When Dr. Benjamin S. Carson gets exasperated at the office, he can't shout to his colleagues, "Come on, this isn't brain surgery!"
That's because Carson is one of the world's most celebrated brain surgeons. In 1984, at age 33, he was named chief of pediatric neurosurgery at Baltimore's Johns Hopkins Hospital - becoming the youngest U.S. doctor to hold such a position. Three years later, he made headlines by leading a 22-hour operation to separate Siamese twins joined at the head - the first such procedure ever to succeed for both patients.
Today Carson is a legend within the medical community. He performs as many as 500 operations per year - more than twice the caseload of a typical neurosurgeon. Yet he focuses on the most fragile patients - children, newborns - and on the most difficult brain-related conditions. Most notably, he revived and refined a radical form of surgery, called a hemispherectomy, that was developed in the 1930s and then abandoned because doctors saw it as too risky. In this procedure, Carson treats children suffering from debilitating seizures by removing half their brain. Because the patients are so young, the remaining half is able to assume the functions normally performed by the missing half. He has done 65 of these daring procedures over the last 12 years.
Carson is more than a medical marvel. He is a folk hero to young people in Baltimore and beyond. His mother, who was married at age 13, had two sons before her husband abandoned the family. But Sonya Carson made sure that her sons defied the odds. She insisted that young Ben and his brother, Curtis (now an engineer), read two books a week and write book reports for her. (Only later did Ben and Curtis learn that their mother, with just a third-grade education, had struggled to read the reports they had written.) Carson has written his own inspirational book, Think Big (HarperPaperbacks, 1992), and an autobiography, Gifted Hands (Zondervan, 1990), which describe his personal journey and religious convictions. Over the last four years, a Maryland theater group has been performing a play, Ben Carson, M.D., that brings his story to life for audiences in schools, churches, and community centers.
Fast Company turned to Carson for advice about living and working on the cutting edge - about handling pressure, planning for problems, and dealing with risk.
Don't Pretend There Isn't Pressure
This may sound strange, but I never downplay the pressures of this work. Every one of our actions has consequences, and unless you are aware of those consequences, you are going to get into trouble. The brain is much more fragile than the heart. When you advance the drill next to that craniotomy - what happens if it slides into the brain? Or when you put in the retractor and start pulling back - what's happening to a blood vessel three centimeters away? You can do some extraordinarily complex, dangerous things, but only if you're always thinking about the consequences.
When we separated the Siamese twins, the most difficult part was having just one hour to divide and reconstruct the sinuses. To do this, we had to put the two patients in hypothermic arrest: You pump the blood out of their bodies, do the procedure, and then pump the blood back in and restart the heart. It's like operating on cadavers. They could tolerate that condition for as long as one hour. We had planned on taking three minutes to cut through the sinuses. But when we got in there, we found the sinuses stretched all the way to the base of each skull; it took us 20 minutes to cut through them. So we had only 40 minutes to complete everything else before the blood was turned back on. We sewed like crazy and finished in 59 minutes plus a few seconds.
Now, that doesn't mean the operating room is always packed with pressure. We play Bach, Schubert, Vivaldi. We talk about the Orioles. My attitude is, we're going to be in this room for many, many hours, so everything should be as pleasant as possible. If I want to create tension, all I have to do is to insist that everyone stay quiet and watch me work. That's not what I want to do.
Plan for Problems
Another way I handle pressure - and this may sound strange too - is to focus clearly on what can go wrong. I seldom do just one operation in a day; I may do as many as five or six. I think through every procedure: how I expect it to go, how long each phase will last, when I can move on to the next one. But the real value of planning comes when things don't go the way I expect. I always anticipate the worst-case scenario: What's the worst thing that could happen? What can I do to make sure it doesn't? What will I do if it does?
Just yesterday, I had a case where a child had an anomaly in the skull and in the sagittal sinus - the channel that carries blood away from the brain. Blood flows through there at a very high rate. I told the anesthesiologist to have lots of blood in the room and to be ready for a major catastrophe. Sure enough, when we lifted the bone, a hole opened up and blood was squirting all over the place. It was a mess.
The resident assisting me started to panic. I said, "Calm down. Put your finger in the dike, just like the Little Dutch Boy." Then I showed him how to peel off the tissue, lift the rest of the bone, take a piece of muscle fascia, and sew it over the defect. Something big went wrong. But it wasn't a big deal, because we were ready. I knew what we were going to do before it happened.
Make Pressure a Positive
No matter how good you are at planning, the pressure never goes away. So I don't fight it. I feed off it. I turn pressure into motivation to do my best. Everything you do in the operating room is so crucial - I mean every little movement - that you block out fatigue, noise, and personal problems, and focus on what matters.
Last night, I didn't get home until midnight. I did three operations, the last of which involved untethering the spinal cord of a seven-year-old child. Imagine if someone took a bunch of rubber bands, tied them all together, and put a stick of dynamite in the middle. And the dynamite will explode if you don't unravel the rubber bands in just the right way - meaning, in this case, that the kid could come out with some degree of paralysis. There were 10 people in the operating room with me. I spent hours looking through a microscope, separating out nerve roots from scar tissue, stimulating the nerves. Technicians sat in front of video monitors, watching the brain's electric impulses, and I'd ask, "Where is this going? What is this doing?" You'd see little channels open up, you'd see nerve roots coming apart. The operation took five hours and turned out very well. To me, it seemed to take about 45 minutes.
Be Confident, Not Arrogant
You need an incredible amount of self-confidence to go digging around in someone's brain. But it's possible to be confident and humble at the same time. We've learned more about the brain in the last 20 years than we knew in all of history before that. And 20 years from now, I'll be able to make the same statement. So I'm always interested in what other surgeons have to say. I like to call myself a "technical eclectic." If I get a patient who's had good results from surgery performed by someone else, I'll talk to that surgeon and perhaps integrate what he or she did into my techniques.
The hemispherectomy I do now is a lot different from the one I did 10 years ago. I used to take out the whole hemisphere at once. Now I take it out piecemeal. When you try to remove half of the brain in one piece, you can't help but pull up the other half and, in the process, disturb the brain stem. Early on, we had some patients who didn't wake up right after surgery. One stayed in a coma for a month. I concluded that the brain stem was moving too much. The more of these procedures we did, the more we learned. If you want to improve, you have to keep an open mind.
You need that same kind of humility in the operating room. You can be a good leader without being a dictator. My team includes other pediatric neurosurgeons, anesthesiologists, physician's assistants, several nurses, and the secretarial staff. I see myself as a conductor. I am orchestrating the procedure and the activities around it. That's one reason I can do 400 to 500 procedures a year - more than twice as many as most surgeons do. It's not because I have superior skills. It's because I'm flexible.
Get Real about Risk
The only way to handle risk is to be brutally honest about it. I give the parents the worst-case scenario - not to scare them but to prepare them. If parents aren't prepared for what can go wrong, then we shouldn't be talking about surgery.
Still, people need hope. The mind controls so much of the body. We are much more than flesh and blood; we are complex systems. Patients do better when they have faith that they're going to do better. That's why I always tell my patients and their families not to neglect their prayers. There's nobody I don't say that to.
I once had a patient with a brain tumor. She'd had radiation, she'd been operated on by several people, but nothing had worked. As I was taking out the tumor, she suffered catastrophic hemorrhaging. Her brain was herniating, and we were trying to push it back in. All I wanted was to get her skull closed, so she could die in the intensive-care unit rather than in the operating room - to give her mother a chance to adjust a little.
When I came out of the operating room, I told the mother the whole truth: Your child's pupils are fixed and dilated. Her brain is herniating. She is essentially brain-dead. The mother was begging me, "Is there one-tenth of one percent of a chance that she will make it?" All I could do was tell her to pray real hard. A few days later, some of the other doctors wanted my permission to turn off the life-support machines. I said I'd do it the next morning. And when we got to the room that morning, the girl's finger moved. After a long rehabilitation, she walked out of the hospital.
That was four years ago. Her name was Cynthia Clayton. I still can't explain what happened. This was a very unusual case. You can understand why I'm a believer. I have seen miracles.
Chuck Salter firstname.lastname@example.org is a freelance writer based in Baltimore.
A version of this article appeared in the February/March 1998 issue of Fast Company magazine.