0:00

How should I refer to you? What do you

0:02

prefer? You know, I can

0:04

go for almost anything. My full

0:06

name is Alfredo Guiones Inocosa. Some

0:08

people can pronounce and some people

0:11

can add and this is why

0:13

people began to call me Dr.

0:15

Q. Dr. Q is a brain surgeon.

0:17

and chair of neurosurgery at

0:19

the Mayo Clinic's Florida campus.

0:22

He's got an absolutely astonishing

0:24

life story, which we'll get

0:26

to later. But first, I

0:28

want to zoom in on

0:30

one of his surgical days.

0:33

He says his work begins

0:35

long before he steps into

0:37

the operating room. So the

0:39

moment someone sends me a

0:41

picture about their scan, their

0:43

surgery begins to happen in

0:45

my brain, the potential complications,

0:48

the potential dangers, the issues

0:50

that can become catastrophic. On

0:52

every surgery day, he follows

0:54

a careful routine. I like

0:56

to come in early in the

0:58

morning. I like to review all

1:01

the films, review my notes about

1:03

the patient and family. Most of

1:05

Dr. Q's surgeries involve removing brain

1:07

tumors. And in the morning, as

1:09

he studies the images, he's mapping

1:12

out the challenges ahead. It's like

1:14

when a boxer walks into the

1:16

ring is when the lights are

1:18

above them. But the real training,

1:21

the real fight happened in a

1:23

dark room, in a dark gym,

1:25

day after day, for many, many

1:27

days before the surgery months.

1:29

In my case, it's many

1:31

years of preparation. But that

1:33

morning, when I'm looking at the

1:36

films, I am cementing all those

1:38

years of training into one

1:40

specific moment where I know

1:42

exactly what I know. need

1:44

to do and I have an

1:46

idea about the potential dangers

1:49

and how to dance

1:51

around those potential dangers.

2:00

I'm Dan Heath and this is

2:02

what it's like to be.

2:04

In every episode we walk

2:06

in the shoes of someone

2:08

from a different profession. A

2:10

hair stylist, a turnaround consultant,

2:12

an archaeologist, an archaeologist. We

2:14

want to know what they

2:17

do all day at work.

2:19

Today we'll ask Dr. Alfredo

2:21

Piniones Inohosa what it's like

2:23

to be a brain surgeon.

2:25

We'll talk about how he

2:27

knows where to cut and

2:29

not cut. What it's like

2:31

when the operation does not

2:33

go as planned and his

2:36

own remarkable path to the

2:38

operating room. Stay with us.

2:40

On the day of a

2:42

surgery, after Dr. Q has

2:44

reviewed images of the patient's

2:46

brain, he visits them before

2:48

their wheeled away to get

2:50

anesthesia. We already spoke about the

2:53

dangers of brain surgery and I

2:55

like to keep it positive. I

2:57

like to make sure that they

3:00

feel my pulse the warm of

3:02

my hand. I like to sit

3:05

right next to them. I like

3:07

to ask them what they had

3:09

for dinner the day before and

3:12

I like to ask them about

3:14

some stories that I could potentially

3:16

use in the operating room because

3:19

the majority of my surgeries are

3:21

with the patients awake and have

3:23

to monitor their speech and their

3:26

function. So the more connections I

3:28

have with them, the easier it

3:31

is for them to overcome the

3:33

fears and anxieties they have. And

3:35

do you still get nervous before

3:38

a surgery? Oh my goodness. And

3:40

every time I am about to

3:42

walk into the operating room, I

3:45

get nervous. is that fine line

3:47

between life and death that gives

3:49

you the pass, the preoccupation, the

3:52

adrenaline to make sure that all

3:54

your senses are hyper, not just

3:57

acute, but are hyper. acute so

3:59

time slows down your ability to

4:01

see here multitask it gets super

4:04

enhancing this that adrenaline in my

4:06

opinion that allows you to do

4:08

things that are sometimes considered to

4:11

be very challenging for instance the

4:13

moment that something goes wrong which

4:15

has happened to me after you've

4:18

done 5,000 surgeries You know, there's

4:20

been moments where suddenly something changes

4:23

quite rapidly, a blood vessel explodes,

4:25

the vital change, a patient has

4:27

a heart attack, the heart stuff,

4:30

you name it, anything. And at

4:32

those moments, your adrenaline goes through

4:34

the roof, your heart goes to

4:37

180 bits per minute, and yet

4:39

you have to remain calm. Pain

4:42

is a picture of what the

4:44

operating room is like for you.

4:46

Like is it is it quiet?

4:49

Are you playing music? How many

4:51

people are in the room? I

4:53

tell you this is the operating

4:56

room for me is like an

4:58

orchestra, it's like a symphony, because

5:00

if you listen to the sounds

5:03

of about 20 to 25 people

5:05

moving around the operating room quietly,

5:08

the anesthesiologist, the machine beeping, the

5:10

machine breathing for the patient sometimes.

5:12

If you then go on to

5:15

the side and you look at

5:17

the neurologists that are helping me

5:19

monitor the brain function with electrophysiology

5:22

and you listen to their keyboards

5:24

as they're entering information or the

5:26

squiggly lines that are beeping also,

5:29

it sort of makes some music

5:31

and then you listen to the

5:34

scrap text. the circulating nurses moving

5:36

equipment and that sound is like

5:38

the precaution you know and they

5:41

bend and and if you listen

5:43

to the steps you know of

5:45

the people moving around quietly in

5:48

the open room, where you listen

5:50

to the scrubs, rubbing, you can

5:52

listen to all that, and it

5:55

becomes the most beautiful music you

5:57

can possibly imagine. What are the

6:00

tools that you have at your

6:02

disposal? What are you holding or

6:04

wearing as you operate? Well, several

6:07

things I have high magnification glasses.

6:09

They're called loops, you know, and

6:11

a headlight. And once I get

6:14

deeper into the brain, I bring

6:16

a microscope that it is more

6:19

expensive than my house. You know,

6:21

it gets in there, it gives

6:23

me amazing light and a microscope

6:26

that I can control with my

6:28

mouth. Wait, say that again, you

6:30

control. I control the microscope with

6:33

my mouth. You control the microscope

6:35

with your, how? Yes, usually I

6:37

grab, I have a small little

6:40

handle that is in my mouth

6:42

that controls this piece of equipment

6:45

that is, you know, over a

6:47

ton, and I can move it

6:49

and it's all the technology then,

6:52

isn't that amazing? And I can

6:54

still talk because I usually use

6:56

my teeth a little bit, and

6:59

I can still talk the ways

7:01

that you hear me talking as

7:03

I'm moving the microscope. So you're

7:06

sort of like chomp down on

7:08

something and you move your head

7:11

to turn it or you're using

7:13

like breath in and out or

7:15

what's the... I use my head.

7:18

I imagine you just you just

7:20

put a pen in your mouth

7:22

and you just moving your pen.

7:25

That's it. That is crazy. Then

7:27

on top of that, I'm not

7:29

done yet. Then I use a

7:32

special chair. that it has all

7:34

kinds of controls. You know, in

7:37

my feet, in one foot, I

7:39

have about 16 controls that allow

7:41

me to do things with the

7:44

chair and the microscope that suddenly

7:46

I am fully connected to the

7:48

patient in such a way that

7:51

the patient, the brain, the microscope

7:53

and myself were almost one person.

7:56

So when one foot, 16 controls.

7:58

with the other foot about eight

8:00

controls and both of my hands

8:03

are underneath the microscope under high

8:05

level of magnification and you have

8:07

instruments that are finer than the

8:10

finest pain you can possibly imagine

8:12

doing microscopic movements to separate a

8:14

small little blood vessel that is

8:17

the size of a hair but

8:19

you know that that little blood

8:22

vessel could potentially mean the difference

8:24

between memories or no memories, speech

8:26

or no speech, motor function or

8:29

no motor function. So that's how,

8:31

and you take your time and

8:33

your patience and you're listening to

8:36

the orchestra, the symphony of the

8:38

operating room and you're handing your,

8:40

you're moving your hands and your

8:43

nurse predicts. the instrument that you're

8:45

going to need, a small little

8:48

microscopic scissors, small little microscopic, very

8:50

sharp instruments that may look like

8:52

a little scoop, small little instrument

8:55

that may look like a little

8:57

spatula that moves the blood vessel,

8:59

the brain, or sometimes you use

9:02

a small little devices that cutterizes

9:04

more little vessels. They look like

9:06

tweezers and you're getting together and

9:09

you're moving around. One of the

9:11

most striking things about brain surgery

9:14

is, as you said, that the

9:16

patient is often awake. Why is

9:18

that important? Well, then, the reason

9:21

why being awake is important for

9:23

me in my specialty, because I

9:25

do brain surgery, there are brain

9:28

surgeons, I do vascular neurosurgery, I

9:30

do brain. tumors. And the majority

9:32

of the brain tumors that I

9:35

do are intricately related and adjacent

9:37

or sometimes invading and penetrating parts

9:40

of the brain. where speech function

9:42

is important, where motor function is

9:44

important, where vision is important, or

9:47

memory is important. And there's no

9:49

machine then in the world that

9:51

can monitor those functions better than

9:54

the patient's own brain. So what

9:56

I tell... patients when they ask

9:59

me why do we need to

10:01

do this surgery awake I said

10:03

because your brain is the best

10:06

neuro monitoring technique that I have

10:08

available in the world to be

10:10

able to do the best surgery

10:13

for you. So is the idea

10:15

that as you're inspecting the site

10:17

of the tumor that you can

10:20

you know, deliver little electrical zaps

10:22

to different part of the brain

10:25

and you're kind of monitoring to

10:27

see, okay, when we zap that,

10:29

does anything bad happen? Is that

10:32

the idea? 100%? I zapped the

10:34

little area and suddenly the patient

10:36

stopped stalking and I know, oh

10:39

my gosh, I should not take

10:41

that out. But how, I mean,

10:43

there's like a thousand different things

10:46

that your brain does? I mean,

10:48

how do you sort of monitor

10:51

for all those things in real

10:53

time? So over the years, what

10:55

we began to realize is that

10:58

the brain has function, is organized,

11:00

has eloquence, has parts of the

11:02

brain that are like oceans where

11:05

we have no idea what kind

11:07

of function is there. So the

11:09

way I do with my patients,

11:12

I asked the question. You know,

11:14

I recently had a patient that

11:17

mathematics accounting was very important for

11:19

him. And we needed to make

11:21

sure that we preserved that function

11:24

to the max. So we for

11:26

going to the operating room, we

11:28

did maximum amount of testing to

11:31

maximize the test that we could

11:33

do in the OR that will

11:36

maximize that function preservation. And that's

11:38

what we do. Wait, so you

11:40

were giving him like math questions?

11:43

Yes, math questions during the surgery,

11:45

absolutely. Very complex math questions to

11:47

which I had no idea what

11:50

the answer was. So you had

11:52

to refer back to his own

11:54

answers to see if he was

11:57

getting it right? Well, I had

11:59

a neuropsychologist, we had a mathematician,

12:02

you name it. And then imagine,

12:04

I had another patient who was

12:06

a patient that was a music,

12:09

a classical guitar expert, and he

12:11

did an amazing job. He had

12:13

a two-hour concerto that he put

12:16

together for me. So during my

12:18

entire surgery, he was serenating me

12:20

with music. from my own country

12:23

from Mexico from the 40s and

12:25

50s. You know, music from the

12:28

United States from the 60s and

12:30

70s. So he had a whole

12:32

two hours because I had to

12:35

make sure that I preserve. He

12:37

says, I'm okay if I cannot

12:39

talk, but I cannot not play

12:42

music. I need to play my

12:44

guitar. You know, I had another

12:46

patient recently that he was important

12:49

for him. He works at an

12:51

airport and he directs. traffic. So

12:54

air control. So we set up

12:56

our computer to simulate what work

12:58

would be like. And during the

13:01

surgery he was monitoring flights, directing

13:03

flights, all kinds of stuff. That

13:05

is so interesting. So it's actually

13:08

different for different patients. I didn't

13:10

expect that. That's exactly. For someone

13:13

like you would have to be

13:15

probably dependent. Just listen to you

13:17

which make sure that we preserve

13:20

your voice, your ability to ask

13:22

all these probing questions in an

13:24

interview and you name it. So

13:27

what are the kinds of classic

13:29

tests that you're administering as you

13:31

work? You're looking for speech comprehension,

13:34

I assume. What else? Well, there

13:36

are some baseline things that we

13:39

have sort of utilized for decades

13:41

the ability to read sentences, the

13:43

ability to understand. complex instructions, you

13:46

know, the ability to produce speech

13:48

that compliments, being asked a question,

13:50

and then being able to answer

13:53

that question, what does the cow

13:55

do? Well, they move, you know,

13:57

what does the, you know, tiger

14:00

do, and so on and so

14:02

forth? So there's a lot of

14:05

questions that are baseline, you know,

14:07

functions, and I follow. The best

14:09

way that I can describe it,

14:12

the brain has soul sci and

14:14

gyra, the best way that I

14:16

can describe it, it has roads,

14:19

avenues. And I go avenue by

14:21

avenue, road by road, and I

14:23

begin to stimulate and put in

14:26

numbers. And when I find an

14:28

area that has a question, I

14:31

pass, I keep going, and then

14:33

I go back to that area

14:35

a few minutes later and find

14:38

out, is that area important? Was

14:40

that just a mistake? Was it

14:42

real? I do it at a

14:45

minimum of three times to confirm

14:47

that it was not just an

14:50

oversight because we all made mistakes.

14:52

So when you hit a part

14:54

of the brain that clearly is

14:57

responsible for some core function and

14:59

you realize it, how do you

15:01

realize it? Sometimes it's so abrupt,

15:04

you know, let's say that I

15:06

have a patient and I tell

15:08

the patient, I want you to

15:11

count from one to 40. And

15:13

they start one, two, three, four,

15:16

five, and I'm waiting until they

15:18

get a rhythm. And then when

15:20

they're like around 10, I go

15:23

ahead and stimulate a part of

15:25

the brain. And there is no

15:27

function. They keep counting like nothing.

15:30

If it is a part of

15:32

the brain where I can literally

15:34

stop language, the patient stops as

15:37

the moment I touch to the

15:39

brain with my stimulator. And they

15:42

passed and I got my stimulator

15:44

on the brain for one second,

15:46

two seconds, three seconds, making sure

15:49

that I don't give any seizures

15:51

and then suddenly I take the

15:53

stimulator away from the brain and

15:56

the patient can. 11 12 13

15:58

and then you ask him what

16:00

happened and they'll be like what

16:03

do you mean what happened I

16:05

was counting they don't realize that

16:08

you have them stop time isn't

16:10

that amazing that's how beautiful the

16:12

brain is that is completely insane

16:15

what is the strangest response you

16:17

ever gotten from one of those

16:19

tests well the stranger response is

16:22

eliciting memories strangest and at the

16:24

same time more and beautiful You

16:26

know, we're stimulating a part of

16:29

the brain and suddenly the patient

16:31

will remember a memory of childhood,

16:34

a beautiful memory of their parents,

16:36

a beautiful memory of their pet

16:38

or something very powerful. And they

16:41

get either very ecstatic, if it's

16:43

a happy memory, or they get

16:45

very sad if it's a sad

16:48

memory. And that to me is

16:50

the beauty of how little. we

16:53

know about the brain and how

16:55

much more we need to learn.

16:57

This is absolutely fascinating. I mean,

17:00

what is so striking is that,

17:02

I mean, here brain surgery is

17:04

surely one of the pinnacles of

17:07

human achievement. I mean, the sophistication

17:09

of the people in the room

17:11

and the tools and the monitoring

17:14

and then adjacent to that. is

17:16

the actual mechanics of the surgery

17:19

are you're going around poking parts

17:21

of the brain to see if

17:23

they're safe to cut out with

17:26

a knife. You know what I

17:28

mean? It's like this incredible blend

17:30

of complexity and almost like plumbing

17:33

behaviors. 100% I agree with you

17:35

and I poke fun of myself.

17:37

I tell people that I'm nothing

17:40

else but a highly regarded mechanic

17:42

of the brain. That's it. As

17:45

I always see myself, and of

17:47

course, I do recognize it, that

17:49

it is very complex, very sophisticated,

17:52

and it took many, many years

17:54

to get to where I am.

17:56

of course, I've been doing this

17:59

for over 25 years, but the

18:01

reality is that there's some level

18:03

of simplicity that you very eloquently

18:06

illustrate. You gotta roll your sleeves

18:08

up and you gotta get in

18:11

there and you have to have

18:13

sometimes little splashes of blood in

18:15

your face, you gotta get a

18:18

little bit of that bone dust

18:20

that comes along when you are

18:22

removing this skull or sometimes a

18:25

little bit of... the smell of

18:27

the muscle as it's being, you

18:30

know, cutter eyes with electricity and

18:32

the little smoke that comes out.

18:34

That's 95% of my work, but

18:37

a lot of the attention isn't

18:39

the 5% because it is absolutely

18:41

remarkable. I gotta tell you that

18:44

the most remarkable thing for me

18:46

is not what I do as

18:48

a brain surgeon, it's not the

18:51

technology, but to me is the

18:53

fact that a patient and their

18:56

low ones are willing to. put

18:58

their lives on the hands of

19:00

strangers. And that to me speaks

19:03

about the power of trust and

19:05

the power of believing, which is

19:07

all in the brain. And that

19:10

to me is remarkable. Hey folks,

19:12

Dan here. Someday there's going to

19:14

be a mattress ad in this

19:17

verbal space, but for now can

19:19

I make this about me? I've

19:22

got a new book out called

19:24

Reset, How to Change, What's Not

19:26

Working. If you feel like things

19:29

in your life or work could

19:31

be better, but you also feel

19:33

weighed down by the gravity of

19:36

the way things always work, this

19:38

is the book for you. It

19:40

got a nice review in the

19:43

Wall Street Journal, and it's a

19:45

New York Times bestseller, so I

19:48

guess it's got bipartisan appeal. It's

19:50

received kind words from Adam Grant

19:52

and Oprah Daily and Apple and

19:55

Amazon and this is maybe my

19:57

favorite. One Amazon... viewers headline was,

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20:02

read, which is admittedly a pretty

20:04

low bar in the business genre,

20:07

but at least you know it's

20:09

not going to be a dry

20:11

slog. And so that's the sales

20:14

pitch I'm going to leave you

20:16

with, reset, not a dry slog.

20:19

The audible or Apple audio

20:21

versions of the book are

20:23

just a click or two

20:25

away, see the show notes.

20:27

So if you need some

20:29

more commute filler in between

20:31

episodes of this show, check

20:33

it out. And now, back

20:35

to the show. What is

20:37

the track record for the

20:39

kind of brain surgery that

20:41

you do? Is it relatively

20:44

high percentage chance of success

20:46

or... Are the situations so

20:48

precarious that any chance of

20:50

success is worth trying or?

20:52

Luckily nowadays is extraordinarily high.

20:54

The chances of complication for

20:56

a healthy person, you know,

20:58

are probably in the one

21:00

to two percent kind of

21:02

complication. Wow. Think about this

21:04

then, 100 years ago, it

21:06

was almost a 100% mortality

21:08

with brain surgery. So we

21:10

have come a long, long

21:12

way. When they brought the

21:14

leaches out, you know. Yes,

21:16

remember, they used to. So

21:19

I think the chances of

21:21

success are very high. Now,

21:23

having said that there's still

21:25

a percentage, 5 to 10%

21:27

that you may have an

21:29

issue, that you may have

21:31

a deficit, whether it's... motor

21:33

functioning, ability to move the

21:35

hand, leg, face, or some

21:37

sort of a speech deficit.

21:39

And at one point, you

21:41

don't know exactly if he

21:43

was done by the surgery

21:45

or exacerbated by the surgery,

21:47

or was it just the

21:49

fact that the air hit

21:51

the brain and you mobilized

21:53

things, or the diseases moving

21:56

so rapidly that is affecting

21:58

other parts of the brain.

22:00

But nonetheless, luckily, the chances

22:02

of success are... so high

22:04

now. Every now and then

22:06

you will have a patient

22:08

where you look at the

22:10

scans and you realize no

22:12

matter what I do to

22:14

this patient all I am

22:16

going to do is do

22:18

a brain surgery and they're

22:20

going to spend the last

22:22

few months of their life

22:24

in and out of the

22:26

hospital. So I want to

22:28

do what is best for

22:31

this patient and their family

22:33

and sometimes what is not

22:35

to do anything. What do

22:37

tumors look like? You know,

22:39

and the MRI, tumors look

22:41

most of the time like

22:43

a light bulb. And people

22:45

say, oh, there is the

22:47

tumor. It should be no

22:49

problem taking it up. Once

22:51

you walk into the operating

22:53

room, many times there is

22:55

no clear distinction between what

22:57

is tumor. and what is

22:59

normal and most especially at

23:01

the edges of the tumor

23:03

when the tumor begins to

23:05

invade the brain and we

23:08

know there are cancer cells

23:10

right there and very likely

23:12

important brain at those edges

23:14

but you can tell the

23:16

difference. What does it feel

23:18

like when the surgery is

23:20

over? Well first of all

23:22

I tell you that for

23:24

me the most stressful moment.

23:26

If everything went well with

23:28

the surgery, as I expect

23:30

that it will go, I

23:32

finish the surgery, I wait

23:34

around until that patient is

23:36

awake and moving. In 2008,

23:38

ABC's documentary series Hopkins followed

23:40

Dr. Kew at Johns Hopkins

23:43

Hospital in Baltimore. Cameras rolled

23:45

as he performed brain surgery.

23:47

What do you think we

23:49

have here? It's fairly straightforward

23:51

meningeoma. Wonderful news. Thank you.

23:53

And the patient is getting

23:55

extubated at the end of

23:57

the surgery, and then the

23:59

anesthesiology is going, show me

24:01

two fingers. No. function. Squeeze

24:03

my hand. No functions. And

24:05

then I'm looking at this

24:07

and I'm getting worried or

24:09

right because I know what

24:11

that potentially means. So I

24:13

come in and I say,

24:15

Michael, squeeze my hand. Squeeze

24:17

my can Michael. Squeeze. And

24:20

you're literally yelling because remember

24:22

they're coming out of anesthesia.

24:24

Squeeze my hand, but. Squeeze

24:26

my hand. At that

24:28

point my heart was about

24:30

to burst out of my

24:32

chest. I was thinking, did

24:34

I do something to that

24:37

patient? That patient is not

24:39

going to be able to

24:41

wake up. Wiggle your toes.

24:43

Can you wiggle your toes?

24:45

There you go. Yes. Very

24:47

good. Yes. Just great. Just

24:50

great. Just great. I mean,

24:52

just... This is what keeps

24:54

me going every day, you

24:56

know, I mean... I deal

24:58

with very bad disease, you

25:00

know, brain cancers is tough.

25:02

But every now and then

25:05

when you just have this

25:07

nice, very good news, it's

25:09

just exciting. Everything is great.

25:11

So he'll be Mike again.

25:13

I think so. Very good.

25:15

Okay. I tell people, we

25:18

are not better doctors than

25:20

many other doctors. We are

25:22

not. better surgeons than many

25:24

other surgeons. I think that

25:26

what makes us special and

25:28

different, why society has put

25:31

us where we are, is

25:33

because we have this amazing

25:35

ability to emotionally deal with

25:37

so much uncertainty and where

25:39

the outcomes and the stakes

25:41

are so high every single

25:43

day between life and death

25:46

in the operating room. What

25:48

is it like when the

25:50

surgery just doesn't end in

25:52

a success? I would say

25:54

that the more... difficult times

25:56

in my life. The moments

25:59

where I have landed and

26:01

got down in my knees

26:03

where life just puts you

26:05

down and you feel like

26:07

there's a fine line between

26:09

not wanting to do this

26:11

again and quitting had been

26:14

those moments where the surgery

26:16

didn't go the way. that

26:18

I didn't want it to

26:20

go. And I cannot tell

26:22

you that it's never happened

26:24

to me. Unfortunately, when you

26:27

have done this for more

26:29

than 5,000 times, it has

26:31

happened to me. I think

26:33

those are the moments that

26:35

have taken years of my

26:37

life then. And those moments,

26:39

I gotta tell you, they're

26:42

not easy for me to

26:44

get over. It takes weeks,

26:46

months, years. And I always

26:48

tell people, I carry those

26:50

cars in my heart. I

26:52

have never forgotten the patience

26:55

that have passed through this

26:57

life where I have wondered

26:59

did I do something to

27:01

accelerate that demise. There's a

27:03

great Netflix. episode about you

27:05

and your work. We'll put

27:07

the link in the show

27:10

notes. But at one point

27:12

you have this quote where

27:14

you said you went from

27:16

harvest to Harvard in less

27:18

than seven years. Tell our

27:20

listeners what you meant by

27:23

that. It was amazing. You're

27:25

talking about the surgeons cut.

27:27

That is a quote that

27:29

Most people don't realize I

27:31

came to this country in

27:33

1987 undocumented from a very

27:35

poor family in Mexico. They

27:38

had, my parents had no

27:40

education. I was undocumented. I

27:42

was poor. I came to

27:44

this country undocumented and poor

27:46

to work on the fields

27:48

of California. in 1987 and

27:51

by 1994 I was matriculating

27:53

our Harvard medical school. That

27:55

is absolutely crazy. I mean

27:57

what do you attribute that

27:59

to? You know I gotta

28:01

tell you that I wish

28:03

I can give you the

28:06

recipe for many is now.

28:08

Now it made me reflect

28:10

about the miracle. And I

28:12

attribute this, I'm going to

28:14

say it, I attribute this

28:16

to how amazing this country

28:19

is. This is the country,

28:21

this is the land of

28:23

opportunities. Now, don't take me

28:25

wrong, we still can do

28:27

a lot for humanity for

28:29

our country, but I cannot

28:31

conceive stories like this happening

28:34

in. too many places around

28:36

the world, and I still

28:38

believe they can only happen

28:40

here in the United States.

28:42

Another point in the episode

28:44

that I appreciated, and correct

28:47

me if these facts are

28:49

wrong, but at one point

28:51

I think you said that

28:53

you're one of 50 grandkids

28:55

for your grandfather and that

28:57

you were the worst behaved

28:59

of the lot. I was

29:02

one of 54 in my

29:04

father's side. In my district,

29:06

I was not the oldest,

29:08

I was not the smartest,

29:10

I was not the hard

29:12

worker. My distinction was that

29:15

I was the one who

29:17

got in trouble the most.

29:19

all the time. I had

29:21

such an inquisitive mind in

29:23

a curious personality and when

29:25

people say no to me

29:27

I wanted to do it

29:30

even more. So my grandmother

29:32

and my grandfather played an

29:34

important role. My grandfather, he

29:36

was an extraordinarily gifted man

29:38

in music and even though

29:40

he never went to school

29:43

he learned how to play

29:45

many instruments and he had

29:47

a wandering spirit he would

29:49

allow me to go and

29:51

explore and I could do

29:53

no wrong in his eyes

29:55

and my grandmother she was

29:58

the opposite she was the

30:00

one who was also by

30:02

the way a town healer

30:04

and a midwife, and I

30:06

saw the amount of respect

30:08

that people had for her,

30:11

the love that people had

30:13

for her, but she had

30:15

also a very strong personality,

30:17

and she was a disciplinary

30:19

towards me. And nowadays then,

30:21

if you look at me,

30:23

if you look at my

30:26

picture, and you look at

30:28

a picture of my grandmother,

30:30

Imagine that you see me

30:32

the more I age, the

30:34

more I look like my

30:36

grandmother physically, spiritually, and also

30:39

in my personality. How much

30:41

does being a brain surgeon

30:43

affect the choices you make

30:45

in your daily life? Like

30:47

are there things you won't

30:49

do because it might injure

30:52

your hands, which are of

30:54

course precious for surgery? you

30:56

have alluded to something that

30:58

I had to think about

31:00

it because remember I was

31:02

a migrant farm worker in

31:04

1987 I fixed a 351

31:07

v6 Chevrolet engine and so

31:09

on and so forth I

31:11

was working in the field

31:13

speaking cotton tomato driving all

31:15

these machines And suddenly, here

31:17

I am, years later after

31:20

Harvard and after my residency

31:22

and being at Hopkins and

31:24

not here at Mayo, where,

31:26

you know, I have to

31:28

be careful with what I

31:30

do. And that came clear

31:32

to me when I finished

31:35

Harvard and I went back

31:37

to California, to the University

31:39

of California San Francisco. I

31:41

had my pickup truck, it

31:43

was a 1987, you know,

31:45

Nissan pickup truck, and the

31:48

alternator needed to be exchanged.

31:50

And I proceeded to bring

31:52

my tools out and exchange,

31:54

and it was a little

31:56

bit rusty, and I was

31:58

struggling, and suddenly one of

32:00

the ranges slipped, and I

32:03

ended up cutting my hand.

32:05

And it was for the

32:07

first time, and I was

32:09

already a resident in neurosurgery,

32:11

it was for the first

32:13

time that I realized that

32:16

what I did had consequences,

32:18

but not just on myself,

32:20

but on the people that

32:22

I cared for, in such

32:24

a way that I couldn't

32:26

scrub. my hands for a

32:28

few weeks until that wound

32:31

healed. So therefore my actions

32:33

could have a downstream effect

32:35

on other people that I

32:37

care for. So yes, there

32:39

are things that I think

32:41

about. You know, and you'd

32:44

be surprised. So, you know,

32:46

the Netflix, you saw it,

32:48

you'd know that I love

32:50

boxing. I don't get into

32:52

the ring anymore. The last

32:54

time was when I was

32:56

17 years old. But I

32:59

love having my punching bag

33:01

and exercising. What do I

33:03

do? I wrap my hands

33:05

and my wrist in ways

33:07

that you could never imagine.

33:09

I also study for many,

33:12

many years, the way in

33:14

which I should sit a

33:16

bag without prompting any injury

33:18

on my fingers, my wrist,

33:20

or anything else. So Dr.

33:22

Kew, we always end our

33:24

episodes with a lightning round

33:27

of questions. Let me fire

33:29

away here. What is a

33:31

word or phrase that only

33:33

someone from your profession would

33:35

be likely to know? And

33:37

what does it mean? Show

33:40

me two fingers. That's the

33:42

diagnostic that things are going

33:44

to. Okay, right? That's exactly

33:46

right. Show me two figures,

33:48

but I also have some

33:50

other connotations, as you know.

33:52

I thought you were going

33:55

to give me some obscure

33:57

neuro anatomical term or something.

33:59

Well, yes, I will do

34:01

that too. Where is the

34:03

inducedum grissum? Above the neck.

34:05

What is the most insulting

34:08

thing you can say about

34:10

a brain surgeon's work? This

34:12

is so funny that you

34:14

ask that. I would say

34:16

that the most insulting thing

34:18

that you can say is,

34:20

is not so much about

34:23

my work, but the profession.

34:25

Because it's actually insulting to

34:27

the opposite profession. When someone

34:29

says to you, oh, you're

34:31

a neurologist. And the neurologist

34:33

gets offended and the neurosurging

34:36

gets offended. The neurosurging gets

34:38

offended because we're not neurologists.

34:40

We know a little bit

34:42

of neurologists. We like to

34:44

think we're not as smart

34:46

as the neurologist. And the

34:48

neurologist gets offended because they

34:51

know that they're extremely bright

34:53

and they don't put their

34:55

hands on the brain. They

34:57

work through diagnosis and medications

34:59

and everything else. So I

35:01

would say that that's probably

35:04

insulting both ways to a

35:06

neurosurgeon, a brain surgeon, and

35:08

a neurologist. I love that.

35:10

It's a rare two-way insult.

35:12

That's right. What is a

35:14

tool specific to your profession

35:16

that you really like using?

35:19

I personally like to use

35:21

a bipolar quagulator, which is

35:23

like a little tweezers that

35:25

allows you to quagulate a

35:27

small little blood vessels. Like

35:29

how small would the action

35:32

zone on this thing be?

35:34

All this would be as

35:36

small as imagine trying to

35:38

grab a small little hair.

35:40

Wow. With these little tweezers.

35:42

You know, and sometimes the

35:45

only way you can see

35:47

that little hair is with

35:49

the microscope. That's why you

35:51

use the highest level. magnification.

35:53

That you're controlling with your

35:55

mouth? That you're controlling with

35:57

your mouth? Yes. Is normal

36:00

life just boring for you

36:02

after spending hours and that

36:04

kind of... Never, never, never,

36:06

and on the other hand

36:08

it allows me to see

36:10

life with such an enthusiasm

36:13

and such a love and

36:15

not take anything for granted?

36:17

What is a sound specific

36:19

to your profession that you're

36:21

likely to hear? sound of

36:23

the anesthesia machine beeping. The

36:25

beep beep beep beep which

36:28

is a heart beating and

36:30

you want to hear that

36:32

sound all the time. And

36:34

I imagine you're so accustomed

36:36

to that that you immediately

36:38

process any deviations from the

36:41

rhythm if it speeds up

36:43

or slows down? 100% and

36:45

you're a tune. and remember

36:47

what I was telling you

36:49

because you listen to the

36:51

music, you listen to the

36:53

orchestra, the symphony, and if

36:56

a note is off, you'll

36:58

recognize it right away. What's

37:00

an aspect of your work

37:02

that you consistently savor? Oh,

37:04

I savor every time I

37:06

finish a surgery and everything

37:09

goes well. I slightly is

37:11

most of the time and

37:13

I put families on the

37:15

room and I walk. into

37:17

the room and the first

37:19

thing that I like to

37:21

tell the family everything went

37:24

well and they all stand

37:26

up and before I even

37:28

get close to them they're

37:30

rushing to hug me and

37:32

those moments are so private

37:34

and they're so beautiful and

37:37

they are they touch my

37:39

heart they feel me with

37:41

hope and they give me

37:43

the energy to keep going

37:45

even in those moments of

37:47

darkness that we talked about

37:49

earlier. Dr.

37:57

Alfredo Kiniones Enahosa is a brain

37:59

surgeon and chair of the Department

38:02

of Neurologic Surgery at the Mayo

38:04

Clinics Campus in Jacksonville Florida. He

38:06

wrote about his remarkable journey to

38:09

the operating room in the book

38:11

Becoming Dr. Q, My Journey from

38:13

Migrant Farm Worker to Brain Surgeon.

38:16

You'll find a link to that

38:18

book in the show notes, along

38:20

with his featured episode in the

38:22

Netflix documentary series, The Surgeons Cut,

38:25

which is brilliant. I

38:27

can't stop thinking about harvest

38:29

to Harvard in seven years.

38:31

Incredible. As I see it,

38:33

it's a story with two

38:35

distinct sides. On one side

38:38

is Dr. Q's vast potential

38:40

and talent and drive to

38:42

have the ability to vault

38:44

himself upward like that. And

38:46

on the other side is

38:48

the ecosystem that allowed that

38:50

potential and drive to manifest.

38:52

So if you think about

38:55

someone you manage, or your

38:57

kid for that matter, you

38:59

can ponder that same two-sided

39:01

story. Are they capable of

39:03

thriving? And one side is

39:05

about their personal capacity in

39:07

drive, and the other is

39:09

about their environment. Are they

39:12

in a place that permits

39:14

them to thrive? It's kind

39:16

of like a plant and

39:18

the soil that it grows

39:20

in. universals with either. Some

39:22

plants are delighted in a

39:24

hanging planter and some plants

39:26

manage to grow 10 feet

39:28

tall in the desert. How

39:31

can we find the right

39:33

soil for the people we

39:35

care about? Dr. Q found

39:37

a place to thrive and

39:39

thousands of families are lucky

39:41

to have received his care.

39:43

Identifying the talents that a

39:45

patient could not stand to

39:48

lose. probing the brain to

39:50

distinguish invader from host, performing

39:52

in the symphony of the

39:54

op- room and sharing

39:56

the news

39:58

with desperate relatives

40:00

that their

40:02

loved ones came

40:05

through loved Folks,

40:07

that's what it's like

40:09

to be a brain surgeon.

40:11

be a brain shout -out

40:13

to to Apple podcast reviewers

40:15

podcast reviewers and J.P.J. Diamond 21. This

40:17

This episode was produced

40:20

by Matt Matt I'm

40:22

Dan Heath. See you

40:24

next time. time.