Interview With A Neurosurgeon
Francis K. Conley Does the Things We Can’t Imagine, and Gives Us Some Details On The Business of Cutting People’s Heads Open — circa: 1997
In the 1990s, the GOP began gutting the National Endowment for the Arts. I began a project to produce an exceptionally strange magazine called Cyanosis. This medical term that means ‘turning blue’ is used to describe the hue of the tissues of the body when the oxygen in the bloodstream has been used up.
I felt that the assault in the arts was the beginning of a far more vast and insidious agenda, and my fears were not only well-founded, they were prophetic. The Arts are and remain a crucial asset in the social bloodstream, and by attacking the NEA, I saw the GOP going for a strangulation move, that would begin there, but extend everywhere… especially into public television, education, the environment itself, health care and social infrastructure in general.
Art and education are the analogs of social oxygen for our minds and intelligences… and when you begin attacking them, well, I think the cyanotic state of our modern situation speaks to the prophetic sense of my now historical concerns.
In terms of the magazine, I wanted to create a visually striking vehicle that would present extremely provocative art, images, literature and interviews. One of the ideas I had was to interview a Neurosurgeon, because I felt that someone who was surgically involved with the brain directly has a peculiarly bizarre mode of ‘editorial’ power. My companion at the time, Amy Lodato, turned out to have a connection not only to a Neurosurgeon, but to a woman who had become something of a legend in both her field and the feminist movement. Her uncle had a connection to Dr. Conley, and we were lucky enough to get an enormous amount of her extremely valuable time.
We arranged an interview. It was the fifth interview I had ever conducted, and I was both ignorant and absolutely fascinated. When we completed the first pass, I explained that, in order to understand her work, I wanted to see her in action, and take photographs. At first she was extremely reticent. Eventually, she allowed us to witness a surgery directly in the theater, but without photographs. Amy and I attended a 5-hour surgery in which she took the top of a man’s head right off, and worked inside his brain tissue for what seemed an eternity. After an initial moment of shock, and near-fainting… fascination took over.
For the rest of the procedure I stood right next to her and asked questions. She showed me the backs of his eyes, and explained everything she was doing. It was a tumor removal, and it was slightly larger than a golf ball. What I learned that was staggering, sobering, and in many ways, terrifying.
The anaesthesiologist was goofing around and showing off to a couple of interns, and was actually smacking into the table while Dr. Conley worked inside a man’s neural tissue. A lot.
The scene in the operating room was unimaginable. Simultaneously advanced and cro-magnon at the same time. I learned a lot more than I was prepared for, and rediscovering this unedited version all these years after the direct experiences and publishing of the (highly) edited version reawakens the entire scenario for me.
This version has never been published. It contains notes and questions that the final version omitted. I will be editing it over the coming days, but right now I am so excited to have discovered it that I wanted to share it immediately. There’s an astonishing amount of radical information, history, and intelligence here.
Enjoy. And just remember: one day you may be ‘on the table’, and a couple of people who are journalists might be looking at the inside of your skull while a master surgeon removes something malign…
FC: Francis K. Conley
AL: Amy Lodato
DS: Darin Stevenson
•°°•
FC: Amy will do the writing and you’ll do the editing— is that generally the division of labor?
DS: No, no.
AL: Not necessarily.
FC: Do you work for this, or are you a free-lancer?
AL: No, I’ve never done anything for (Cyanosis), but one of my ideas is that part of this might be utilizable for someone like Ms., maybe, if we get to that segment.
FC But you are a freelancer, right? I mean you are a freelancer and you just dragged him along because it’s convenient? (laughter)
AL: No, he publishes this and he’s a freelancer too...
DS: Yeah, we were sitting down and talking one morning, and one of the goals I had when I started this was to get not just artists and writers, but people who are involved in scientific endeavors involved in it, because there’s a lot of art journals and there’s a lot of scientific journals, and
FC: and there’s very few that bridge the gap. I think you’re very smart. Certainly we always talk about the art of medicine as opposed to the science of medicine and indeed that really is true. Because most of us exist or most of the things we do truly are in a very gray area. There are very little that are totally black and white. It’s very difficult to get attorneys to understand that. They want things to be one or another, to make it very neat and clean for them. But I’m not sure (what we do is?) an art, not a science. (I hadn’t thought of it quite that way before?) (015A)
DS: Well that’s interesting that you mention attorneys, because a lot of uh, I think, medical practice in this country is somewhat dictated by the legal environment.
FC: That’s— oh, very much.
DS: And since the legal environment is so black and white—
FC: it makes things very difficult for us
DS: for everybody.
FC: yes, and that’s why the costs of your medical care are astronomical.
DS: Yeah, one of the things I’m going to publish in the next issue is a, um— I realize this is— I may have like, crazy questions.
FC: (protesting)... no, that’s the way we start companies, you know, where ideas come from.
AL: Do you do that too?
FC: I’ve been involved in a start-up company.
AL Of what? What does it do?
FC: It’s a pharmaceuticals company. (unclear024A)
DS: Um, one of the things we’re going to publish is a medical bill. Which is not related to this interview, so...
AL: an itemized—
FC: oh, I love it, I love it, where the Maalox costs $5.00 and
DS: right (laughter)— a friend of mine had an appendectomy and it cost $18,000.
FC: an appendectomy?
DS: there were no complications...
FC: the bill was correct?
DS: well, it was like a ten-page bill
FC: right
DS: with like thousands of items on there but we’re going to publish the whole thing
FC: I love it
DS: Because I don’t think— well, for instance, I’ve never availed myself of medical care whatsoever under any conditions,—
FC: well, you’re young and you haven’t needed it yet. Just wait till you’re my venerable age—
DS: well, actually I’ve needed it on many occasions. I had an abscessed tooth for ten years which I was unable to get treated... (FC laughs) I wasn’t living at home, when I was a young man I lived on the street so medical attention really wasn’t—
FC: was not a high-priority item.
DS: Right, or even a possibility, and I um think a lot of people are probably in the (place?) where they just don’t go for medical attention until they’re nearly dead.
FC: Well, I think that’s right and once we get them into the hospital they’re so much sicker than they would have been had they come at the time they needed the care—
DS: right
FC: In some ways, you know, the VA is very nice in that regard in that they get health care free of charge. I don’t have to worry about the costs that I incur (with any patient? 038A) I don’t have to worry about it. I worry subliminally, because I really do feel constrained to keep total health care costs down, but in terms of the individual patient I don’t have to— and that’s really, it gives you a sense of freedom. That I don’t have (in private practice?041A).
AL: Is this the first time you’ve had that situation? (Or have you been here all along?)
FC: Well, I’ve been here since 1975 so I’m very used to having the two different roles, but the two different roles are becoming much more divergent. It used to be that health care insurance or Medical or whatever would pick up the majority of problems but now we’re seeing so many patients, particularly in your age group who don’t carry medical coverage, and then they get in a motorcycle accident...(044-046 undecipherable— sense is: “and who’s going to pick up the bill?”).
DS: Um... When did you first start having interest in becoming a medical scientist and surgeon?
FC: Ah, I think when I was a teenager, and I really can’t tell you why. I really have no idea. My parents are both professionals, my father is a professor here at Stanford, but in geochemistry, and my mother was, was trained in psychology and then has a secondary degree in education, so she’s a secondary-school teacher. And I was very fascinated during my teenage years about what makes people tick. So I thought I was going to go into medicine to become a psychiatrist. That’s what I planned to do. And then I found when I got to medical school that psychiatry was not the end all of all end alls— I mean you really can’t help the majority of the patients you see. And at that point I enjoyed the mechanical aspects of surgery, as a medical student, not knowing that I was going to. And I made a decision when I finished medical school (to make surgery my priority? 054A).
DS: And how old were you when you made that decision?
FC: Oh, let’s see, I finished my— that’s ancient history, isn’t it?— I finished in 1966, so I was 26 (?) years old.
DS: And how much experience did you have in surgery at that time, and what exactly was the nature of that experience?
FC: Yeah, when you finish your clinical, pre-clinical years, which are two years or three years depending on how many years your medical school training is, you’re all in classrooms and you’re doing lectures and you’re doing laboratories, period, then all of a sudden you become a clinical clerk, which means you’re on the wards, and you have to take core rotation, so you have to spend an eight-week time in medicine, eight weeks in surgery, eight weeks in obstetrics/gynecology, four weeks in psychiatry and pediatrics to (complete?) the core, so you then get your schedule and you have the chance to say, “well, I want to this, this and this sequence, and I chose to take surgery first when I finished my pre-clinical years, because I knew I was not going to be a surgeon, and therefore I wanted to get it out of the way.
And I had, just a fabulous time. I mean it was just— something just clicked. Yes it uses an intellect that I enjoyed— I enjoyed the thinking and the problem solving that surgery gives you, but it also combines that with a mechanical ability— you have to use your hands, and it’s very productive— and so, you know, I really got smitten by the first rotation I was on. I think that should be tempered with the fact that I found all of medicine terribly fascinating, and I probably could of been happy being any one of a number of different types of practitioners. It really didn’t matter, it was just one of those things where things just happen to fall in.
AL: At what point did you actually do brain surgery as opposed to general surgery?
FC: I can tell you when I made my decision in 1966 to go into surgery, that was not a popular choice. (laughter) And I was pretty well convinced that the only field in surgery that would be open to me would be plastic surgery. That women, you know with their delicate hands and their delicate sensibilities in terms of particularly cosmetic types of surgery (072A)— that it was probably the only thing open.
I had a plastic surgery residency totally lined up. And as an intern, when you then choose to go into surgery, you spend your first year on multiple surgical disciplines. With a heavy emphasis on general surgery. But during that year I had the chance to spend a month on plastic surgery, a month on orthopedic a month on neural surgery, a month on neurology, a month on cardiovascular surgery, so I had experience in a lot of different specialties, and I adored neurosurgery. Found it just absolutely unbelievable, and I really liked neurology as a medical student. And the combination of the two were, for me again a kind of magic situation. But then I took my month on plastic surgery, thinking that this was going to be my career, and I found I was absolutely bored out of my mind. Just really bored. The surgery itself is great fun. I mean plastic surgery is just a wonderful discipline, in terms of the mechanical aspects of it. But there’s no diagnostic. There’s no intellect— intellectualization of it.
(DS: Problem solving?)
Yes— the nose is too big, the boobs are too small— there’s no, there’s no thinking involved, in terms of what, what can I as a practitioner do, because I am so much smarter than you are. And maybe what I’m saying is I needed a specialty where I got tremendous amount of ego gratification in terms of my talents. And plastic surgery did not seem to offer that to me.
DS: Why did you feel that plastic surgery was the only option open to you? I mean, I heard what you said before about you know, being a woman—
FC: I mean women were not supposed to do surgery.
DS: What does “supposed to” mean though?
FC:— Stereotypically. Women aren’t supposed to be surgeons. You don’t think of your neurosurgeon being female, do you? You think of your neurosurgeon being (Ben Casey? 087) don’t you?
AL: Actually, I think of them as female now, because of you.
FC: But I can tell you that is not the stereotypical perception of a neurosurgeon. It’s really very interesting as you go along in life— up until this last year, if I would meet somebody, say at a reception we have frequently at the academic center, and they say, “oh, what do you do? What department are you in?” I will answer very matter-of-factly, “I’m a neurosurgeon.” And you can see the person’s brain, all of a sudden the gears starting to roll, you know, they’re not going to call me a liar, but they’re going to tell me, their facial expression says: “I’m sorry, but you don’t make it. I’m sorry, but you don’t match the image I had in my mind of what a neurosurgeon looks like. So, I find it hard to accept you.” And I think that does rule, a lot.
DS: Oh sure. No, no I would certainly agree, but I guess what I’m curious about is— you made it sound as though you did not feel it was open to you. What exactly did that mean to you?
FC: It meant that I was very willing to accept something where I thought I had a chance of getting into it and making a career out of it without having to continually bat my head against a brick wall.
DS: Aah.
FC: Which was, to be a plastic surgeon.
DS: I see.
FC: I mean, when I was an intern, they didn’t have on-call quarters for me. Hospital was moved down here in 1959— in 1959 there was no, ah, expectation that any women would train in surgery at the university. The on-call quarters for women had not been built for surgeons.
DS: And now what is the situation?
FC: Oh, we have a lot of women in surgery.
AL: And in neurosurgery too?
FC: Ah, fewer, but there are many more women now than there were, absolutely.
DS: What percentage of the neurosurgeons that are functional in the country are women do you think?
FC: 1.5 to 2 percent. The same as your (...?104A)
AL: And, when you left Stanford and started to make moves, with all this conversation about sexism in the system, what did you find out was still going on— I mean, how many medical students come in as women and where do they decide what they’re doing— how does that get thinned out to the point where only 1.5 of them—
FC: It starts very early in their careers— AL: what’s the process? How is that happening?
FC: Yeah, yeah, let’s go back to college, I mean we can go back to grade school if you want to —
AL: I know…
FC: There’s a wonderful study by Wellesley College showing that women— girls in school— are treated very differently from boys in school, in terms of being called on, answers being accepted by teachers, etc. And there’s fascinating work being done now with videos in classrooms showing who gets called. And one teacher, he came in and gave a talk, he said: “I’m a teacher. I teach fourth -graders. I have a sociologist in my class, I knew I was being watched, and I was absolutely horrified to find that I’d called on boys 35 times and I’d called on girls 9.” Even knowing that this was the thing that was being watched!
DS: Yeah which probably means—
FC: It probably means it would have been 30 to 1— I mean it’s incredible! He was just destroyed— (he said) “I have two daughters!”
DS: The other thing—
FC: I mean, let me finish your question; it has been well shown at the college level, women come in as freshmen, particularly at your very prestige colleges where they are the creme de la creme, they are the top, you know, one half of one percent in terms of intellect, coming in wanting to do— astronauts, or electrical engineering, you know, whatever, just really high hopes for career aspirations— by the time they pick a career, I mean major, at the start of their junior years, they are— very different from what they expected to be when they came in as freshmen. Very different.
And it’s because when they talk to their advisors, their advisors tell them, Well, dearie, wouldn’t it be more acceptable, and wouldn’t your lifestyle be easier IF you are... a teacher. You are a secretary. You are a— whatever, rather than be something that’s really way out. And women have bought into that myth time and time again. That you cannot have a demanding career, pursue it aggressively, and have a rich, happy family life. You buy into that myth every single (? 123A) And because of that myth, women— I mean those that get to medical school probably have at least said to their advisors, look I’m going to be human biology major, I’m going to medical school, but by the time they get to medical school they are told that pediatrics will be open to them. You know, intro general practice, family practice. Are the fields that are open because, dearie, darling, you can control your life in these fields. These are where you can set your hours somewhat more. Surgery— oh my, my, my— you might be up a few nights a week. You can’t have a family and be up a few nights a week, can you? They are told very very early in their careers.
DS: And who does the telling?
FC: Usually it’s advisors. AL: Professors.
FC: Yes, advisors, professors, in a general way.
DS: And when they tell them that something is quote not open to them, what they’re saying is, are they saying you’ll have problems in this field because of the hours and the expectations and duh duh duh, or are they saying “there’s not enough jobs for you in this field.”?
FC: It may be a little of both.
DS: Ok.
FC: I think probably most men genuinely feel that they are giving the correct advice. Most male physicians have a wife at home who does not work. We are the— you know when you go to that Republican convention the other night and I hoped you two watched it, I sat there and said, “they just negated my entire existence.” By the comments and the speeches they made. They really have negated me. But in truth, that is a fantasy land that does exist for probably one or two percent of our country today. And it’s fine!
And these men with their wives at home, taking care of the kids, keeping the house nice, playing golf, you know, doing their tennis or whatever, it’s wonderful, you know, we’d love to have it— I’d love to be able to go to Kennebunkport every weekend, go to Camp David, have my food fixed for me— it’d be wonderful! Reality is such that that is not true for the majority of people, it truly is not. And yet, as I said, in medicine, you know, they’re very high earners and many of them don’t— they have very traditional wives. And they cannot understand how someone could have children, keep a house, cook all the food and do the job they are doing. And they’re right, they can’t. They have to have the help of a mate who buys into their career.
DS: If I understand you, you can correct me, but what you’re saying is one of the ways these problems could be addressed is through the educational advisory, that women should be actively encouraged to pursue whatever kind of profession—
FC: Yeah, women who are at your top echelons of schools— I’m not saying that every woman should strive to be a neurosurgeon,
DS: Right
FC: I mean that’s just not it’s unrealistic and certainly not everyone is going to be suited for it. But the message at some time in the educational concept has to be given to our girls that they can do that which they are capable of doing. They do not need to accept a channeling of their drives or their ambitions or their talents. And that message is not being delivered in many public school situations. I spent two years at Bryn Mawr, my first two years at college, and that the first time I heard it. Here I am, I’m the daughter of a college professor with two PhDs before he was 30, brightest man I’ve ever known, and their expectation for me was that I’d get married and have children. I would get a college education, no question about that, but that thing which you see on my computer is part of my hope chest. If you can believe it, my mother made sure that all three of my two sisters and I knew how to embroider, knit, crochet and sew. I sewed every single stitch of clothing I wore through college. Ok? That was the expectation she had for us, and it was a very traditional expectation, yes I would going to be educated but I was expected to get married and have a family. The message that I had from my family was that somebody was going to be there to take care of me. And yes, I found somebody— he’s wonderful, he’s delightful, but in addition I needed something above and beyond that. And fortunately I found someone who bought into it.
DS: Yeah. How did you escape or transcend the pitfalls that awaited you in school? As far as trying to keep you out of the profession you were most interested in? I mean at what point did you say to yourself: this is what I want, I can have that, and this is how I’m going to go about it.?
FC: I think luck had a hell of a lot to do with it. When you look back on things. I mean I didn’t apply— and right now a medical student coming out of medical school who wants to be a neurosurgeon will apply to probably 50 programs. They will interview at 20. I mean it’s a tremendously expensive proposition you have to go through. I went up to the director at Stanford— I caught him at a bad moment— and I said, ”I want a position in your program.” I mean that was just luck. Now you have to go through a matching process— none of that was operational at that time.
DS: Now at what point in your education did this occur?
FC: I— right when I finished my plastic surgery, I said— I can’t do this. I can’t do this. This is my chosen field and I’m going to be bored. And of course the person who was most distressed by it was my husband.
AL: You were married then.
FC: Yeah
DS: same person?
FC: same person. We’ve been married for almost 20 years now. He thought at that time, I remember his comment very clearly because it just really hit me hard, he said, “What are you doing? Choosing the most difficult thing you can possibly think of?” I mean I told him I’d asked for a position in neurosurgery. He said, you know, what are you doing, making your life as difficult as you possibly can? So again, his perception was that I was trying to go off the deep end. And maybe that’s just me, I don’t know. (unclear167A)
AL: What do you think what you did last year has done, do you have any idea?
FC: You mean ramifications for the society?
AL: Or even just for Stanford.
FC: I think it’s too early to tell whether anything is going to be permanent. The one thing that has happened is there’s much greater dialogue, and how long that will last I don’t know, but at the minute they’re talking to each other, which they did not do before...
AL: A lot of people have taken note, I just went to a music festival in AK and (Darin) called, I guess, while I was there, so I told a few people, oh it’s so exciting, I’m going to meet this woman, and everyone had heard of you. In Fairbanks Alaska.
FC: I think in the medical community, yeah—
AL: These are all musicians...
FC: Yes, that’s even worse. My husband’s comment a couple of weeks ago was, “every medical school in this country knows the name Conley.” And in that milieu, yes, I think that is true. That people are saying, wait a minute, let’s look at our situation. (Unclear175-6) You’re not going to break the traditional stereotypes that easily. You really aren’t. And medicine is as ingrained as any, because it’s very very carefully constructed structure over the many many many years. And I think it will be the last to fall, and interestingly, academics will be the area of medicine to change least and last. Because that’s where everybody— you know all your private practitioners look up to the mecca— the place where things are happening, where new things are being tried and so forth, and mecca is where they want to preserve the status quo.
AL: Can I ask a slightly off— combine this with something else: have you done anything about gender difference as it relates to neurology? or is this something that happened only with social norms? Have you every studied anything about— are there brain differences between the genders?
FC: I am not— you really have to go to social psychology.
AL: So that’s where it is. It’s all about socialization, not about the brain.
FC: It’s very difficult and it’s all how you measure it and of course when you measure something when did that— you know, what caused that? Was it because the minute a baby is born there’s gender discrimination the minute the doctor says— it’s a girl. I don’t know, and I don’t think anyone knows. I think anatomical differences in the brain have been shown to be very very small. And so it’s mostly social psychology. And maybe— I mean if you tell a girl “you can’t do math, you can’t do math, you can’t do math,” she may try it, but she’s going to find she can’t do it. I mean the power of negative reinforcement is phenomenal! I mean I heard an advertisement on the radio this morning— I forget what it was for, mastercards or something like that— but they were going through, the examples they used that the woman was (coming to work for? 189) that she was using her skills in language and when it was a mathematics type of a problem— oh, can’t do that, can’t do that. Again, just totally stereotypical thinking of what women do best and what they don’t do well.
DS: Um, let’s see. What was your first experience actually working on a human body surgically, and do you remember it, and what did you feel about it?
FC: Yeah, I think the first case that I really remember very clearly was a case I did as an intern, you remember the cases that are given to you— you understand what I mean, I mean when you’re helping, you know, surgical teaching is a gradual process; you watch, then you get a chance to assist, and then comes that magic day when the surgeon says, “all right, give the scalpel to Dr. Conley. And the one that I remember that I think was the first case that was ever given to me, it was a lady, it was a general surgery case, she— it would not be general surgery today, it would probably be handled by plastic surgery or orthopedics— she had had a bad cut in her arm a few years before and the scar had separated so she had this huge cut in her arm all the way down to the bone. She wanted the thing fixed in terms of having the muscles be pulled together again, which meant incising the scar down to the bone and pulling the skin together and making sure that the closure was in layers so that it would stay closed. And that was the first case that I had. I mean, it’s not a terribly difficult case, but it was fun, it was exciting.
DS: And how did you feel about cutting into someone’s body?
FC: It was fine— you don’t worry, by that time, it just doesn’t... (someone) asked, are you aware of the patient as a person during the time you’re operating and you aren’t, you really aren’t. They are a person until the drapes get put on. Once the drapes are on, only a small area, the surgical area is exposed it becomes very mechanical, it becomes a thing that needs to be corrected. And the personality of the patient involved truly totally disappears. And then as soon as the drapes come off again, you see the patient again all of sudden yes you remember what the wife looks like, what the husband looks like, that they have kids. It disappears through the time you’re working.
DS: And what is the process like of training to be a neurosurgeon, I mean outside of book study and the academic aspect of it, what is the process of actually training to perform surgery...
FC: It’s a tutorial, it’s a tutorial just like if you were a carpenter. If you were an apprentice carpenter. Or if you were an apprentice plumber. You wouldn’t know how to take care of sinks and pipes and things unless you follow a plumber around. You can learn so much from books, you know the U thing that you unscrew here and usually that’s where the fat’s going to be, and the— because the stupid woman has poured her fat down the sink and hasn’t used enough hot water to run it through— but beyond that it’s part of the mystique of plumbing, of carpentry is in the people who do it all the time. The same thing for us. We are a tutorial and again I work with residents— every resident is different. They all have different capabilities; they learn at different rates; some are better at surgery than others. How they use their— clumsiness of hands— no question there’s a difference between human beings. And so what you do is very gradually give them more and more difficult cases. Again, I mean my first priority is to the patient. Each patient outcome has to be good. If a resident has trouble with a case, if a resident has (? 213), then I might take over. But I want the resident to do as much as they can, you know. You’re not going to learn to play the violin by watching me play.
DS: So for you then it was a process of watching surgery—
FC: and then trying it. I mean if you’re in an operating room with me and a resident is working with me, I will talk the resident through the case, I mean I am having to do the case through somebody else’s hands. And, that in and of itself is a true art and not every surgeon is going to be good at that. I think the art of teaching a craft to somebody else is a difficult one, and a lot of people bail out of that in medicine, in surgery— they’re not comfortable with knowing they have to control somebody else’s hands.
DS: Oh yeah, well that’s a two-sided art, the art of teaching and the art of surgery are two very different things.
FC: But they’re intertwined, and have to be. They truly have to be. I have to be able to talk somebody through a case, and know that those hands will do those things as I direct them to do it. I also have to know that I have to have exquisite discipline between me and the resident, so that if I tell him to stop, he will instantaneously stop, because (unclear 220). So there’s that aspect of it also. The control is phenomenal.
AL: Do you remember what was one of the worst things that ever happened in surgery?
FC: Yes, well, isn’t it nice that human beings— god made us remember the positives and forget the negatives, truly, when you think back on your life—
DS: Really. That’s an interesting viewpoint! Not one I’ve encountered very often. I remember mostly the negatives.
FC: I think we learn from the negatives. But to dredge them up and recall them, I think is much more difficult. At least it is for me. I tend to remember the positives. I mean when you go on vacation, not every aspect of the vacation is pleasurable, right? You might have an argument or something— you don’t remember that. You remember the fun of the vacation right?
DS: (laughter) I’ll take your word for it.
FC: I think the worst thing that ever happened to me was in my first year as a teacher, and a professor, and a resident... took a drill... and went right down into the patient’s spinal cord.
DS: From where?
FC: From the anterior approach. He was trying to remove a disk that was pressing on a nerve in the patients neck. And he took a drill and went BZZZZZ! and it was just a sickening feeling. And he took the drill out and I saw... spinal cord tissue, and cerebral spinal fluid, and I just thought oh... The person was paralyzed.
DS: Did that person continue to practice in medical?
FC: Yes, he’s a neurosurgeon, if you want to know where he practices so you can drive carefully... (laughs).
DS: Huh, how do think that affected him?
FC: Ah, well, certainly in that kind of case, he does that kind of case extraordinarily carefully. Probably takes him 15 minutes longer to do that kind of case than it does anyone else. But he didn’t stop medicine.
DS: I think that’s one of the things I’m interested in finding out about, is that certainly whether or not you have a surgeon present with you as you’re working, one would have a certain intimidation factor about the delicacy, or the possible delicacy of the structures you’re dealing with as a surgeon.
FC: What do you mean by the intimidation factor? Who’s being intimidated?
DS: The surgeon. Whoever’s using the tools.
FC: Ok, whatever. But they’re intimidated by whom?
DS: By no person. By the delicacy of their work. And how did you feel about that fear in your early practice? Did you feel intimidated?
FC: Oh, intimidation’s not the right word. I think you love it, you have that awe for the normal body and the functioning thereof, and I think you can develop a true reverence for knowing that you have the capability of truly helping somebody. I mean neurosurgery probably more than any other specialty has that capability. I wouldn’t say intimidation but reverence and awe. And you know the tragedy is when you haven’t planned things carefully, and you screw up because you didn’t do the proper thinking beforehand. And that’s really what I like about neurosurgery, is that as I talked about plastic surgery before, you know you go in and you fix a nose. Big deal. In neurosurgery you have to really be sure you know where you are. There’s no such thing as exploratory surgery in neurosurgery— opening the belly, and opening everything wide open and taking a look-see. You don’t do that in neurosurgery. You have to know exactly where you’re going.
AL: And is it pretty exact? Do people really have a good map of the brain at this point?
FC: Sure, they know. And I mean scanning is phenomenal. But you have to know landmarks, you have to know what’s underneath them, you have to know what function that part of the brain is serving, what the spinal cord is serving— all of that. If you haven’t thought things through carefully in terms of how to maximize your ability to function as a surgeon during that particular case, you may run into trouble. I mean I’m doing a deposition this afternoon on a case that was handled at an academic institution in the area, and they got into trouble with swelling in the brain. Just incredible, awful, idiopathic swelling. And the question is did they think carefully enough about how to manage this case? did they really do all the steps they should have done in order to keep that from happening? But you know it’s that sort of thing— I enjoy it, I love it. The cases that I hate in neurosurgery are the one’s that I get called on at three in the morning. Because then there’s no thinking.
DS: Right. It’s an emergency.
FC: You’ve got someone’s brain coming out of their head because a car’s hit them. They’re (something—249). They’re not intellectually satisfying. Whereas I like to have something there, and if I plan it perfectly and then I give them that plan, the patient (recovers?)
DS: Well, those are two different arts too, dealing with you-have-to-move-it-now and there’s just no choice, and trying to make— they’re two totally different decision-making processes.
FC: Yes, that’s right. And I think there are basic personalities who like the blood and guts of emergency type of work, the thing that I think that personality likes is that they don’t have to accept the responsibility for wrong decision-making nearly as much as you do when you have a plan.
DS: Have you ever been really surprised in surgery? By something that happened or something you encountered other than (? 253)?
FC: Yeah, if so, it doesn’t register. I sometimes am surprised by outcomes. Sometimes patients just do so much better than you expect them to do. But again, it’s the positive rather than the negative— we don’t really think about the negative aspects, but some patients just do so spectacularly, and they’re not really expected to do as well as they do. And again you develop a reverence for the fact that god and nature as a great deal— a part to play in all that we do.
DS: What is the majority of your surgical practice? What kinds of operations does it deal with? Can you give examples so that people who don’t understand neurosurgery would have some idea of what you do?
FC: Sure. In general neurosurgery involves the brain and spinal cord and the peripheral nerves. And that really covers the entire field. And what that entails is operations on the brain to remove such things as tumors, or infections that are localized, such as an abscess to the brain. That’s the type of problem. Troubles with the blood vessels: breaking in the brain, blood clots in the brain, blood clots on the brain.
AL: You do invasive surgery for blood clots?
FC: Yes. they need to be drained usually. It depends where it is, but yes, that would be a big area that we deal with. Tumors involving the pituitary gland, problems with drainage. The brain makes fluid all the time— cerebral spinal fluid, and if the chambers if the drainage isn’t correct we need to correct or bypass that kind of thing.
DS: When you do that— I’m sorry, when you say bypass do you mean, put your own plumbing in?
FC: Yes, right, you put your own plumbing, that’s correct. And then of course all the trauma that happens to the brain: skull fractures, depression fractures, you know, that sort of crap. Then again in terms of spine work, there’s tumors in the spine, there’s infections to the spine, there’s compromised spinal cord function or peripheral nerve function— the vast majority of work to the spine is for (?266) to the spine— (?) upper disks to the bone, or for the neck and lower back— that’s a huge area of work for neurosurgeons.
The peripheral nerve work usually are entrapment type of problems, where you have for example the nerve that runs here, goes to this part of your hand, if it gets entrapped at the elbow ... carpel tunnel syndrome is an entrapment syndrome to the wrist— you open that to work on that particular nerve. The area that we do a lot of work at here is carotid surgery, it’s vascular surgery type of procedure, but the big arteries in your neck are the ones that feed blood to your brain. And when they get into trouble with arteriosclerosis (?), i.e. the clutch closes down, it’s the brain as the end organ that’s affected. And so these patients tend to come to a neurologist or a neurosurgeon because they’re having small strokes or something like that. So we here at Stanford neurosurgery are all trying to do some carotid artery work. At many institutions, the vascular surgeons do that. It’s a shared type of thing.
DS: And what is the majority?
FC: It depends on the neurosurgeon actually—
DS: for you.
FC: For me, I do spine work more than anything else. Here at the VA it’s blue-collar workers primarily, they use their backs and necks in the course of their work, and they have tremendous amount of degenerative spinal problems. (275)
AL: We looked at some abstracts of articles that were published about research you were doing with tumors in mice—
FC: Yes, my research is totally different than my clinical work. Up until a year ago I had a very large research facility— the thing that happens is that when you first start out as a neurosurgeon you do a lot of work in the laboratory, hands-on work yourself— it really is fun to do. But as you get busier and busier with patient activities, more and more of that goes off to technicians and (..?279). When the lab was in its heyday four years or so ago, we had probably 50 people working in the lab, doing a lot of different experiments. My whole thrust in research has been trying to use the body’s own immune mechanisms to halt the growth of cancer. And with mice and rats we can really do quite a good job.
DS: And is that your main interest research? Using the body’s own mechanisms..
FC: Immunotherepy in brain tumors is what I do.
DS: Could that be fairly relevant to AIDS research and the problems they encounter with AIDS?
FC: It can. AIDS patients do tend to develop a type of cancer in the brain called lymphoma, and the problem of course with AIDS patients is that they don’t have an immune system for me to work with. By the time they get their AIDS or have a problem with their brain, there is nothing I can do to hype their immune systems and get it working, so AIDS has not been a prominent part of the tumor type of work we did. The work I’ve done with AIDS patients has been again with the serendipitous type of thing that happens when you’re running a large research enterprise: we were using as one of the agents to hype the immune system against chronic infections with an organism called toxoplasma. I’m sure you’ve now heard of toxoplasma. I can tell you at the time we started working with it, nobody had heard of toxoplasma, because it wasn’t considered an important infection at all! But what it does well, probably with human, certainly with mice, is that it hypes the immune system wonderfully if you have an intact immune system when you give the infection to the animal. 288A
And, the toxoplasma organism goes to the brain. so that the brain’s immune system is also hyped—you can use toxo to stop tumor growth—mice with toxo don’t get tumors—you cannot induce tumors in a mouse with a toxoplasma infection, it’s very difficult to do, and so, if you can get something like this to the brain, the brain’s immune system works very nicely against tumors. And so what happened was, we were fiddling with staining the toxo organism because I needed to know where the organism was in relation to what I saw in my slides—you have to stain specially for toxo, because you cannot see the infective organism—and so we developed a stain for the organism. I published that right before the first cases of AIDS, that’s when it came out. Now the first reported cases of AIDS, if you’ll remember, came from Haiti into Miami, and I got a call about a week after this paper was published on how you can use this lovely stain to look at toxoplasma infection—I thought I would get at least three reprint requests because nobody was used to working with toxo—but what I got was a call from this pathologist in Miami who says ‘I’ve got seven cases of cerebral toxoplasmosis, would you confirm it for me with your stain…’ I said, ‘You don’t have seven cases of toxoplasmosis—there’s only about that number in the entire world literature…’ of cerebral toxoplasmosis at that time, and all of those were cardiac transplant patients, which, interestingly enough, are immunosuppressed because of their strange heart.
He said that he thought that’s what he had, and I told him I’d be glad to run the slides for him-but I was sure he didn’t. Unfortunately he did, and this was the first evidence we had that toxoplasma infection was going to be very devastating in immunosuppressed patients. And then, for two years after that my laboratory stopped doing tumor work and we did nothing but AIDS patients—I have seen more cases of central-nervous system toxoplasmosis than probably anybody that’s ever lived—that’s all my laboratory did—cases from all around the world.
AL: Did you get a lot of money suddenly for that kind of research?
FC: Well, nearly all of the research funding that I get is either from the National Institute of Health or the Veteran’s Administration, and it’s on competitive grants, and at that point, that’s where the funding came from—and I still have funding from the NIH to continue the AIDS/Toxo research.
DS: Do you feel helpless working with AIDS patients, in general?
FC: Well, yes and no. I’ve taken care of a lot of AIDS patients, and the thing that you have to realize, even if it sounds a little strange, is that there’s something called a ‘quality of life’. And if, as a practitioner you can enhance the quality of life, even for a short period of time for somebody…that has meaning to the practitioner…it really does. And I think it has meaning for the patient also—yes, they have a death sentence, but they aren’t the only ones in that situation—a patient who has a malignant brain tumor, without AIDS, is still in the very same situation—they’ll be dead within nine months to a year and a half, I mean Filante, for example, the assemblyman who’s running for Barbara Boxer’s seat has a (?gliobastoma,?) he’s not going to be alive in a year and a half, by all the odds…but his quality of life can be kept good until such time as it’s no longer possible, and it’s the same thing with AIDS patients.
DS: What sorts of things that you deal with in your patients are almost always fatal?
FC: Well, as a neurosurgeon, the things that we deal with that are that way are the malignant brain tumors…and there’s really nothing that I can do about it. The AIDS patients we see are primarily the one’s with toxo, where we have to biopsy the infection, and I’m not usually the primary care physician in those instances, so we don’t really see that many.
DS: Have you encountered patients with malignant brain tumors where the patient surprised you by surviving?
FC: Oh, yes…I have a gal I did…when I operated on her I was chief resident at Stanford and she was sixteen at the time, she has a highly malignant tumor. I remember coming out of the operating room and talking with her folks, and I said, you know, I’m sorry, I have very bad news for you, the pathologist has said that it’s a very malignant tumor, and probably her life span is very limited…
DS: Very limited meaning…
FC: A couple of years at the most. So the pathologist came back a couple of days later with the results from the permanent section, and they confirmed the diagnosis. She’s still alive today. That was in 1975. She has a calcified mass in her brain where the tumor was…and it’s just sitting there—doing nothing—and she’s fine! And so now her folks think that I’m god, you know, that I walk on water…
DS: And what exactly did you do in the operating room?
FS: We did nothing, I mean we biopsied the tumor and we radiated her. Period. We did the standard therapy on her…but the thing that keeps a cancer researcher going are cases like this…because something happened inside her body that stopped the growth of that tumor. I have no idea what it was…
DS: How do you feel about the standard western approach to cancer therapy?
FC: Well, you’re going to have to define what you mean by the words ‘western approach’, you’re talking about that verses holistic types of therapy?
DS: Well, I’m not really familiar with the realm of other treatment options, and I don’t know what they are, or what your familiarity and experience with them is, but there seems to be a lot of controversy surrounding the fact that the western approach seems to pretty much limited to surgical removal when possible, radiation and chemotherapy. And I’m wondering whether you feel that these techniques are truly positive, workable therapies for cancer…
FC: Well, my candid opinion is that 200 years from now people are going to look back and call us barbarians…the way that we look back on the use of leeches and bleeding to cure patients many years ago…you know, for many ailments you’d simply pull off a unit of blood as treatment. Radiation therapy is, in some (?ways totally unphysiologically?) sound…but you have to balance that with the fact that, right now, there is nothing better…
DS: That you know of…
FC: …that’s right…and we save patients now that would have been impossible to save before the advent of some of these therapies…I mean, a kid with leukemia can live forever, Bush lost a daughter to leukemia—today he probably wouldn’t loose that daughter, there’s a good chance that he wouldn’t lose that daughter. Ahh, lymphoma…Hodgkin’s Disease—was a death sentence when I was in medical school, and Hodgkin’s Disease patients, in general, do just fine. I mean, we have come a long way with certain cancers, because of radiation therapy—because of advanced chemotherapy. But, in terms of how we’re going to look at his 200 years from now, I think we’re going to have far better tools and techniques…
AL: And you think that these tools will come mostly from molecular biology rather than invasive techniques and further advances in radiation therapies?
FC: I do…that’s the reason behind my interest in working with the immune system. I mean it’s a marvelous system, absolutely marvelous…and if we could just be smart enough to be able to nudge it here and there…to direct it a bit and make it work extra hard for us…
DS: Don’t you think that AIDS is going to force us in that direction?
FC: Exactly. AIDS is an untreatable disease at this point, and since it’s viral, and the virus has a high rate of mutation…I mean, this situation gives you no break, because as the researchers work on a vaccine the virus continues to mutate…possibly staying way ahead of the research.
DS: Now I understand, I think, what you’ve just said about chemo and radiation therapy—I guess my question will be why you think things are going to change, I mean, is there not, to a large extent a serious monopoly of funding and research grants focused upon this one area…I guess that I’ve heard that there’s sort of this covert ‘old-boy network’ that wants to maintain the use of these therapies as the primary method of dealing with cancer.
FC: I don’t have any idea what the NIH is doing in this area, say in the last two or three years…
DS: …what’s your feeling?
FC: Well, my feeling is that that is not true…that there’s a tremendous amount of energy and research being done to define the neoplastic process…which is truly what we need to know—why does a cell become eternal?—truly, that’s what a cancer does—a cancer cell is marvelous—it has machinery that can keep it alive forever…there’s no other cell in your body or mine that can do that, and that’s why we die. A cancer cell lives forever! What a marvelous piece of machinery, right? We need to know why what happens with a cancer cell that allows it to divide forever—I can cut cells from you and put them in a tissue culture and keep them alive for ten, maybe fifteen generations—and then they poop out, (?a cancer cell will keep dividing luxuriously…??)
DS: But is it a ‘cancer cell’ or one of the body’s own cells that’s mutated in some way?
FC: I don’t know…has a cancer cell mutated? What’s happened to it?
DS: We don’t even know that?
FC: We really don’t know—there are certainly a lot of forces that act on a cell, some radiations can cause changes in a cell, make it become cancerous—I mean cancer is defined as a cell that can perpetuate itself, for all intents and purposes, without limit.
DS: But it is one of the body’s own cells to begin with, correct?
FC: Yes…
DS: Ah, that was my original question.
FC: But in terms of the research, the reason why we still have this hold onto chemo and radiation therapy is that the FDA sets its own rules and standards, by which any therapy to be tried on humans has to be measured…so that, for example, we did start a phase one study one the use of immunotherapy on brain tumor patients based on my work. The FDA, however, constrained us by stipulating that we could only use patients who had failed to respond to radiation therapy and/or chemotherapy, which leaves me dealing with a patient in end-stage disease who has a life span of maybe six weeks from the get-go.
AL: So this is where the bureaucracy enters in and extends drastically the time between research and end-use of a possible therapy…
FC: That’s right. As we talked about earlier with the problem of the legal profession being involved, if the FDA gave carte blanche to any researcher, to do anything, I can tell you that the legal profession would have an absolute heyday…there would be no ‘big-brother’ watching over you—but at least the FDA gives us, the researchers, some level of protection. On the other hand, my feeling is that radiation therapy quashes the effectiveness of chemotherapy—no question about it, so it’s a (?complicated problem?)
DS: But what I’m concerned about is the idea that some researcher, or group, could come up with a workable model of treatment, say something like inducing toxoplasmosis in individuals with healthy immune systems…your work for example…and the work would never get to the public. I mean your studies on mice seem on the surface to have some promise…
FC: But it’s also possible that what works on a mouse doesn’t work on a man…
I mean the FDA is saying ‘Congratulations Dr. Conley, you’ve cured brain tumors in mice—what a wonderful feat! But how do we have any idea whatsoever that your work will be applicable to humans?’
DS: But don’t you go to a simian model after a mouse?
FC: No. It’s very difficult to do that. I mean, they’re not available, the animal activists go bananas, and it’s extremely expensive. Generally speaking we’re going from rodents to man, directly.
DS: From rodents to man?
FC: Yes. Sometimes you’ll have an intervening rabbit or dog, but often not even that…
DS: So some of the work you did could have a profound effect on dealing with human brain tumors, but we’ll never really know that…
FC: Of course you will…
DS: When?
FC: Well, it will get picked up on and carried on by other people, I mean for an example, what has happened with the next step is that people are using a herpes simplex virus—which we’ve always known goes to the brain, that herpes goes to the brain and causes terrible disease, particularly in babies…so they’re using a modified version of this thing (?we call a disease?) to bring inflammatory cells into the brain—a wonderful idea! The same idea I had with my toxoplasma infection 20 years ago…the idea’s the same…
DS: But why did it take twenty years? And how long would it take to go from a rodent model to a human model with a potentially workable therapy?
FC: It’s totally dependent on the…
DS:…is it arbitrary?
AL: It’s political.
FC: Yes, it’s political, it’s a matter of the time and effort that the investigator puts into it, ah, it’s a matter of the research funding and who’s providing it—I mean, the variables are incredible…I can’t tell you…
DS: So, in a sense it’s somewhat similar to you running into a professor who was willing to give you a position in neurosurgery because you caught him on a bad day…
FC: Listen, in research, serendipity plays one hell of a large roll…it truly does—and that’s the fun of it, you don’t know what’s around that next corner…
DS: But isn’t that frustrating?
FC: Sure, but if you were doing research all the time that was the same thing over and over, and you always knew what was around the corner and never had any significant fights or branches…it would be boring…
DS: But that’s not what I’m talking about…
FC: But that’s what happens…we found a ‘Y’, a branch—that staining technique that we developed was for my information only, the fact that that has had tremendous applicability to hundreds of thousands of patients is wonderful! But it was totally serendipitous. I didn’t set out to develop that to be able to diagnose AIDS patients with toxoplasmosis…
AL: And this comes back to the idea of medicine as art…
FC: Exactly, that’s what it is, and that’s the fun of it. To have something turn up unexpectedly is wonderful, it puts you up on the ceiling.
DS: I guess it’s just frustrating to me, though I understand some of the necessity of it, that researchers have to labor under the kinds of FDA constraints that they do in order to get their projects to a place where they become applicable as positive treatments.
FC: Well, I think that you’re enough of a revolutionary that we could really utilize someone like you—what you need to do is go and eliminate the intermediary party, and that’s the legal profession. If we didn’t have to worry about being sued for that which we do on an experimental basis with patients, a lot of this stuff would go a hell of a lot faster.
AL: Do you think that this could be easily accomplished by getting patients who would simply volunteer…
FC: (?It’s a whole lot worse than that?) I mean, I could show you the consent form that we had to draw up in order to allow a patient to enter our immunotherapy project—22 pages long, and the patient reads it, and you read it with them, you make sure that they sign every page, that they have read it—and I can tell you that after all of that, if a patient were to question it in a court of law it would be worthless. Just as operative permit that you get a patient to sign is totally worthless in a court of law.
AL: Why is that?
FC: It’s because if what happens to a patient is unexpected and untoward, all bets are off. It truly doesn’t matter—it’s amazing, we have zero protection.
DS: Do you think that there’s any clandestine research going on?
FC: What do you mean by clandestine?
DS: Research conducted by say neurologists or cytologists that either have access to laboratory equipment or have built labs at home that are doing unsanctioned research, pursuing their own interests and goals?
FC: You’ve been reading too much science fiction, I can tell—there’s some wonderful books on that kind of thing, Blood Music, by Greg Bear, for instance…
DS: But do you think there’s any of that going on?
FC: I can tell you that when you turn up a ‘Y’, or a branch, on a research project that you will sometimes follow that, even though it’s not a part of your written protocol. I mean I submit grants, that explain what I’m going to do and how I’m going to do it, and in general, that’s the blueprint that I follow. But if you have something interesting come up, you usually will follow it, you will not usually take the time to go back and re-write the protocol. Where it gets hairy is if, for example, the branch that you’re following involves a different procedure on experimental animals—you are in violation of the law by not having that written (?into the protocol?) And I can tell you that this does happen, it just does, there’s no way around it…once you turn up that information, you’ve just got to follow it—and it would take you at least six months to get it through the bureaucratic mechanism in order to get back to work…
AL: Assuming that you could get it through at all…
FC: Exactly.
DS: But do you think that there are, for instance, researchers who say, have a laboratory at home, who are doing their own thing on their own time?
FC: Certainly, there are a number of laboratories that have started in people’s garages, with mice…you can buy experimental mice…
DS: And most of whatever other equipment you might need assuming you have the means?
FC: That’s right, yes. I think my basic concern about this sort of thing is the use of the animals, I just can’t stand to see animals mistreated. That to me is the most troublesome aspect of this idea…I mean, certainly people are doing what you’re talking about, but the thing that troubles me is that they might be inflicting terrible suffering on the animals.
AL: You feel that the animal care here is humane?
FC: Yes, all of the animal care here is very humane.
AL: Yet this doesn’t seem to calm the activists at all…
FC: Well, they don’t want animals used at all.
DS: Well it’s a difficult question, I was an animal rights activist when I was younger, and I’ve always loved animals and had a deep respect and admiration for them, and yet I’ve always been fascinated by science as well, and this presents a seemingly insoluble dichotomy…
FC: Yes, it really, truly does—and I think that each individual investigator has to choose…has to draw the line for him or herself. My own line is drawn at rats. I will not use an animal that’s bigger than a rat for experimental work. I cannot work on dogs and cats, I just can’t do it, I’m sorry, I happen to adore dogs and cats—and rabbits, well, I’ve kept a few rabbits to make antibodies for me, but they’re really not a very useful research animal. I don’t think that I could bring myself to work on monkeys at all, just couldn’t do it. Mice and rats I have no problem with—I mean, my cats drag in mice and rats, and they mutilate them far worse that I ever do, so it’s been an acceptable thing for me…and maybe that’s wrong, but on the other hand you pick up a steak in the store…I mean, do you know how that cow died? Probably a bullet in the head, poor, dumb thing, after a long cramped trip in a truck where it’s crushed or suffocating…I mean we accept that! If we stopped to think about the totality of how animals are treated here you’d never touch another piece of meat in your life!
DS: Forgive me for changing the subject so suddenly, but what is the most frustrating thing in your work as regards the state of equipment, knowledge and technology that you’re dealing with in your day to day work?
FC: The most frustrating thing is having a resident who won’t listen! (Laughing) The human factor, is far more frustrating.
DS & AL: (Also laughing) OK, what’s the second most frustrating thing…
FC: That would be, believe it or not, the paperwork. We are absolutely inundated with paperwork…letters that have to be written, insurance forms…it’s unbelievable.
AL: But don’t you have someone else who can do that for you?
FC: Most insurance companies won’t accept forms not filled out by the surgeon.
DS: So we trained a neurosurgeon to fill out insurance forms?
FC: It’s unbelievable. And the fact that hospitals are constantly being monitored by governmental agencies, like the JCAH, the Joint Commission on Hospital Accreditation, or whatever it is…you have to have your residency program accredited every three years, or you have to have your this or that done… and all of this stuff requires just reams and reams of paperwork—data, that sure, you can have somebody help you with, but someone, in control, has to put all of it together and check over it—that’s my job. And it is a pain in the ass. I did not learn how to be a neurosurgeon to sit here filling out paperwork—and that is terribly frustrating.
DS: I understand your frustration with that however…
FC: (Laughing) That wasn’t what you had in mind…
AL: Wrong Answer!(Laughing)
DS: Well, let me tell you why I asked the question…where I used to live, in Santa Rosa, there was this medical channel that I would often watch, and they would run footage of surgery, I imagine it’s the kind of thing that residents might watch for instructional purposes because the surgeon would explain everything as he did it. Anyway, one morning I turned it on an this surgeon was performing knee surgery on a woman. Now my experience of this was fairly shocking to me, because I had no idea of the way in which…well…meat and bone were treated in surgery, and it looked a lot more like auto mechanics meets carpentry than what I had expected…
FC & AL: (Laughing)
FC: Yes…
DS: I mean they were drilling out chunks of bone and cartilage with this huge drill, slamming shivs and braces into this person’s kneecap with a hammer…there was none of the delicacy I’d expected to see…
FC: Yes, well orthopedic surgery is a very crude from of surgery in many ways. The thing that’s helped orthopedic surgery in many ways is the development of the (?orthoscope?), which limits some of the exploratory surgery involved.
AL: And what has helped you the most in your work, the MRI*, or?
FC: Two things, yes, the ability to scan for diagnostics, and the stereotactic localization…
DS:…and what is that?
FC: If you want to localize a lesion in somebody’s brain, you can now do it. You can get a three dimensional ability to image a patient with regards to where things are in space rather than just a two dimensional scan…right now it’s done with a frame around the patient’s head, but the next step is frameless stereotaxy which we’re developing here at Stanford. (reset at 0) What’s done now is you put a frame around the patient that has bars up and down it, then you scan the patient— the bars, you know where they are in relation to the lesion on the patient’s brain, and you have things set up— it’s all been calculated before hand, and all you do is set things according to how the computer tells you to set them, and you can localize a lesion that big totally, exquisitely and exactly. It’s unbelievable. So that for us, yes, we have revolutionized my own field.
DS: And yet you use things like this
FC: That’s orthopedic type surgery—
DS: to hold a spine together—
FC: yes.
DS: I was looking through some neurosurgery books the other day at the library and I saw, you know, threaded bolts drilled into vertebrae it looked like about half an inch, and then snipped off and bolted in there and I was just going— How does the body react to metal?
FC: Oh, it’s totally inert. This is stainless steel. It doesn’t do anything.
DS: The body doesn’t really care about it. Because it doesn’t have a biological identity, is that why?
FC: And it’s not seen as foreign, it has no protein...
DS: So it’s not self or not self, it just gets ignored.
FC: Yes, that’s why it can be used.
DS: That seems so bizarre to me. But this gets used on elderly patients as well, no?
FC: Well, it depends on the patient, it’s used more on younger patients actually. Maybe in the orthopedic world— hip replacements, shoulder replacements, knee replacements, that sort of thing.
DS: Huh. Because I was curious to see that kind of work being done— the example I saw was an elderly patient, and elderly patients in my limited understanding have problems replacing bone marrow and things like that, yes?
FC: Certainly the bone loses calcium and get softer as we age. I think a bigger question, and it gets back to the art rather than science, is that— what are the economics of the situation? You know we do a lot of work that is very expensive, on people who don’t live very long after they receive the expensive treatment. And where do we draw the line? Go back to the very beginning of life. How about the world’s babies that are born after five months in uterum that are that big (indicating about three inches between her forefingers) that we know have the technology to keep alive? It’d be fine if every one of those babies grew up to have an IQ of 100 or more. But 50% of those babies grow up mentally retarded, will never be functional working citizens of the country. And to keep them alive costs well over one half of one million dollars. OK, now—
DS: But is a functional working citizen our only goal...
FC: Now, you’re a homeless person, with an abscessed tooth. And because a baby gets $500,000 worth of care so that it can be a mentally retarded person that our society then has to care for the rest of that patient’s life, and it can be a perfectly normal life span— is that worth your suffering from an abscessed tooth? You see the trade-offs are there. Ergo, on the other side of it, an 88 year old man rolled into my station about a month ago. He had subdural hematoma, which is a blood clot over the brain. Ronald Reagan had it, that’s what he went to the Mayo clinic for. It can be very easily taken care of, from my point of view, it’s a very easy surgery, doesn’t require much thinking, all that sort of stuff. And we had no question that that should be taken out and drained. Which we did. And he made a nice recovery for about four days, and then his heart pooped out. He died of a cardiac arrest.
DS: And what was the cost of that surgery?
FC: Oh, it was here at the VA so we didn’t cost it out, but undoubtedly the cost for my fees would have been $3,000, and then there’s the ICU, we have the imaging before and after that, the nursing care he had... we’re talking $15,000. At least. Is that right? Is that the way? Or should I have let him die?
DS: Another problem is, where does that money come from? Who paid for that operation? And who actually pays for operations that come out of insurance?
FC: Does it really matter when you know that the GNP, the Gross National Product of this country— now is 13 to 15% being spent on our health. That’s obscene! It’s obscene, I’m sorry. But it means that money is not available to do other things, such as provide you a home. It’s a matter of choice.
AL: Do you see a way to change, besides taking out the legal fees?
(DS: excise the attorney! )
FC: The decision-making process in this country is wrong. The problem we have in America today is that we have always been able to afford life. We truly have been. And so we have learned to value it. At any cost. That’s truly true, we come in— it’s me, it my life, it’s my health, do anything doctor. I don’t care about the cost, when it’s your life. We have to figure out some way of making decisions that are rational about who is going to be recipients of that health care dollar and who isn’t. As far as I’m concerned, a baby that is born “that big” (makes a four-inch size with hands), should be left under a fig leaf outside. I’m sorry, why every kid in this country shouldn’t come in with a full deck is beyond me. We still have more babies being born than we need in this country, even in this country, let alone in Somalia or wherever. Every human born should come in perfect, I think. So one place you could start is by bombing neo-natal units.
DS: The other problem is that choices are being made now, they just don’t appear to be.
FC: Of course they are. But they’re not rational.
AL: And they’re not extended to the best for all, they’re extended to who can afford it or who’s in the right (position)—
FC: That’s exactly right. And maybe in the future what we’ll have is genetic capability of getting a genetic profile from you, that tells you that your person is going to develop diabetes, or heart disease or emphysema (sp?), because of your genetic predisposition, and because of that, at the age of 60, pffft, we turn off health care for you. I mean sure it’s radical, but... The possibility exists.
AL: Is this something you would approve of?
FC: You want to ask me, where I am on this question— I think I’ll be long gone by the time... But I’m serious, you have to start thinking of this stuff. I mean, I think it was wrong to treat that guy’s subdural at the age of 92. I truly do. I’m sorry but I truly do. I think we prolonged his life in a very ungraceful manner, from a very vibrant, active guy who was living at home at the age of 92, which he should be congratulated for. Not having his chest pounded for 45 minutes to try to get it started again. I thought that was appalling.
DS: But at the same time, the idea of what you’re talking about with genetic mapping to allow prediction, it’s a wonderful idea, but not in this country.
FC: Not yet.
•°°•
Interview II : The Return Visit
AL: What happened with the patient that we watched you perform surgery upon?
FC: He did very well, he didn’t turn a hair.
AL/DS: Really?
FC: Yes…at least those were the immediate post-operative results—he had perfect function of both sides of his body, and just did fine.
AL: And did the operation relieve the symptoms that he was experiencing?
FC: Yes. Now, what will happen in the future is still up in the air. He missed his appointment to see us six weeks later, and we tried calling him, but the phone has been disconnected, and so it might be that we’re going to lose follow-up—in terms of the fact that he has a very funny family situation, it’s very unstable, and he may have gone to live with one of his other relatives. I’m sure he’ll surface again when he gets into trouble, but he did very well.
DS: And he has what’s called a multiform glioblastoma, correct?
FC: Yes. The most malignant type of glial tumor.
AL: And you left parts in that were still…
FC: You never can take all of these kind of tumors out…you just know that—especially third time around, which he was. And so what you try to do is to remove enough to relieve their symptomatology without leaving them neurologically devastated. I mean it’s not worth it to someone who has a limited amount of time left to spend most or all of that time hemiplegic, being able to move half of your body or something like that—it’s ridiculous.
AL: And your prognosis was a year and a half of life for this person, correct?
FC: Yes, but I’ll be surprised at this point if he gets that—it’s too long.
AL: And how do you feel about the operation itself?
FC: Well, in terms of am I glad I did it, I would say yes. I mean he will live a lot longer, and some of the problems he was experiencing, [such as fainting and loss of motor control] have been at least temporarily alleviated. And he’s gone a long time with this tumor—he was originally diagnosed in 1980, so he’s gone 13 years with it—much longer than we would have predicted.
AL: You didn’t do all three of his operations, did you?
FC: A man did the first one, but I think I did the second and third—but I’m not sure—we all share patients here, so it’s sometimes hard to remember.
DS: Now it seemed to me that you spent over 70% of your operating time simply trying to get hemostasis—to stop the bleeding Conley.
FC: Well, in my recollection, it wasn’t that long, but it does take a long time…I think that I left, though…I turned the patient over to the other doctor, and he fiddled around with it for a while. The thing, in the immediate post-operative period, that kills these patients, is if they bleed into that wound. They get a big blood clot in their brain, which of course they don’t handle well.
DS: And how can you tell if that’s happening?
FC: He would have been very different when he woke up, you can tell almost immediately. I would expect him to awaken promptly and to be moving all four extremities. Had he not done any of those things, we would have taken him down to the [MRI] scanner to find out what we were faced with. You can tell if there’s a problem most of the time simply by the appearance of the patient, and then, if you have any suspicion at all, you take them to the scanner.
DS: The doctor who took over for you during the clean up/closure seemed to me to approach the patient in a very different way from you…
FC: Tell me how…in what way.
DS: Well, he seemed almost flippant.
FC: Well, I had something else that I had to get to, and I had mentioned it to him earlier, that I might have to have him come and close the case for me. We were two ships in the dark…so he was aware that he might be called up there—but I don’t know what his demeanor was when he walked into the operating room.
DS: He was joking…he looked into the patient’s head and said something like “Jesus Christ, what are we doing to this guy—will he even be able to open his mouth with a hole like that in his head?”
FC: He thought I had been a bit aggressive in my resectioning. I know that did come across.
AL: Oh really? He was taking issue with your medical decision?
FC: Right, right. But, as it turned out, I was actually correct in my decisions—so, no problem.
DS: Is this sort of thing common?
FC: Well, I don’t know if it’s common, per se, but I have no problem with having one of my staff, or one of my residents question what I do—I mean, this is a learning environment. I don’t particularly like the fact that he was saying it in front of a lot of other people—I think that that’s not right—he tends to do that, and he gets into trouble for it sometimes.
DS: And then he pulled the surgicell [a cellulose material used to create a barrier between the exposed tissue near the excision and the cavity remaining after excision] which you had so painstakingly placed to stop the bleeding, right out. I mean, I had just watched you spend…
FC:…twenty minutes…
DS:…well, it seemed like forever…(everybody laughing) but we’ll go with that figure, twenty minutes.
FC: It’s tedious, and there’s nothing happening, and you’re trying to get hemostasis, and then he comes in and pulls it off, and the bleeding starts right up again. But it went fine.
DS: I guess why I was asking that question is to try to get an idea of your working relationship with other doctors and staff—how is it for you, how does it feel to you?
FC: Well, you have to realize that, here at the VA, I’m in the kingpin position, I’m the chief here, and so what I say goes. Dr. Anderson and I get along I think really quite well—but we have an open atmosphere here where we can discuss issues that are controversial. I mean, you have to realize that management isn’t all black and white—there is never one right answer and one wrong answer, there’s a huge area of gray—and more than one way can be the right way of getting from A to B. I think that I’ve certainly tried to keep a very open way of thinking so that we can talk to each other about our differences in the ways we approach a particular problem—I think that’s the only way a resident really learns. I try very hard to keep an open atmosphere…
AL: So that’s great that you’re able to dictate the tone…
FC: Yes, and it seems like a good tone here—we’re friendly and we like each other—my secretarial staff gets treated well, my nursing staff in the operating room gets treated well, and I think they enjoy working with us—and that’s what I like to have.
DS: What sorts of obstacles do you have to keeping that atmosphere?
FC: The obstacles are when you get someone new. Every July 1 is a very tense period. If you had come to a case in the first two weeks of July, you would have probably come away with a slightly different feel for the intensity in an operating room because at that point I’ll have a new resident.
AL: And they’ll be more attentive?
FC: No— it may be more attentive, may be more directable. But frequently more arrogant or wanting to show that they have ability, that they want to be in control, that they aren’t going to take my direction. Neurosurgical residents tend to be self-selected for their arrogance. (laughter) In some ways they have to have that to survive in the field, but it is a difficult situation to bring them under the umbrella of my control for the first couple of weeks. It’s an interesting experience; we had a resident a couple of years ago who had the worst reputation at Stanford ever for a neurosurgical resident— he was truly hated by a good portion of the staff over there. I thought I might have problems when he first came here.
But he found very rapidly within the first week and a half of being here, that you could achieve as much by being nice to people as you could by being arrogant and nasty. And so he spent his whole year being very nice to people, and when he left— I’ve never seen the outpouring of love and admiration and respect from the nursing staff and from the secretarial staff. It was wonderful to see, and it really gave him a pat on the back that you don’t need to have this aggressive, nasty— I’ll put it, male-dominated— type of master of the ship aspect about your personality to achieve things. You can do it a very different way.
AL: Do you think you yourself ever could afford that personality? Did you ever go through that?
FC: Well we’re taught that, and I certainly tried. It didn’t work at all, but you don’t know that when you’re training. You truly are the second fiddle to the staff physician who is calling the shots, and you’re working through that person’s direction. All I had seen was top-down management style, and when I came on faculty I sure tried it— boy it sure didn’t work. Nurses are not about to take directions from another woman. Particularly 15-20 years ago, and particularly from one that was younger. So I very rapidly changed my style, and it’s worked very well.
DS: Did it put you at a disadvantage at all?
FC: Sure it does, but I think you’ll find that if you talk with a number of women physicians, the ones that are most successful say “I have no problem with my nurses— none at all.” Yet many women physicians have come up to me over the past year and a half and said, “the population I have the worst trouble getting along with is the nursing staff.” Well I worry about those women physicians, because something is happening in their attitude toward their nurses that is wrong. Nurses are true professionals and without them I can guarantee that the medical profession would not function. And I think it behooves us to remember that. I have always tried very hard to make the nurses a part of my team; we’re in this together for the good of a patient. The rub has come that when a woman doesn’t give them the respect that they feel they deserve from the entire medical profession, she gets a double whammy. Whereas male physicians really don’t. They are not particularly liked or respected or admired if they put down the nursing staff, but it’s so ingrained in the culture that God is Doctor and nurse is subservient female, that they don’t get the backlash that a woman physician who tries to do the same thing gets from her nursing staff.
AL: I want to ask about your schedule. Can you go through and breakdown your day, or week, from the time you get up until you go to bed?
FC: It truly depends on the day. This week, starting Monday, I got up at 5:00— my alarm clock goes off at five every morning— I did a light weight workout and walked my dog a couple of miles, then made rounds at Stanford by 8:00. I came back here to the VA and had an hour or so to finish moving into my new office and do paperwork. Then I had a case to do here which was a carotid andorectomy [?] — it only took a couple of hours, then I went back to Stanford to get some paperwork done, and then I went swimming. I’ve been swimming because I’ve got a ruptured Achilles tendon and can’t run. When I can, I run between three and five miles every day. After that I went home, had dinner my husband had fixed, and went to bed. I go to bed at nine, nine thirty-ish every night. Tuesday I got up, walked about three miles with the puppy and she ran away from me, for the first time in ages. My husband was furious when I got back to the house— no dog, plus we had to take my car in that day. So anyway I got to work and had a clinic at Stanford all day— I saw my first patient about 8:30 and got done about 2:00. Then my husband had to pick me up, bring me back to the VA, the car was not ready, I did office work.
DS: What does your husband do?
FC: He takes care of me. Facetious comment. (laughter) No, it’s a full time job. We really have had a fair amount of role reversal. He does all the grocery shopping, a fair amount of the cooking. He will always do the main meal preparation. He gets a lot of my clothing. Shopping. But he also does investment management— he has his office in the house. So he makes money with money— a lot easier than being a neurosurgeon. But really, it’s said that every woman who wants to get ahead in the world needs a wife, and in some ways we really have adopted that lifestyle. My career has been the dominant one. He gets enough perks out of it, that I don’t think it bothers him too much. So he picked my up about 5:30 and I got home early (usually I don’t get home before 7:30), read the Wall Street Journal from the last two days, got some reading done, then had dinner, went to bed.
Yesterday I had a case to do at 7:30 AM, that took until about 10:00. I then went swimming, came back to the VA and took care of the 25 phone messages that had accumulated since the night before, went back to Stanford to check on two cases, and then yesterday about 2:30 I left the airport. I was in Las Vegas last night to do a talk for the American Association of University Women. They had about 400 people at the Tropicana hotel— we had a fine time. I spoke on— I forget what my topic was— something about gender inequities and that sort of thing.
AL: Did you write a speech for that?
FC: Oh yes.
AL: When? On the airplane?
FC: Oh no, no, no. A week ago. I have to go over my talks before I give them. I usually do most of my writing on the weekends. So I got back on the plane at 10:00 last night, was home by midnight. This morning I got up at five, and... here I am. [at 8:00 AM]
[The next section is a long, rather boring bit on Matrix pharmaceutical. Worth transcribing?]
DS: Last time we were here I asked you several questions about how you felt operating on people’s bodies and so on, and you mentioned a sense of awe; you mentioned creation, nature, even God, I think.
FC: That I am? That I’m God? (laughter) I would doubt that, but...
(AL: [laughing] Would you?)
DS: What I’m curious about is your own feelings about spirituality. Do you have a sense of personal spirituality, and if so, how would you describe it?
FC: Well, organized religion and I have never gotten along very well together, and part of it has to do with family upbringing and the values that were given to you along the way. My folks— my mother was baptized a Catholic and was never raised a Catholic, but she resented, badly, the fact that she’d been baptized into the Catholic church, and so when she and my father got married they decided they would not baptize their children into any religion. So none of us, me and my three sibs, have been baptized into any church. We were exposed to all religions: I know of Buddhism, Shintoism (?), we were sent to Sunday school in Presbyterian church primarily. So we had good exposure to a religious upbringing— my father read out loud to the four of us the entire Bible and I know about the Koran, the Book of Mormon— I have a very good foundation in organized religion.
It just has never meant anything to me.
I’m getting to your spirituality question in a moment, but I think it’s important to have the background. So much of one’s spirituality, at least as accepted by others, is things like going to church every Sunday, etc. I think it really hit me when my husband and I went to get married. I’d always thought I’d get married in the Stanford chapel— it’s an absolutely beautiful place to have a wedding. And I was perfectly eligible to use the chapel: my father was on the faculty and I was an alumnus, alumna. We went to the minister who was Episcopalian, and he said either my husband or I would have to be baptized to be married in the church. We looked at each other and said, that’s ridiculous. So we got married in my folks’ back yard; it was a beautiful garden wedding with a Unitarian minister who was very willing. That’s when you really start questioning the meaning of organized religion. The one thing that did always impress me was the comfort that people who do believe in a religion, get from it. It’s quite remarkable and I’ve seen it for a number of years in medical practice— the comfort that they get from turning to the religion of their forebears, or what they’d been brought up with— it’s very enviable. I started thinking about it after we got married and there’s no question that I get my spirituality from being outside. My running in the morning is a spiritual experience. The beauty that you get watching the sun come up every morning, the raindrops, the train that’s sometimes a river... going out in the desert. That’s really where I get my awe.
The question is will I— as I get older and face traumas in my life, since both of my folks are still alive, still doing great— I mean the worst thing that’s happened to me— it’s terrible to say it, was the death of a cat! When you think of other people— my father-in-law died, my stepmother died, but the thing that’s probably affected my husband and me most was the death of a very beloved animal. And when traumas hit harder, as they undoubtedly will as I get older, will I find the spirituality that I get through the mountains and so on, enough?
DS: I’ve had two or three conversations in the past week with people about this very issue, and I’m quite surprised to find that often the most traumatic memory I person will have is the death of a pet. They could have dead parents, they could have dead brothers and sisters...!
FC: I know. And the sad thing for me is that society doesn’t allow, does not allow you to mourn.
DS: It barely allows you to mourn the death of a person.
FC: That’s true. But animals really... I should give you a story I wrote. I’ve never had it published. But I wrote a short story about the death of that cat. I’ll run a copy of it for you.
DS: That would be great. Yet there is something interesting in the fact that you’re dealing with patients that are dying all the time.
FC: Oh no! Most of my patients do just fine. I mean that’s the basic premise, isn’t it. I mean you have to realize that death is a continuum of life, isn’t it. And it’s my job to try to make that life the best I can.
DS: So for you it’s a matter of perspective.
FC: Absolutely. All of us are going to die. I don’t deal with death, I deal with life. The highest quality of life I can provide by my special expertise. And most of my patients are very much alive when they leave my care.
DS: But you’re constantly in a situation that would be perceived as traumatic...
FC: By you.
DS: You’re invading the body, you’re performing surgery...
FC: But only as a means to a much better ends.
AL: So what about this idea you touched on last time about the possibility of genetic testing in the future and perhaps start removing the care once the patient becomes— ah, evolutionarily unfit?
FC: You’ve got it. (a short laugh) I think we are going to have to be very realistic about the value that’s placed on life. Right now this country for so long has been so wealthy we’ve been able to preserve any life at any cost. We are a quote “civilized country,” so we are able to incorporate the handicapped, the babies who are premature infants, 50% of whom end up retarded and drag on the rest of society for life. Well I can tell you that people in Somalia look at us and think, “what in the hell...?” I mean it’s just a different perspective because we’ve had the luxury. I’m not sure that luxury will be with us indefinitely.
DS: But how do you actually feel about it?
FC: I, I find it— I think one of the most interesting studies done in the last five years is on condition I take care of as a neurosurgeon, and that is spinagbifida(?) with [malamalingacy?]— where the baby is born with an opening in the back, where the spinal cord is not formed properly, and the baby usually doesn’t have functional use of the legs. They also have increased pressure in their heads. When the study went back and asked the parents who’d cared for these children into their teenage years, “would you do it again? If you had the choice of having the neurosurgeon do the shunting procedure and everything else that goes along with it”, 80% of them said the would not. 80 percent of them. That is remarkable. That truly is remarkable. I think that tells you something. It breaks up families. Happy relationships are torn asunder by a handicapped child. So I think the real question is, shouldn’t we bring in babies to this world that are 100%?
DS: But then— this is so cliché I’m embarrassed to put it on the table— but then we have the Stephan Hawking phenomenon, right?
FC: I know, and he’s remarkable, isn’t he? And if had not been allowed to live, we would have been minus Stephan Hawking. Absolutely. I know a neurosurgeon who is one of the (spinal blah blah) babies. She gets around on crutches and leg braces and she’s definitely impaired in her ability to walk. Smart as a whip. Good neurosurgeon. She’s just terrific. So. Yes, you’re going to lose the few. Question is, can we afford to lose that few for saving— at incredible billions of dollars— others who are not going to be dependent on society all their lives.
DS: Now of course even though we constantly look at lives in terms of dollars in this countries, overall we don’t like to think that we do. We like to think lives and dollars are two things that can’t be compared.
FC: Well I think increasingly this country’s going to start looking at lives and dollars in the same breath.
DS: Uh huh. And how do you think about them personally? I understand some of the clinical, practical questions about this issue. But I’m very concerned with your personal opinions, how you personally feel.
FC: Well, I, I personally feel that medical care should be available to everybody. Regardless of income or anything else. That’s one reason I love the VA. It’s available to anyone who’s a veteran, no matter what walk of life. Practicing medicine here is fun because I don’t have to worry about dollars. The question is more about what do I think about the maintenance of life or the quality of life, and how does one draw the line on that. And to me that’s a far trickier issue than saying that health care should be available to everyone. What do you do with a patient whose quality of life is not very good? What do you do about the Alzheimer’s patient who’s dribbling, incontinent, doesn’t recognize the family— is no joy to the family whatsoever. We can’t tell if they’re enjoying themselves or not because there’s no way of getting into their damaged state... What do you do with that patient? That a more telling question. Those patients cost us millions of dollars a year in upkeep. Is it worth spending the money on a patient for whom right now we have no cure and no pleasure derived, but we keep them alive.
DS: And your feeling is that...
FC: I think we probably should not. I mean I think as a way of cutting costs there’s the two ends of the life spectrum. I would not keep a premature infant that’s six inches long. I’m sorry, I just think that’s wrong.
DS: You’re not sorry though.
FC: Well I use it as a figure of speech, yes. I think we are overpopulating our world anyway, why not have baby be brought into this world absolutely perfect at the time they start?
DS: But what lengths should we go to to accomplish that?
FC: I don’t know. The problem on that end is that technology has overcome the ethical considerations. We can do it now.
DS: But it’s also increased the cost—
FC: Oh enormously. And just because it’s there, should we use it? It’ll put some doctors out of work if we decide no. The neonatologists would be out of work.
AL: (pause, then laughing) You look so happy about that.
FC: (laughing) No I don’t.
DS: The controversy surrounding the genetic mapping of embryos— what do you think about the possibility of those tests and files being used to determine the social class of those embryos?
FC: Right. I gave this as part of the commencement address last year to the Harvard School of Public Health. We’re going to have that capability in the not-too-distant-future. We’ll be able to tell which patients are at risk for heart disease and who won’t. Will they then go into different classes when allocating the resources? If only one bypass is available, how do you decide who to give it to? Do you use the profiles from genetic testing? My extra added play on that was, my bet is if you had a housewife who’d raised three children and was now 55 years old, vs. a CEO of a company that had made billions of dollars, both with identical genetic profiles— guess who’s gonna’ get the bypass.
AL: Well, that’s already true. 35% fewer women than men are diagnosed with heart trouble, when they manifest the same symptoms— they’re told it’s psychosomatic and sent home.
FC: That’s exactly right. And so I think if we’re going to do this we have to extraordinarily careful. I mean look at India. It is estimated by population geneticists that 22 million women are missing there, due to bride dowry/bride death, female infanticide, aborted female babies... They should have 22 million more women in their population than they do right now. Oh, it’s frightening as hell. I mean this program showed women seven or eight months pregnant who have ultrasound, find out they have a girl, and go into the next room for an abortion. Or they kill it when it’s born.
AL: Given where we are psychologically and socially, do you really think this kind of genetic mapping pragmatism could be beneficial?
FC: Well, yeah, I think they’re quite remarkable and we shouldn’t ignore them.
DS: And what do you think about insurance companies getting their hands on it, people being denied jobs—
FC: Yes, it’s a frightening prospect—
DS: But what do you think about it—
FC: What do you mean, what do I think about it. Do I think it’s going to happen—
DS: I guess I mean, as a human being what do you think about people being shunted into these classes—
FC: Yes, well, I guess the bigger question is, can you eliminate disease totally by picking people genetically who will live until they’re 150 years old. That possibility also exists. I wrote a paper for the business school— it was one of these papers where you’re allowed free-floating thinking, about a new technology. Most people wrote about new types of machinery. And I wrote about the creation of human beings through technology. It’s there. One of these days we will be able to raise a human being totally outside the body. The technology’s not that far away. Once you can do that, you could clone yourself totally.
DS: But of course they’d all be different.
FC: Oh no, they’d all be exactly like you. They’d be different if societal and environmental influences were different, and we don’t know how pervasive those are versus genetic profiles. Psychologists and social theorists have done a lot of studies on it and there seems to be a lot of seed/soil theory, but it’s an unknown.
But suppose you could do that. Would you want to, for example, clone a group of people with IQs of 80, so that you could always have someone who’d clean your house for you. And be perfectly happy cleaning house! Perfectly contented! Because they don’t have an IQ of 150, having to flip hamburgers in a Jack in the Box.
DS: But this is the question of age-old import, right. There are those who say there will always be masters and slaves because there are those who prefer to be slaves.
FC: And that’s possible. And that’s unanswerable by the three of us, probably, in this room today. My conclusion at the end of that paper was: our society will not allow it to happen. Because we are going to see an incredible resurgence of religion. We are going to see religion become alive again.
AL: Fundamentalist religion, you mean.
FC: Absolutely.
AL: You don’t mean real religion.
FC: (general laughter) Well, I don’t know— you certainly laid your cards on the table with that one, didn’t you. We are going to go back to the basic tenets that we don’t have the right to make that kind of decision— that that is something that supersedes any of us on earth today.
AL: And you disagree.
FC: Not, not necessarily.
DS: You’re being so evasive though, about what you truly—
FC: Because— (AL: It’s too abstract) yes, it’s abstract. It doesn’t have reality. And I’m will to be a philosopher to the point of being able to deal in the abstract, but when it comes down to the concrete, no— it doesn’t— Would I like to have someone with an IQ of 80 clean my house? Absolutely, it’d be wonderful. But would I be content to breed a group of people so that I could always have a housecleaner? Probably not.
AL: Considering that we have twenty minutes left, let’s go on. I have two things. One is, why did you do this interview for Cyanosis? Did you want to, did you do it as a favor to us, or...?
FC: I probably did it more because I am so fond of your uncle. You gave me the magic name, and— I’d do anything for Frank. Your publication’s intriguing. And I’ll be interested to know how it comes out.
AL: That’s kind of what I thought. The next thing is, we started with this question of art and science—
DS: Which we’ve addressed rather poorly so far—
FC: Yes, well, I’m not very artistic, that’s the problem.
AL: Well that’s the more personal part. We were discussing it in a rather abstract way, but I’m curious about there are art forms you particularly like, that have made a difference in your life, or if you’re just not that interested...?
FC: Well, I read a tremendous amount for pleasure. Music was very important to me in my earlier years. I still much prefer to listen to classical music than leave radio or TV on. You could ask a Walter Mitty-type question: If you could do anything you want, what would you do? I would go back into music. I’ve never taken a music class in my life, but I used to play flute. I’d love to compose. I think music is one of the finest things that ever happened to the human race.
AL: So why do you say you’re not artistic?
FC: I just think of art as being something you put on the wall, or sculpture or something.
DS: And what sorts of reading do you most enjoy?
FC: I love biography more than anything else. Believe it or not. After biography, I go to things that are very far-out in terms of the writer’s imagination. I love Robert Ludlum, Clancy’s writing, something that can grab me and is a total escape for me.
DS: What biographies do you most enjoy?
FC: I love Antonia Frasier, with Mary, Queen of Scots, Queen Elizabeth I, that sort of thing. There’s not a lot of good biography. Most of the crap that’s written today about people who are still alive, in the Hollywood set— no. But I like historical biography.
AL: You know it’s a commonplace, when things are difficult, for people to say, “well, it’s not brain surgery! “ Right?
FC: Right. My husband collects those when they’re in print.
AL: So the question is, what things do you find difficult or intimidating? Is there anything?
FC: You mean about my profession?
AL: No.
FC: Well, I’m afraid of guns, I’m afraid of knives, I’m afraid of walking by myself in an unprotected dark night. I’m afraid of the usual human things. And I’ve gotten more fearful, as I’ve gotten older in our society, which is very sad commentary. I used to go out and run with complete abandon— never thought about it. And then you have a man expose himself to you when you’re out running. And what do you do? If he wanted to come after me he sure could have done it. I mean a man is always going to be able to overtake a woman in a short type of race. So I now run with a dog. But I’m intimidated by the usual things. Just because I’m a neurosurgeon— what am I going to do, wear a t-shirt saying “I’m a neurosurgeon, don’t touch me”?
AL: Well, no, and that wasn’t completely my point either. Are there internal things— for example, well, you don’t dread public speaking, it seems pretty clear. Or do you?
FC: No, actually, I quite enjoy it.
DS: Is there anything about your job, any procedure that you find most challenging or intimidating?
FC: Yeah, anything in the brain that’s especially deep always gives your stomach acid a rise. You get a little worried, sure.
DS: I’m glad that you do.
FC: Oh good, I’m glad you’re glad.
DS: Is there something you’re afraid of that’s unusual?
FC: I’m claustrophobic, is that what you mean? Yes, I don’t want to be buried alive.
AL: Is there anything you do (although after hearing your schedule I don’t know when you’d have time), but is there anything that you enjoy doing even though you don’t feel you’re any good at it?
FC: You know, I’ve thought about that question a fair amount, because in general I’ve chosen to do those things that I think I can excel at. Why do something that you’re not going to do well in, right? I mean, I guess the closest thing would be golf. I always considered myself a relatively good athlete, and I can tell you that went out the window when I went on the golf course. I’m terrible at golf. Yet I do enjoy going out and being outside on the course.
DS: Do you have the feeling that you have something that will hang around after you’re gone?
FC: Do I want it or do I have it?
DD & AL: Both.
FC: No, I don’t feel I have anything. Would I like to, sure. Wouldn’t we all.
DS: Have you ever been unconscious in such a way that you were aware, in your life?
FC: What? I don’t understand your question.
DS: I know that sounds like a dichotomy. I was just wondering— well, have you ever been unconscious?
FC: Have I ever lost consciousness. I’ve been under general anesthetic. And that just totally— I mean, the difference between a general anesthetic and sleep is that under anesthetic you have absolutely no concept of the passage of time.
DS: I’ve some experiences of unconsciousness where—
FC: You’ve had (body memory?)?
DS: Yeah.
FC: Yes, I’ve never had that. You probably scrambled a few eggs inside your head. You’ve probably lived a less, what shall I say, a less protected life than I did.
DS: So you don’t believe— you think that when the body dies, that’s it.
FC: That’s the end. That’s it.
DS: That’s interesting. That must really affect the way you live your life.
FC: Yeah, you live for the fullest and you enjoy... I think I do enjoy life to the fullest.
DS: Do you see that as open to change?
FC: You mean will I change my outlook?
DS: Do you suspect that there might be another way for you to look at it? That something might happen that would change your perspective on it?
FC: Well, who knows. Again as I said when we talked about the religious outlook, I know what the religions of the world say, and the Catholic Church is marvelous in giving you the hope of life eternal— you’re only spending a little of your existence here on earth and the rewards are in heaven. I mean you go to a Catholic funeral and it’s magnificent! All these promises and hope and golden light and angels and singing— it’s terrific. The comfort that people get from that has to be phenomenal. But I’m sorry, it doesn’t mean anything to me. Will it in the future? I don’t know; I would have to become encompassed in that kind of religion.
AL: It seems more like a grief response, too. If you feel unbearably cut off from loved ones or something, then you have to have something to hold onto. It also seems like something that people who have children often need.
FC: That’s very possible. I think that’s one reason we keep animals around. I mean they’re a pain in the ass, they really are— get the house dirty and everything else. But they’re wonderful pets. Something that will respond to you. That warm fuzziness is very nice for human beings, and children are much the same way.
AL: Did you decide deliberately not to have children, or—
FC: It kind of just happened. I just never time for it with my career, and fortunately my husband never really wanted kids.
AL: Did you ever have a conflict about it?
FC: No. None at all. Probably if [my husband’s] father had lived a long time— he’s the last living male, and that might have caused conflict.
AL: But you yourself never felt conflict?
FC: Nope. I’m so glad I don’t have children, actually. When I’m 75 I may be sorry, when I need someone to put me in a nursing home and I don’t have anyone to do it, but...
AL: Why are you glad you don’t?
FC: It just would have complicated my life so incredibly. One gets so torn by doing a good job, even just the job I have— do I do a good job taking care of patients, do I do a good job doing research, do I do a good job teaching— to have to worry about doing a good job raising my children in addition to that just would have been more than I could handle. I really admire women who can do that.
AL: I think you said in print once that it was perfectly possible for women to have a career and children—
FC: Yes, yes. It is. But I think it makes it that much harder.
DS: Do you miss doing research?
FC: Yes and no. The fun part of research is questioning the unknown. Taking a question and trying to find an answer. Sometimes you find that answer and it’s phenomenal. The nitty-gritty aspects of doing research right now are not that much fun. You spend all of your time raising money.
DS: If you didn’t have to do that, would you prefer research to surgery?
FC: Yes, well I’d still like to have a mixture. It’s fun when you first start out research because you’re on someone else’s grant. The ideal of everybody who thinks about research is to get a Macarthur— manna from heaven that drops in your lap and all of a sudden you can just roll. But it’s not very often. Probably I would miss research if there were more time. But this past year the time that would have been spent on research has been taken up with travel, talking to people, doing interviews. I don’t miss it yet.
DS: Do you feel that your surgical work is creative?
FC: Yes, of course it is. (Tapes are turned over and part of answer lost. I remember her talking about how at this point most procedures are routine, but we don’t have it on tape.)
DS: How do you deal with the ethical nature of your work, internally? How do feel about taking responsibility for choices that you know will profoundly affect your patient’s life?
FC: I have no problem with it. That’s what I’m trained to do. Are there external constraints on that— yes. There’s the family to be considered, there’s the patient, and that person’s desires, and then there is the legal profession. The legal profession has been far too profound in medicine. Because of it, we all have to practice defensive medicine.
DS: What do you think about the prognosis for socialized medicine in the United States?
FC: There is going to be some type of socialized medicine in the United States. I think it’s fine; I have no problem with it. I do think Clinton will do some things. I think we need to reevaluate values in this country in terms of pay. I think it’s obscene for a CEO of one company to be paid a billion dollars. I think it’s nuts for NBA basketball players to be paid six million dollars for a year’s salary— I think that’s nuts.
AL: Do you think doctors are paid too much?
FC: I think some doctors are paid too much. When I can go into an operating room and on an hourly basis earn $3,500 an hour, that’s too much. But I can’t. Some procedures I do are billed at that high a rate.
DS: But is not part of that the massive quantities of insurance that are required?
FC: Sure, you’re talking about a sickness that’s very institutional, but I can tell you we’re not the only profession that’s out of touch with reality in terms of values. We are probably more in spec with them than Michael Jackson or Barbara Streisand. I mean, give me a break.
DS: What can we do to get back in touch.
AL: (laughing) Come on, don’t you have an answer to that?
FC: (laughing) If I could do that I’d be a president instead of a stupid neurosurgeon. I don’t know. But I’m serious that’s where we have to start. How do you measure the contribution of a Michael Jackson or a Madonna? What have they contributed in a meaningful way, that’s going to be long lasting? I personally have no question about that. (Laughter)
DS: What artists did contribute in a real way?
FC: Well, some of your violinists, Isaac Stern, Perlman. Some conductors. They must have a good life. They’ve all lived very long.
I am insatiably curious about the nature of living beings, intelligence, language, and nearly everything else. I hope my work may contribute to our ability to assemble the authentic sources of what our modern cultures are but the broken remnants and falsified costumes of. Together. With and for each other and our world.
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