Chair's Corner Blog

In 1969 I was elected vice president of my high school class, and had to give that year’s commencement speech. It was a very tumultuous time, with the organization of the massive Vietnam Moratorium demonstration protesting the war and a year after Dr. Martin Luther King Jr. was assassinated. I felt strongly that our school should have done much more to commemorate Dr. King on Martin Luther King Day and what was happening with racism and civil rights in our country, and I criticized the school’s administration during my speech. When I was finished, many of the school’s staff did not applaud and it was clear that my criticism did not go over well. Nonetheless, I made a commitment then to continue to follow my beliefs, and while I did not go on to become a political activist, I’ve continued to carry those same beliefs throughout my life.

As a neurosurgeon and Chair at Stanford, I’ve been in a position that allows me the privilege and power to act on those beliefs by encouraging, mentoring, and hiring a diverse population of  surgeons, scientists and residents. When I first became Chair of the Department of Neurosurgery at Stanford in 1995 we had only 5 faculty members, all white, including  one woman. It was one of my priorities to increase the diversity of the department, and I’ve made a concerted effort to identify and train people who represent cultures and backgrounds different from my own, or who don’t look like me. Our faculty now comprises  33% women and other underrepresented minorities, and our residency program boasts 30% women and other underrepresented minorities. While I’m incredibly proud of those numbers, unfortunately, they both represent some of the most diverse populations at a neurosurgical program in the U.S. There’s still enormous room for others to catch up to our numbers, and for us to continue our progress in this area.

The past year has only increased my resolve to continue to push for a more diverse faculty and resident composition. With hate crimes on the rise and issues of diversity and gender equality in our everyday news streams, it seems a propitious time to talk again about the statistics and the importance of increasing diversity within our institutions. Issues of diversity in leadership, discrimination, and the wage pay-gap persist, and there is still considerable work to do.

A couple of months ago - 48 years after I gave that high school speech - I was giving another speech during a national neurosurgery conference to a group of young neurosurgeons, residents and medical school students. As I looked out at the room, I was deeply encouraged. The audience was different from the audiences I’ve seen during these conferences over the last few decades. No longer was the majority white men; the room represented a diverse population of ethnicities and races, and a high distribution of women. I spoke to the group about the rigors of a career in neurosurgery, the tough decisions that someone in leadership needs to make, and the surprising highlights and pitfalls of dedicating one’s life to research and medicine. At the end of the speech, many of the questions and comments from the audience focused on one thing: diversity. How can we ensure more women assume leadership positions? How do we encourage more underrepresented minorities to go into neurosurgery? How do we expand inclusivity within the field? It became clear to me that these issues are all just as important to the young people entering our beloved field as they have been to me - and that gives me great hope for the future.

Most doctors, especially those who are considered renowned experts in their field, often get requests from family, friends, colleagues, and even strangers for medical advice. I am no exception. Whether it’s by phone, email, and most recently social media, I am often asked to review the medical history of people who are not my patients, and unfortunately, there really wasn’t an appropriate, legal, or streamlined way for me to accommodate those requests. Until now.

Starting this month, Stanford Health Care and Stanford Children’s Health launched a new program, called Online Second Opinion. The new program is a service provided by both hospitals for neurosurgery patients. If you or your loved one have recently received a diagnoses that may require brain surgery and are looking for a second opinion, this service may be right for you. Once you create an online account, my team will be able to review your previous health records and images, and provide a recommendation regarding whether surgery at Stanford is an appropriate option.

Our team of experts are available to review diagnoses for a variety of conditions that require surgical treatments, including cerebrovascular and spinal vascular surgery, aneurysms, Moyamoya disease, pituitary tumors, meningiomas, and more. Being able to provide this option to people around the world has been something I’ve been looking forward to for a long time. As I’ve mentioned in previous posts, I believe our expertise should not be limited to only those who live in the places we practice. The new online program is yet another way for us to increase our reach and make our years of experience, and our services at Stanford, available to many more people.

International travel is incredibly beneficial, not just in terms of finding time to relax or spend quality time with family, but also as a means of learning about new cultures and people, and expanding our own perspectives about our world. If you’re lucky, your adventures will preclude any medical mishaps or emergencies, and you’ll travel through a country never needing the expertise of the local health care providers. In turn, many of us never consider that there are places in the world where medical care is not just lacking in quality, but is altogether scarce. While there are underserved, low-resource communities in the United States, lack of proper medical care in some parts of the world is chronic, and this is particularly true when it comes to neurosurgery.

Since neurosurgery is so highly specialized, incredibly competitive, and requires years of training, there just aren’t that many neurosurgeons in the world. The latest numbers available from the World Health Organization, as of 2004, indicate a total of just over 33,000 neurosurgeons in 103 countries. What is particularly problematic is the distribution of neurosurgeons is entirely unbalanced, with the majority residing in North America and Europe. For example, while in the United States, there is approximately 1 neurosurgeon available per 80,000 people, in some parts of the world, the distribution is 1 neurosurgeon for 10 million people. As the population grows and ages, the need for neurosurgeries will also grow. Simultaneously, our techniques and technologies for treating neurological conditions and diseases have dramatically improved in just the last couple of decades, but many people still do not have access to even the most basic surgeries we perform. These surgeries can save lives, and I feel, as do many of my colleagues, that these procedures, and our expertise, should not be limited to those who live in the places where neurosurgeons are most concentrated, but should be available globally.

At Stanford, we believe outreach medical work is not just important, but necessary. I’m a strong advocate of neurosurgeons spending at least some portion of their time traveling to countries where we’re desperately needed, working with local health care providers, and performing the surgeries that no one else can. For that reason, we created the Stanford Neurosurgery Global Health Initiative, an effort funded by grants from a variety of organizations, that allows our attendings, residents, nurses, and medical students, to travel and work internationally in areas with some of the greatest need for neurosurgeons. As part of our Initiative, our faculty, staff, and students have been traveling regularly to Uganda, Jamaica, and North Korea, where they help the local medical personnel with emergency treatment, pre- and post-operative care, neurosurgical training, and conducting research.

Traveling to remote places of the globe can make for memorable vacations, but international travel can also translate to meaningful work and helping others. In the case of neurosurgeons, it seems especially important to dedicate time to taking care of patients who have no access to treatments that make the difference between decrease in pain or greater independence, and oftentimes, the difference between life and death. I’m proud of the work we’re doing around the world, and encourage others in my field to consider spending some of their international travels working in places where people like us don’t yet exist.  

While activity on the Stanford campus begins to wind down in preparation for the lull of the summer months, at our Department, late spring is a time for reflection, renewal, and transition. In a few short weeks, I will once again bid farewell and good luck to our graduating residents, and reflect on the accomplishments of our faculty over the past academic year.

Our graduating residents, Dr. Linda Xu and Dr. Kai Miller, are preparing for their new adventures. Both accomplished students and excellent surgeons, Dr. Xu will join the team at Allegheny General Hospital in Pittsburgh as an attending neurosurgeon and the director of Brain Tumor Research, and Dr. Miller will travel to Utrecht University Medical Center in The Netherlands to complete his Van Wagenen Fellowship. I wish them both the best in their future endeavors. At the same time, I welcome a new cohort of trainees to our Program. Our new first-year residents – Dr. Adela Wu from Johns Hopkins, Dr. Ryan Jamiolkowski from University of Pennsylvania, and Dr. Dan Herrick from Tufts University -  will each add their unique interests and perspectives to what is an already talented group of residents. Our Residency Program continues to recruit the best and brightest, and I am looking forward to another year of teaching and mentoring our trainees.

The past academic year has also been filled with many faculty and resident accolades, from large grants for stem cell and head injury research, travel fellowships and research awards for our residents, faculty promotions that made history, to the many recognitions of our faculty’s research and clinical work by outside institutions and governing bodies, we all have much to be proud of. Despite the hectic and transitional feel of the end of the academic year, I hope you all also have a chance to enjoy the mild spring weather as you reflect on your past accomplishments and the many new adventures that await you.  

For 40 years, I survived on very little sleep. And it was just survival, no one thrives on four hours of sleep a night. As I was going through training and became a practicing surgeon, the general thinking was that sacrificing one’s own basic needs – sleep and rest, proper nutrition and exercise – was what good surgeons did to commit fully to the profession. But attitudes about self-care and wellness, especially for physicians are changing quickly, for the better.

Nationally, physician burnout has reached an all-time high. Over the past decade, national surveys indicate doctors suffering from emotional exhaustion, loss of meaning in their work, or a sense of ineffectiveness and lack of engagement with patients, affects more than 50% of those surveyed. This trend is bad for doctors and it’s bad for patients. At Stanford, leadership took notice of these trends and in response, implemented the WellMD Center, and became the first academic medical center in the country to hire a Chief Physician Wellness Officer.

In our own department, we want to ensure our residents and faculty feel supported and are encouraged to take good care of themselves too. We do our best to create a balanced on-call schedule that provides enough nights and weekends off for each surgeon to have time with family or for activities outside of work. We encourage our faculty to take time to travel or pursue educational and research efforts that expand their skill set, but also contribute to higher levels of engagement in their work. We provide individualized mentorship, and even offer regular Pilates classes for our residents. Our efforts are working. In the latest Stanford physician wellness survey, our Department reported a 25% burnout rate, as compared to 49% reported across neurosurgery departments nationally. In addition, our neurosurgeons reported a 35% professional fulfillment rate, as compared to only 18% nationally, and we ranked second highest in that category among Stanford School of Medicine departments.  

I’d like to see our Department’s burnout rates continue to decline, and our fulfillment rates continue to improve. But saying that I support these efforts isn’t enough. I’ve taken serious steps over the past year to change my own lifestyle. I now insist on 7-8 hours of sleep per night. I’m exercising more regularly, and making more nutritious food choices. Despite having spent most of my career neglecting in some ways my own wellness, being in a leadership position means I can teach others not to make mistakes I made. I want to set the example for the next generation of surgeons that taking care of one’s self doesn’t have to come at the cost of professional success. In fact, according to the data, and my personal experience, when doctors are well rested and enjoy their work, they end up taking far better care of their patients. We don’t want doctors who are just surviving; we want doctors who are thriving in all aspects of their lives. Their wellness is the key to our patients’ wellness and to fostering a leading neurosurgical program.

What makes Stanford unique isn’t just its beautiful and sunny campus, or its proximity to Silicon Valley, it’s also our faculty’s commitment to tackle the most complicated, unusual or mysterious medical cases, and their determination to find solutions. Sometimes this means developing treatments and cures, but more often it entails years of spreading awareness, engaging the community, and affecting policy changes, in hopes of expanding resources for some of the rarest conditions. When I first became a neurosurgeon, I did not think that much of my career would be spent treating patients with a rare disease. While we didn’t know as much as we know now about the nervous system, and more specifically diseases that affect the nervous system and how to treat them, I certainly didn’t imagine a rare disease like Moyamoya would be central to my research and clinical care. But, it turns out, rare diseases affect many of us, not just those of us in healthcare.

According to the NIH, there are approximately 7,000 identified rare diseases in the U.S., defined as a disease affecting less than 200,000 people. While individual rare diseases affect small portions of the population, the combined total of people living with a rare disease in the United States is estimated at 25-30 million. So, it seems a fair assumption that at some point in your life you, or someone you know, will face dealing with a rare disease, and will likely find that little information is available and that few medical centers treat it.

One of the greatest problems with rare diseases is that there is so little awareness and education about them, that even specialists do not identify their symptoms right away, or sometimes they remain undiagnosed or untreated all-together. At Stanford, everything we do is based on a drive to discover answers, particularly for those with the most complex or rare disorders. In addition to my research in Moyamoya, many of our faculty focus their research and clinical efforts on rare diseases. For example, Dr. Gerald Grant is collaborating with experts at Nicklaus Children’s Hospital in Miami to conduct a trial using focused ultrasound for children with tuberous sclerosis, a rare genetic disease that causes tumors throughout the body. Several of our specialists across the Stanford campus are joining forces to create a comprehensive skull base surgery program that pioneers the least invasive, most effective treatments for rare disorders such as adenoid cystic carcinoma. In our new Neurosurgical Anatomy Lab, veteran surgeons are teaching residents how to perform complicated and nuanced surgical procedures for treatment of rare aneurysms. Next month, Dr. Steven Chang is hosting Stanford’s first Facial Pain Association Conference, aimed at bringing together clinical experts and patients to develop new solutions for those affected by the rare and painful disease, Trigeminal Neuralgia.

Many of our patients come to us because they have a rare disease and so few other places have answers for them. World Rare Disease Day is recognized just once a year, but in my line of work, we think about rare diseases every day, and we’re working hard to ensure all patients, no matter how rare their neurological disease, can find answers and therapies that will extend and improve their lives.

I’m incredibly proud of our department’s accomplishments over the past year, and am confident the work we are doing continues to improve the quality of our patients’ lives.

In 2017 we welcomed four new faculty to the department, including two translational scientists, a new pediatric neurosurgeon, and a peripheral nerve surgical specialist. Our scientists and surgeons continued to push the boundaries of translational research and refining surgical techniques; integrating pioneering use of robotics in surgery, implementing the use of virtual reality in the operating room, and publishing results from a wide variety of studies focused on everything from epilepsy to brain tumors.

This past year our team worked with California legislatures to pass a new resolution declaring May 6 Moyamoya Awareness Day in California, an important step in spreading awareness for this relatively unknown disease. We also saw a renewed public interest in, and a great deal of media coverage about our stem cell therapy for stroke studies - culminating in a special ceremony where I was honored by the Smithsonian Institution with their Annual American Ingenuity Award for Life Sciences. I was surprised and humbled by the recognition!

I’m pleased to kick off the new year with the launch of our Department’s first e-newsletter, which will provide insights and the latest news to anyone interested in staying up-to-date with our Department. I am also looking forward to continuing to expand our department in 2018 with the hiring of new faculty specializing in skull base and pituitary tumors, complex spine surgery, and stem cell research. I’m eager to see what new scientific discoveries and clinical advances our researchers and clinicians will develop in the coming year, and am looking forward to sharing many more of our upcoming achievements with all of you. Happy New Year! 

It’s been a little over a year since our findings from the Phase 1/2a study testing the safety of transplanted modified stem cells in patients with chronic stroke, were published. Those results stunned many of us in the neuroscience community, myself included. The goal of the trial was to assess the safety and feasibility of such a procedure. We didn’t expect to see functional recovery, certainly not in patients who suffered a stroke more than 6 months prior to the trial, and whom we presumed would never regain the abilities they lost to stroke. Nevertheless, the hype around the trial and the use of stem cell therapy has not subsided. Over the past year I’ve continued to receive invitations to present the findings at scientific conferences, and am contacted regularly by national and international media outlets requesting interviews about the trial’s results.

The hype is understandable; the results completely changed our notions about what happens to the neural circuits after stroke – we now know that these circuits can be resurrected in some patients, even years after a stroke. One patient, Sonia Olea Coontz, could barely move her right arm, could walk only with great effort, and her speech was difficult to understand when I first met her. She also refused to go through with her upcoming wedding, too embarrassed about her gait to walk down the aisle. When I came by her hospital room the day after she was treated with the stem cells, she could lift her arm above her head, and her speech had vastly improved. Now, more than  4 1/2 years out, Sonia’s functional recovery is sustained. After the trial, she walked down the aisle, and in 2016 she gave birth to her first child. The trial changed Sonia’s life, and the hype that continues to surround the trial is one born out of hope that this therapy may do the same for many more stroke sufferers. But there are serious risks to overpromising the results of the trial, and it’s important to remember that Sonia is just one of over 7 million people who currently live with severe disability from stroke  in the U.S.

The trial was small, only 18 patients were treated, and so many unanswered questions remain: What types of stem cells are most effective? What is the best mode for delivery of the cells? Why did someone like Sonia experience such remarkable improvements, while others less so? Is it best to transplant the cells shortly after stroke or should we wait several years? I suspect that as we continue to test this therapy we will continue to face only more questions. And while I am pleased about the results of this early phase trial, I continue to approach each subsequent phase with appropriate caution.  

I have spent my entire career focusing on the translation of science into medicine, and I am aware the process is long and arduous, and often filled with bumps along the road. We are not pursuing a quick fix. The goal of these trials is to find a safe and effective treatment that will reverse the damage caused by stroke for the long haul. Meeting that goal will take time, and we can’t let the excitement render us careless. We have already seen too many cases where the promise of stem cell therapies sold to desperate patients ruined lives, instead of improving them. This past year alone, we witnessed numerous scientific reports about patients paying thousands of dollars to clinics touting unproven treatments; the most recent of which left three women in Florida blind, after stem cells were injected into their eyes to treat macular degeneration. These unproven therapies can be quite dangerous, and it’s our responsibility as scientists and physicians, to set realistic expectations, and to proceed with care.

We are moving forward with the second phase of the trial, which unlike the first phase, is far larger – we’ve enrolled 156 chronic stroke patients - and involves multiple centers. If the current trial confirms the safety and efficacy of the first phase, then we’ll move onto the third and final phase 3 larger randomized, blinded, controlled trial. And, if we find positive results in the final phase, then I hope to see FDA approval and commercialization of stem cell therapy for chronic stroke victims. At that point we will likely want to try to apply the success of the therapy to other patients suffering loss of neurologic function from other neurologic disorders like traumatic brain and spinal cord injuries as well as degenerative diseases such as ALS (Lou Gehrig’s Disease) and Parkinson’s Disease. It’s difficult not to get excited about the future of stem cell therapies, but for now, I remind myself to remain cautiously optimistic, and to take each step at a time.

As neurosurgeons, our aim is to continually search for, and find, technology and tools that will make our diagnostics and operations quicker, less-invasive, safer, and more effective for our patients. We are incredibly fortunate at Stanford to be located in the heart of Silicon Valley, where technological innovation surrounds us, compels us to keep searching, and provides us with so many opportunities to try new tools that will help us achieve our goals. From rapid improvement in imaging and the integration of robotics in the operating room, to the development of implantable devices and brain-computer interface, I see indications that the future is already here.

Our diverse team of surgeons and scientists are at the forefront of developing and implementing these new technologies. Our spine surgeons, such as Dr. Atman Desai and Dr. Anand Veeravagu are now using robots in the operating room to fix spinal deformities and remove tumors. Just last month, neurosurgeon, Dr. Casey Halpern, was the first to perform robotic-assisted surgery to treat epilepsy. In many cases the robots can see what the human eye cannot, and can place surgical tools more safely and accurately. Surgery times  are now shorter, less invasive, and lead to quicker recovery and less pain. 

One of the technological advances I’m most excited about has been the integration of virtual reality in neurosurgery. We are now using patient-specific, 3-D virtual reality to train students, educate patients, prepare for operations, enhance visualization during surgery, and assess effectiveness of treatment post-surgery. The use of virtual reality allows us, for the first time, to see in 3-D, parts of the anatomy we could previously only imagine. Whether presented to the patient, the patient’s family, the surgeon, or trainees, 360VR offers a way of communicating with what seems to be a universal language - adept at quickly conveying complex, context-specific spatial information, bridging the gaps between technology, patient, and physician. Another use of VR, the EyeSync, developed by neurosurgeon, Dr. Jamshid Ghajar, is helping sports medicine professionals determine if an athlete needs to be removed from play in less than a minute. This new technology is significantly advancing diagnosis of concussion, an injury that has been plaguing the worlds of football and other contact sports.  

We are also re-thinking our approach to treating paralysis and disability, embracing the use of computers and implantable devices to help us restore abilities to those who thought they’d never be able to speak or see again. Neurosurgeon, Dr. Jaimie Henderson, is leading an effort using brain-computer interface to allow people to communicate – people can now command a computer to type for them, only using their minds. Dr. E.J. Chichilnisky, professor of neurosurgery, is also using the idea of interface between an electronic device and the brain to produce a bionic eye that will allow the blind to see again.

This is an incredibly exciting time to be in this field and to watch these technologies transform the way we do our work. From the future implementation of augmented reality in the operating room, to the possibility of performing operations remotely, I’m eager to see how these technologies will continue to transform diagnosis and treatment in neurosurgery.

There was only one woman faculty neurosurgeon working in Stanford’s Neurosurgery department when I joined the department in 1987. 30 years later our department has grown to include 6 practicing female neurosurgeons and another 12 women faculty scientists. If that progression seems very slow, that’s because it is. And yet, despite the crawling pace, with nearly 25% women faculty clinicians and researchers, ours is still one of the nation’s leading departments in terms of gender diversity. While I’m very proud that our percentages are high, relatively speaking, it’s clear that we’re a long way away from parity.

Talking about gender equity can sometimes be uncomfortable – for those of us who fall into the majority and can only digest the experiences of those in the minority second-hand, and for those in the minority who may not be sure how to get their voices heard without stigma or fear of repercussion. But talking openly about these issues is critical to fixing them. As a white male, it takes conscious recognition and correction, and repeated self-reminders, that my experiences are vastly different from those of women and underrepresented minorities; and while I’m hoping that within my lifetime we can refer to all physicians, surgeons, and scientists without having to insert a qualifier, the reality is that we need to continue to talk publicly about the barriers to parity, so that we can more quickly achieve it. On that note, while it’s important that someone like me recognize the lack of gender and ethnic diversity in our field, it is equally important to give voice to the people who are at the brunt of breaking down those barriers. As part of shedding light on some of the experiences and perspectives that I cannot personally, we are launching a new series highlighting the experiences of the women of Stanford Neurosurgery. From who and what inspired them to pursue science and medicine when they were young, to the methods they each developed to persevere, despite the push-backs they received when entering the field, “Women of Stanford Neurosurgery” is just one avenue to give voice to those things that we don’t always feel comfortable talking about, but must. While the women highlighted in the series have had different life experiences and come from different backgrounds, the stories of their journey into a field so heavily dominated by males tend to be universal.

I do feel it’s incumbent upon us men, to listen to these stories, and to move forward with conscious recognition of the obstacles women face in our field. I don’t want to give the wrong impression – I have not spent my life fighting for women’s rights, and when I’ve hired women to our department or promoted them within, it was not because they were women, it was because they were the best possible candidates. However, I do believe that to affect lasting change both men and women have important roles to play – on the part of men, we must push ourselves to more consciously recognize the types of experiences our women colleagues face that are often manifested in subtle and unconscious sexism. We understand, as a matter of fact, that women are as equally capable of achieving success in science and medicine, as men are. Yet, women still make up just a tiny percentage of many programs, and even less so when thinking about women in leadership positions. There are numerous reasons for this, and we know the pipeline is no longer the main culprit we once thought it was. Things are changing, but the change is extremely slow, and in the meantime, we all lose out on the best and brightest entering and excelling in our field.

I hope this series will in the least, shed light on what it took these individuals to get to where they are today, and at most, foster the kinds of conversations that lead to actions that bring about concrete change. Expanding diversity across science and medicine will be a win for us all. 

Becoming a neurosurgeon is a long and difficult journey. Residency, particularly at Stanford, where expectations are high, can be grueling. Our program only accepts three new residents each year. For those chosen, the 7-year process is challenging, but hopefully it’s also fulfilling, engaging, and formative.

This summer, we are proud to announce our chief residents, Henry Jung and Maziyar A. Kalani, have successfully completed our residency training program. Henry has come a long way from his upbringing in rural Indiana, where he spent his time chasing wild animals and fishing. His interests have centered on neuroengineering – using brain-machine interface and scientific computing to advance treatments for neurological disease and injury. He is starting his neurosurgical practice at Kaiser, Sunset Los Angeles.  Maziyar, who grew up in California, has an older sibling who is also a neurosurgery resident. His  interests have focused on spine surgery and opportunities to improve the value for outpatient surgical care. He will be completing a complex spine surgery fellowship at Cleveland Clinic over the next year and then pursuing an academic faculty position. I am incredibly proud of Henry and Maziyar and what they’ve accomplished over the past 7 years, and know they will represent our training program well wherever their future work leads them.

As we say goodbye to our chief residents, we are also thrilled to welcome our interns – our new first-year residents. Drs. David Dadey,  Michael Jensen, and David Purger. All three have already accomplished much in their academic careers - they all hold MDs and PhDs from reputable institutions - each with their own unique life experiences and perspectives, and a passion for medicine, patient care, and scientific research. We are certain they have a bright future at Stanford and welcome them to our program. 

It’s been nearly three decades since I began performing surgical revascularization to treat Moyamoya Disease. In 1991, when we first offered the surgery, we didn’t know much about the disease. We didn’t yet realize its genetic links, its connection to other rare disorders, or the psychological impact of its symptoms on patients. We did know that the TIAs, strokes, and seizures associated with Moyamoya would continue without surgery, and unfortunately, 26 years later, this is still the case – there is still no cure for the progressive and rare disease.

At first, what was particularly troubling to me was seeing young children affected by Moyamoya, the disease was impacting their cognitive abilities during a critical time of development. We needed to come up with viable surgical solutions to treat small kids, sometimes just toddlers. Over time, we managed to greatly improve treatment, reducing surgery times, refining techniques, and enhancing anesthesia administration.  But, after thousands of these surgeries and greatly improved outcomes, I still don’t have all the answers I’ve been searching for.

How can we diagnose the disease before symptoms appear? Are there other types of procedures that we haven’t tried that would be more effective or less invasive? When is the best time for surgery? Are there non-surgical solutions we can develop? What are the long-term outcomes – will patients remain symptom free for the rest of their lives? What effect does the environment have on disease development? What can our genes tell us about the disease?

As with any intellectual pursuit, the more I’ve learned about Moyamoya, the more questions I have. I’ve spent quite a bit of time both in the lab and in the clinic trying to find answers. We did recently discover that outcomes improved when we delayed surgery for a few weeks following a stroke, so we have adjusted our treatment protocols accordingly. We’ve also begun developing a new laparoscopic approach, transposing the omentum (the fatty tissue in the lower abdomen) to the brain, when prior revascularization has failed. This novel approach substantially decreases recovery time and reduces the risk of complications compared with a laparotomy. We’re also spending a significant amount of time in the lab trying to identify genetic markers for Moyamoya, in hopes that these findings could lead to genetic screening of the disease or potentially to gene-based treatments.

When I first learned about Moyamoya, my focus was on perfecting surgical revascularization, to ensure that the options we were giving patients had merit and could halt symptoms immediately. Today, my focus is on understanding causation and tackling the disease on a genetic level – I want to stop the disease before it has had a chance to develop. Experience and time do matter, all these years later, and thousands of lives saved or improved, we’ve gained an enormous amount of knowledge for better detection and treatment. Public awareness about Moyamoya has also grown tremendously, in fact, just this month, California became the 5^th state to recognize an official Moyamoya Disease Awareness Day. In the decades to come, my hope is that our understanding of Moyamoya continues to expand, so that one day we may be rid of the disease, long before one must suffer its consequences.

This past week I attended the 85^th Annual AANS Scientific Meeting in Los Angeles. I wanted to mention this because I think it’s of great significance whenever the top minds in my field take the time out to gather and re-connect. Many of us dedicated almost an entire week to meeting, presenting, learning, and discovering. What makes this annual gathering unique, is that it focuses specifically on neurological surgery, and that the attendees range from first year residents to neurosurgery’s long-time and foremost experts.

By bringing together neurosurgeons at all levels, from around the world, this annual meeting provides the perfect opportunity for us to reflect on our accomplishments in the year since we last met, share and discuss the latest research we’re excited about, and inspire the newest generation of neurosurgeons. It also provides a new and different platform for many of us to learn and teach new approaches and refined techniques.

This year’s meeting theme was “A World of Innovation,” an apt theme considering the advances rapidly being made in neurosurgery around the planet. From stem cell therapy, brain mapping, and devices, to virtual reality and robotics, these advances are quickly changing our perceptions of what is possible.

I was fortunate to have the opportunity to re-connect with old colleagues and to meet those just entering the field, and to take home new information that will help to advance research and clinical care, back here at Stanford. I look forward to seeing everyone again at next year’s AANS Annual Scientific Meeting.

It wasn’t lost on me when I heard that Dwight Clark, the famed former 49ers’ wide receiver, announced publicly that he had ALS, that the announcement also took place during Brain Injury Awareness Month. Hearing about an ALS diagnosis is deeply saddening, it is a devastating disease, but it did not surprise me to hear that Clark himself acknowledged the development of the disease was most likely linked to his years playing Football. In 1999, after several concussions sent then 49ers star quarterback, Steve Young, to my office for a series of neurological exams, my recommendation that Young retire from football to save his brain health was considered quite controversial.

At the time, many were reluctant to acknowledge the strong connections between head trauma acquired during sport and the development of brain disease. Today, the NFL publicly recognizes that head trauma is much more serious than previously believed, and the public is far more educated about the risks associated with concussions. Despite the progress made, there is still much we need to learn about concussions and brain injury. This is an area of research not only football players should be concerned with; nearly 2 million people suffer a brain injury in the United States every year, most of which are caused by auto and motorcycle accidents, falls, and violent assaults.

The effects of brain injury can be overwhelming; disability, increased aggression, anxiety and depression, or loss of memory or functionality are all common. Many of these symptoms can linger for months, and sometimes years after injury. At Stanford, we have focused our efforts on research that will help us better understand everything from mild concussion to severe injury, to more quickly identify symptoms and improve outcomes.

At our Concussion and Brain Performance Center, our physicians and surgeons including Jam Ghajar, MD, PhD and Gerry Grant, MD are developing a much-needed new brain trauma classification system that will help standardize definitions of concussions, and aid in developing more effective diagnosis and treatment. At the VAPAHS, Stanford neurosurgeons such as Odette Harris, MD, MPH are working with veterans to advance our understanding of how neurosurgical intervention after brain injury can help repair damage and restore function. In addition, our doctors have studied how traumatic brain injury (TBI) specifically affects women. There has been a notable research gap, with much of the studies on TBI focused on men. Having already identified significant ways these types of “invisible injuries” affect men and women’s brains differently, we tailored treatment and policy recommendations specifically for women veterans.

We are currently studying the process of neurogenesis, in hopes we might one day manipulate the process, and repair damage to the brain once thought irreparable. Additionally, we are testing the safety and efficacy of stem cell therapy in increasing mobility for people rendered disabled from traumatic brain injury. Soon, we will be evaluating the use of deep brain stimulation as a potential treatment for TBI.

Those of us who have been studying the neurosciences for decades have been aware of the many connections that exist between head trauma and its long-term implications to brain health. I applaud sports organizations for publicly recognizing the seriousness of concussions, and players themselves talking about the sport and its connection to their brain health, or in some cases donating their brain to scientific investigation. I am encouraged by the military’s commitment to investment into neuroscience research and development of diagnostics and novel therapies. I am hopeful when I see public awareness growing, with the creation of Brain Injury Awareness Month or individuals raising funds for additional research. Football has positive aspects related to participation in a team sport and isn’t going away any time soon, and we certainly can’t eliminate accidents, but the efforts to focus on better understanding and treating brain injury will lead to improved therapeutic options for all of us; athletes, veterans,  you and me.  

Most people rarely consider the impact of disease or injury until they face the unfortunate circumstance of having to seek treatment for themselves or a loved one. By the time someone finds themselves in this predicament, they are hopeful that research and experimentation were long-ago completed, and therapies have been technically perfected and proven effective. The reality is that the journey from basic science research in the lab to its translation into clinical application, can be a long and drawn out process.

Luckily, we scientist-clinicians are aware that the long-awaited discovery we seek will take time and effort, and are motivated by the process. We’ve spent much of our life learning basic science, dedicating years to research, and testing potentially-life saving therapies in clinical trials; all so that one day, when a patient walks into our office seeking that perfected treatment, we’re able to offer it. That laboratory-clinic connection is the foundation to everything we do, and we are keenly aware of the need to focus much of our energies on that less recognized part of our field – the years in the research lab.

Those years spent in the lab can be difficult. Aside from the fact that most research scientists don’t receive the public recognition they probably deserve, finding therapies and cures can take decades, and can sometimes remain elusive beyond a lifetime. As research scientists, we must also learn one of life’s greatest lessons early – repeated failure is necessary, it allows us to learn and grow, and improve. Toiling in the lab is not without some obvious upsides. Discoveries in the lab, when translated to clinical application, can give someone a second chance at life, or at a minimum, teach us something new about the way our body functions that we didn’t know before.

I feel quite fortunate to be in a place where so many people deeply understand the importance of research, and have been extremely proud when those efforts are rewarded with the discovery of new diagnosis and therapy options.

In a very short time, our labs at Stanford alone have made discoveries that will change the way injury and disease are treated in the future. From testing the effects of hypothermia on protecting the brain from damage caused by stroke, to inventing the CyberKnife radiosurgery system for treating brain tumors and other neurologic disorders, to using stem cell transplantation to restore function after neurologic injury, it is incredibly exciting and fulfilling to see how far we have come in just a matter of decades. We are testing the efficacy of using new brain-computer interface technology to allow paralyzed people to communicate, and have successfully shown how using awake brain mapping techniques helps to retain language skills during tumor resection. We study the impacts of genetic changes on conditions like autism so that we can one day prevent its occurrence, and have proven the efficacy of using MRI-guided ultrasound to reduce the severity of chronic tremors. We support over 30 active labs investigating everything from brain injury, degenerative spinal conditions, and deep brain stimulation, to the retina’s role in vision loss, epilepsy, brain tumors, and the effects of stress and aging on the nervous system. My own lab focuses on investigating the pathophysiology and treatment of acute stroke, as well as methods to restore function after chronic stroke. The work my colleagues  achieve in our labs fills me with hope for the future.

While most people tend to consider just the outcome, we scientists are always considering the journey – what basic science understanding are we still lacking that may help us on the road to discovery; what questions must be answered to find better, less invasive modes of diagnosis; and what steps must we still take to find new therapies and cures? The journey can be long and arduous, but in many cases, that journey is what got us hooked on science, and what ultimately allows us to find answers that heal.

As we usher in the New Year, I have spent the last few weeks also reflecting on all of the incredible accomplishments and lessons we learned in 2016.

Our tireless commitment to improve care and outcomes for our patients continued to drive innovation in 2016. We were proud to announce the pioneering of new techniques in stem cell transplantation, innovative treatments for spinal cord injuries, the use of technology to create new means for brain-computer communication, technology that makes brain surgery more safe, and improving our understanding of causes and potential cures for Parkinson's disease.

I was also reminded of the amazing people we serve-patients who despite immense health challenges, fight not only for their own healing and regained strength, but for others like them. For example, 12-year-old Kendall Kemm, who after successful Cyberknife treatment at Stanford for a hemorrhagic stroke caused by a rare defect called AVM, decided to form Kendall's Crusade-a nonprofit aimed to provide financial assistance to families affected by AVM, raise overall awareness of the condition, and support neurosurgery research.

I am also incredibly proud of the many talented and compassionate physicians on our team, whose work continues to make us a world leader. In fact, I'd like to give a special recognition to our own Dr. Laurence Katznelson, Professor of Neurosurgery and Endocrinology. Helping us kick off the New Year right, Dr. Katznelson was selected by the Endocrine Society for their 2017 Outstanding Educator Award which recognizes exceptional achievement as an educator in the discipline of endocrinology and metabolism. Congratulations, Dr. Katznelson!

I was especially excited to share the news this past Fall, of the opening of the Stanford Neurosciences Health Center, a one-of-its-kind outpatient facility that brings together 21 neuroscience sub-specialties all under one roof. The new Center offers patients a unique experience, providing the convenience of one location for all of their diagnostic and treatment needs.

Finally, I was also humbled and thankful to be honored this past year with the prestigious J.E. Wallace Sterling Lifetime Achievement Award in Medicine from the Stanford Medicine Alumni Association. I have dedicated my life's work to advancing science and medicine in Neurosurgery, and was very touched by this recognition.

I continue to be inspired by the community of people I work with every day; our brave patients, committed and passionate surgeons, caring and experienced nurses, innovative researchers, dedicated donors, and visionary students. As we continue together to seek new ways to translate discoveries in our labs into new therapies for our patients, I’d like to wish all of you a happy and healthy New Year, filled with many new achievements in 2017.  

Stanford Medicine's signature event, Frontiers in Medicine hosted nearly 320 guests at the Bing Concert Hall on Wednesday night. The topic this year – the powerful healing potential of our own bodies.  Some of Stanford Medicine's top scientists shared how they are harnessing this incredible potential- utilizing disease-fighting stem cells, the immune system, and the microbiome.  Among the expert speakers:

• Crystal Mackall, MD, professor of pediatrics and medicine who recently joined Stanford from the NIH. Dr. Mackall has been in the news quite frequently after being appointed Director of the Parker institute for Cancer Immunotherapy at Stanford, a historic cancer fighting collaboration of six of America's leading academic medical centers featured recently on Dateline NBC. 
• Justin Sonnenburg, PhD, associate professor of microbiology and immunology and author of the highly acclaimed book "The Good Gut" who has recently had his work featured in the New York Times and published a piece for the  LA Times on the protective, regulating power of the microbiome.
• Gary Steinberg, MD, PhD chair of neurosurgery, founder and co-director of the Stanford Stroke Center whose success in pioneering clinical trials in stem cell therapy for stroke patients has received a great deal of recent international media attention.

Featured musical entertainment by Malcolm Campbell, notable professional  jazz musician, composer and Stanford neuroscience PHD candidate. Having performed at world-class venues such as Carnegie Hall, the Montreux Jazz Festival and others, Malcolm provided a special evening show for guests celebrating the intrinsic connection between medicine and the arts.

A peak into my career journey, and how I started out studying psychiatry but ended up a cerebrovascular neurosurgeon.