Neurosurgeons rely on judgment as much as surgical skill

“Good judgment comes from experience, and experience comes from bad judgment.”

Dr. Bill Monacci has long remembered an instructor passing on those words during his medical training to become a neurosurgeon. They underscore the critical role of judgment in his highly specialized field.

It is the very gravity of his profession that continues to impassion him. “I chose neurosurgery because of the broad spectrum of problems that patients face, and the variety of ways that I can help them,” he said. “The nervous system is the most complicated and most elegant system in the body, and having the potential to impact it in a positive way is totally gratifying,” he explained.

Dr. Monacci marked a year of practicing here in January, 2007. Before coming to Lancaster, he was Neurosurgery Consultant to the Army Surgeon General and Chief of Cranial Surgery at Walter Reed Army Medical Center. In that capacity, his judgment calls affected wounded soldiers, as well as the doctors he deployed to military zones.

“The whole process of medicine is a continual education,” he says. “Your judgment and skills are honed over time.”

His associate, Dr. Chris Kager, agrees. “The key to treating patients is in the breadth and depth of our training, plus the cumulative experience,” he said. Dr. Kager, who came here in 2001, credits Dr. Edward Benzel, Chairman of the Cleveland Clinic Spine Institute, as an important influence. During his fellowship in complex spine surgery at the institute, he says that Dr. Benzel drummed home biomechanics, a physics-oriented approach to diagnosis and treatment. “It looks at the forces and stresses on the spine in a pragmatic way,” Dr. Kager explained.

The judgment required to determine the right choice for each patient -- whether they would benefit more from surgery or from non-surgical therapy -- is just as important a skill for neurosurgeons as their ability to perform surgery, both doctors maintain. “Our function is not just to operate, but to make a good diagnosis,” Dr. Monacci says. The majority of patients who see a neurosurgeon do not end up having surgery, he explained, saying that it is the last tool in their arsenal unless the need for it is clear. “We’re getting better at determining the origin of pain in patients with particular spinal disorders. We’re learning how to best apply surgical techniques, and far more often, how to use non-surgical therapies to alleviate pain and restore mobility,” he said.

Dr. Kager says that with experience comes “a more total view of the patient.” “Instead of focusing on the fact that you’re dealing with a disc herniation, you tend to take a more global view -- how it impacts their life, their work, and their family,” he explained.

They see a very bright future for neurosurgery, and anticipate more applications of neuroscience to health care. One reason that they both chose Lancaster was because their group, Lancaster Neuroscience & Spine Associates, includes physiatrists. “The physiatrists are non-surgical spine specialists who are partners in solving the pain questions,” Dr. Monacci said. “Together we look at conservative treatments and judicious use of medication as our first line of defense.” The practice also offers acupuncture, a non-traditional approach that is effective for some patients.

Educating patients and helping them understand the treatment options are a challenging part of the job, they add. And most difficult of all, they say, is dealing with a young person with a serious head or spinal cord injury.

Whatever the situation that brings a person to them, Dr. Monacci and Dr. Kager are confident in their own judgment and deeply satisfied with the profession they chose.

“As you progress through training, it becomes important to discern who you can help with surgery,” Dr. Kager says, “but it’s equally important to know that some people are not going to respond favorably, that for some people it would be too much.”

There is another quote Dr. Monacci recalls from a teacher. “Remember, you’re going to walk out of the operating room”, he was told. “Give the same consideration to your patient.”