perform,” he said.
Over time, that rule began to feel inadequate. Friends his age were developing degenerative spine disease and, in some cases, receiving advice he believed was misguided, being told they needed fusions when they did not, or decompressions when they did.
He reconsidered.
“I started saying, ‘If you’re comfortable with it, I want to be your surgeon,’” he said. “Because I know I can do what you need as well as anybody else in the world.”
The shift required confronting fear directly, not eliminating it, but dismantling it.
When fear recedes, he said, something else takes its place.
“Some people call it confidence,” he said. “But what really shows up is love.”
That perspective was tested one Friday afternoon as he prepared for a complex operation that had been delayed for hours. He was exhausted. The case was unusual. And moments before heading to the operating room, he received a call informing him that his father had been diagnosed with an aggressive leukemia.
“I thought, ‘I can’t do this surgery,’” he said. “I’m not in the frame of mind.”
When he went to speak with the patient, he saw the patient’s wife and daughters waiting.
“They were looking at me like, ‘We need you,’” he said.
In that moment, something shifted. He decided to dedicate the operation to his father.
“When I reminded myself of who I was and why I do this, my fear diminished,” he said. “I loved my father more. I loved my patient more. And that’s what made that case go flawlessly.”
Vocabulary shapes performance
Dr. McLaughlin believes leadership under pressure often comes down to language, both internal and external.
“I’m a huge believer in vocabulary,” he said.
Words like worried, he noted, are fear-based. Replacing them with prudent changes how the brain approaches risk.
He often challenges trainees to distinguish between fear and prudence when approaching risk, urging them to focus on methodical identification rather than anxiety.
The distinction matters.
He applies the same principle to his team in the operating room, which he likens to an orchestra. Each person, scrub nurse, anesthesiologist, circulator, brings their own stressors into the room.
“It’s my job to get everybody to feel like themselves,” he said.
When tension surfaces, he addresses it directly, not punitively.
“That’s not you,” he’ll tell a frustrated team member. “And that’s not helping us.”
Infrastructure protects judgment
Beyond the operating room, Dr. McLaughlin said sound decision-making requires deliberate infrastructure, systems designed to absorb administrative noise before it reaches the surgeon.
“You have to create an infrastructure that protects you from the nuisances of medicine,” he said.
When problems arise, he approaches them with curiosity rather than frustration.
“Every problem you’re struggling with is something someone else has already struggled with,” he said. “There’s someone smarter who’s figured this out.”
Why compartmentalization doesn’t work
Contrary to common advice, Dr. McLaughlin does not believe surgeons should compartmentalize their lives.
“I take my home to work and I take my work home,” he said. “I don’t think there’s any way around it.”
Sharing difficult days with family, he said, allows stress to dissipate rather than accumulate.
“I’m much happier doing it that way,” he said.
That philosophy underpins what he calls unburnoutability — a belief that, with the right mindset and systems, surgeons can remain engaged and fulfilled throughout their careers.
“I really believe that if you follow these steps, you’ll love medicine till the last day,” Dr. McLaughlin said. “I have no intention of retiring. I love doing it.”
Staying sharp over decades
Sustaining performance, he said, also requires humility.
Dr. McLaughlin focuses on a defined set of procedures he knows he does exceptionally well. When cases fall outside that scope, he refers them to partners with complementary expertise.
“You have to know what you’re great at,” he said.
At the same time, he surrounds himself with younger surgeons who challenge his assumptions and bring new energy and ideas.
For spine surgeons navigating an increasingly complex landscape, Dr. McLaughlin’s message is clear: pressure will never disappear. But fear does not have to dictate performance.
When surgeons replace fear with presence, language with intention and isolation with infrastructure, clarity follows, even in the moments when it matters most.
