• Aneurysm

Despite our confusing yet enduring polysyllabic labels as interventional neurologists, interventional neuroradiologists or endovascular neurosurgeons, there is a common feature we all share. Our success is largely defined by our procedural proficiency, which can dramatically restore function or cause frightening neurologic injury. We routinely get thanked for ‘saving someone's life’.

This inherent focus on procedures that have profound implications may have an unintended effect on how we practice medicine. In the office we introduce ourselves, obtain a focused medical history, perform a medical and neurologic examination, review the imaging findings, and then decide on a treatment option. As a practice gets busier and even more data need to be reviewed, to save time, this consultation is further distilled down to the essentials. Then, we start talking at our patients. We start talking in more absolute terms. We remember our patients more by their angiograms than their faces or personalities. Decisions are quickly reached and we find ourselves persuading patients to follow our plans. With time, a sense of infallibility grows.

Whether in private practice or academic medicine, physicians are directly incentivized to serve themselves first. Compensation often increases for greater quantity, rather than quality, of procedures performed. To grow practices, physicians are increasingly promoting themselves on webpages, social media, and online videos. Promotion in academic medicine is based on documenting a long list of personal publications, accomplishments, and accolades. The process of maintaining an academic CV often feels narcissistic.

Nearly all of us have been approached to participate in lectures, proctoring, trialing of new devices and even showcasing actual live cases to sales representatives or conferences. The financial incentives, promise of innovation, and opportunity for self-promotion are compelling. These interests mutate our focus and insidiously influence how we determine procedural indications, timing of the procedure, and technical approach. It is a shame when patients (fortunately not often) are harmed as a direct result of trying to satisfy these competing interests.

Whether it is the rising use of social media (#humblebrag) or a culture that increasingly accepts self-celebration, there are now more opportunities for self-promotion than ever before.1 Even the word ‘humbled’ has been misused to describe a happy sentiment after achieving an accolade. Communication is becoming increasingly faster, louder, less subtle, and more abbreviated. Interacting with others via social media prioritizes the ability to immediately attract attention.2 Daily life is viewed more through the lens of whether a thought or event is worthy of a status update. The more ‘likes’ the better, and the ‘score’ is available for everyone to see. Again, the maintenance of an ‘online brand’ in this way becomes yet another ostentatious exercise.

Preoccupation with self-promotion and external validation is usually inversely proportional to developing strong inner character. The self-promoting person becomes fragile and grating. They tend to be highly competitive and are constantly trying to distinguish themselves. The opinions of colleagues are quickly dismissed. When things go awry during a complicated procedure, there may be rapidly escalating expressions of anger, blame, and tension. Physicians with unchecked arrogance contribute to low hospital morale, excessive stress, and high staff turnover.3

With our proclivity to feeling infallible, incentives, industry interests and a culture that encourages self-promotion, we are increasingly at risk of losing track of a defining trait for all physicians. We all value several traits including erudition, technical skill, wisdom, compassion, and humility. T. S. Eliot wrote, “Humility is the most difficult of all virtues; nothing dies harder than the desire to think well of oneself”.4

Although Webster defines humility quite simply as ‘freedom from pride and arrogance’, there are many nuances to it. There is the self-debasing humility from someone who truly feels inferior, to the diabolical pseudohumility characterized by Uriah Heep. There are the arrogant types who are ‘proud in that they are not proud’, which may have led to the modern day ‘humblebrag’, a phenomenon that is likely a product of social media. Immanuel Kant more precisely captures the essence of true humility with his famous quote, “Out of the crooked timber of humanity, no straight thing was ever made”. Those who take humility to heart acknowledge that all of us have deep divisions and flaws.

Humility should not be mistaken for mediocrity, indecisiveness, or incompetence. It is the essential motivator to the sustained pursuit of knowledge. Humility allows us to challenge fundamental assumptions when new evidence arises. It motivates us to prepare for complications before they happen,5 and often eases the emotional toll when they do occur. Humility clarifies our limitations and allows the recognition and respect of the expertise of others. We need an element of humility to allow gratifying collegial relationships and build well-functioning multidisciplinary teams. The self-effacing person is not preoccupied with keeping score or proving himself or herself. As a result, they are more disarming and gracious, which yields admiration and companionship. Humility is the awareness that there's a lot you don't know, and even what you think you know may be distorted or wrong.6

Many neurointerventionalists have concerns over the perceived threat of non-neuroscience trained physicians who are familiar with catheters, in performing mechanical thrombectomy. This reaction is an understandable survival instinct. Humility helps us redirect our focus back to the patient. Rather than using the concept of ‘appropriate training’ as an excuse, it should be taken to heart and directed to ourselves first. A colleague I know regularly reviews her cases at the end of the day, takes notes in a journal of the devices and techniques she used, what didn't seem to work, and hypotheses as to what might be a better approach next time. The intention of this process is not necessarily to create material to be later published. This is a deeply personal exercise and is intended to improve her ability to care for patients, to perfect her craft, mind, performance and judgment. Rather than fretting over politics, she is known as an erudite and skillful physician who continually strives to be better.

Humility is an internal code of conduct that keeps us disciplined in our thoughts and actions. It helps keep feelings of infallibility, incentives, industry, and cultural influences in perspective. We can recognize the value in taking extra time to have an open and honest conversation with patients. Talking with patients instead of at patients promotes trust, and allows the physician to build respect for the complexity of each patient. It becomes easier to treat patients the way they should be treated. As a result, patients become the highest priority in every decision.

It is a more difficult struggle to triumph over our weaknesses rather than garner external approvals, incentives, and ‘likes’. Humility helps us endure these temptations, and with time, builds resilience. Humility also helps develop the necessary equanimity to manage our busy and tension-filled days. It is an essential step in the struggle for a solid moral code, which over time yields character. Level 5 physician leaders, according to Collins,7 have a genuine humility defined as a contagious, burning obsession and ambition for their patients and their work, not themselves.