Dr. John Boockvar#239
Back when she was growing up on Long Island, my wife dated a kid who became a doctor. Which, hey, is totally OK. I mean, heck, there are lots of doctors out there. Doctors who help children get over coughs. Doctors who remove moles from wrists. Doctors who fix feet, doctors who heal knees, doctors who …
This doctor is a neurosurgeon.
But, eh, not just any neurosurgeon. One could argue that Dr. John Boockvar is the neurosurgeon. He’s the director of the Brain Tumor Center, Pituitary/Neuroendocrine Center and the Acoustic Neuroma Program of the Division of Neurological Surgery and the New York Head and Neck Institute at Lenox Hill Hospital and Manhattan Eye, Ear and Throat Hospital. He’s a professor of neurological surgery at the Hoftstra-North Shore-LIJ School of Medicine. He’s helped spearhead a ton of well-documented research that (just being honest) I lack the capacity to fully understand. Hell, he even has a Wikipedia page—which doesn’t happen to any ol’ physician. Worst of all, he’s a handsome, smart, cool guy with a fascinating Twitter stream (But I write sports books!).
In all seriousness, this is one of my all-time favorite Quazes, and I’m thrilled to welcome Dr. John Boockvar to the arena …
JEFF PEARLMAN: OK, John, so I’m going to ask something I’ve thought about myriad times, but have never asked anyone in your shoes. Namely, what goes into telling a person he/she is soon going to die? What I mean is, how do you prepare/steel yourself for that conversation? What are the emotions immediately before the words? Does your closeness with the particular patient impact the approach? Are you nervous? Comfortable? Do you ever cry afterward? Has it become common enough that it’s not as hard as it once was?
JOHN BOOCKVAR: This is one of the hardest parts of my job. However, if you can provide peace to the patient and the family while doing it, then it can be a comforting experience. It takes practice unfortunately, and in my field we do get that practice.
My emotions are always sadness and reflection. I remember my own experiences with my father before he passed and the disappointment I felt with the doctors taking care of him. Every time I have these conversations with my patients, I promise not to replicate the lack of compassion those doctors showed toward my family at the time of my father’s death.
Closeness to the patient does impact me. But we get close to all of our patients at this point. If we are having those discussions about death, whether we know them for one hour, one month or one year, we have become close to them. We know their loved ones, we have seen pictures of them in their “prime.” I have the same approach with all my patients at this point. I always say to them that we would like to adhere to the wishes of the patient and the family. Obviously that includes difficult decisions about end-of-life care, artificial resuscitation, etc. I tell them they should all be on the same page and respect each other’s opinions even if they are not always in agreement. Some want every medical treatment done, others want nature to take its course. Being a caregiver at this point is like being a family coach. I always remind families that “death dies, but regret lives.” I don’t want any family who has lost a loved one to also suffer from the regret of either not doing a particular treatment or from not adhering to the wishes of the patient or family member.
Rarely at this point in my career am I nervous. Actually, I am usually very comfortable and motivated to help the family get to the next phase of dealing with a tragedy or loss of a loved one.
I tell all my students, residents or fellows—I have cried many times in the stairwells of hospitals. It is important to be able to take a moment, step away, put your head between your knees somewhere and let the tears roll. You develop a real appreciation for what is most important in life, your health and the health of your wife, children, siblings, parents and loved ones.
J.P.: So, like my wife, you were a kid in Hewlett, N.Y.—good student, athlete, popular, etc. And here we are, 30-some years later, and you’re the director of the Brain Tumor Center, and the Pituitary/Neuroendocrine Center of the Department of Neurological Surgery and the New York Head and Neck Institute at Lenox Hill and Manhattan Eye, Ear and Throat Hospitals. I’m a HUGE fan of paths—so what was yours? When did you first know you wanted to pursue medicine? Was there pressure, coming from a long line of doctors? When did you first think, “Brain surgeon”? And were there moments along the way when you thought, “Eh, this just isn’t for me”?
J.B.: The most important influence on my career path was my father, who was an ophthalmologist. In fact, medicine runs deep in my family. I am a fourth-generation physician dating back to Dr. John Baily at the turn of the century. I have cousins and uncles who are physicians and an older brother Kenny who went to medical school before me. Going into medicine seemed only natural to me.
I don’t remember any pressure from my parents to become a doctor. Lots of pressure to do well in school though.
The most difficult decision you make in medical school is whether to be a surgeon or not. For me, I knew that I wanted to be a surgeon. I also had studied the brain at Penn as an undergraduate. So when I went to medical school with a particular interest in neuroanatomy and neuropsychopharmacology, combined with my love of surgery, neurosurgery was a natural fit. I sat my parents down in my kitchen as a third-year medical student and I remember telling them that I was going to pursue a career in neurosurgery. I remember my parents thinking I was crazy. How would I have time for grandkids? It was the right choice for me. I have never had any doubts this was the perfect career choice for me.
J.P.: Six years ago you were featured in the New York Times for your work on a trial where you would treat glioblastoma by spraying the drug Avastin directly onto the tumor. It was amazing; I mean, just reading it I thought, “This guy was at my wedding!” So two things: A. What has happened since then? B. How does a guy in your position come up with the idea, “You know what we should do? Spray the thing with Avastin! That could work!”
J.B.: One thing that we as scientists and surgeons have trouble doing is getting good drugs into the brain due to the blood-brain barrier. I have been studying brain tumors now for almost 20 years so this is of particular importance to helping our patients survive longer. We have learned a lot about how to deliver drugs into the brain since that New York Times article in 2009. We have improved the frequency of delivery of Avastin and the dosage. We have also moved ahead with four other drugs using the same delivery technique—Temodar, Carboplatin, Cetuximab and Herceptin. We have also begun to combine drugs and have used this modality to treat kids with brain tumors, too. We continue to publish our techniques so my colleagues can also help to move these advances forward.
Serendipity is often the root of all good ideas. I have been fortunate to be surrounded by very smart people as well. Many of my Penn neurosurgery residents have been my colleagues as well over the years. One of my partners now, Dr. David Langer, was my chief resident when I was at Penn. When I was at Weill Cornell as an attending I was working closely with another very talented former Penn resident, Howard Riina. The story went something like this … in about 2007 we were at his house for a barbecue when he got called back to the hospital because of a patient with a stroke. As an endovascular neurosurgeon, he was going to the hospital to use microcatheters to either break up a clot in the brain or retrieve the clot and pull it out. He left and told me to man the grill. He returned within two hours having saved the person from the effects of a devastating stroke. As a neurosurgeon focused on neurooncology I had not kept up on the advances in microcatheter technology. I became fascinated with the new speed and agility that these surgeons had in using these tools. I immediately challenged him to use these catheters to delivery high doses of new drugs that we had to treat brain tumors.
J.P.: I feel like, much like 95 percent of the technology we use, humans have little knowledge of what makes the brain tick, and how absolutely amazing it is. So, John, how absolutely amazing is it? What can you tell me about the human brain that most of us don’t know? That’ll blow my, eh, mind?
J.B.: The brain is so perplexing it is hard to comprehend. We know less than five percent of how it actually works, how it heals, how it degenerates.
The most amazing thing about the brain is how unpredictable it is. Particularly the pediatric brain. I had a teenage patient who stuck his head out looking for the next subway and was hit by the next subway. He came in essentially brain dead. We took him to surgery right away and saved his life. His brain healed and he is normal. I operated on a window washer who fell 47 stories and lived! I tell every family who has suffered a major tragedy that, with some good decision making and some good luck, miracles can occur.
J.P.: How do you feel like being a doctor has impacted your thinking on your own mortality? Do you fear death? Think about it more than your average person? Or has it become so common that it’s almost less daunting and forboding?
J.B.: I don’t think about my own mortality much. I don’t fear death or illness. I think about the health of my family all the time. I treasure it. I think about the ‘what ifs’ … the time the other shoe will drop. Is that black and blue mark on my 12-year old an early sign of leukemia? Is my daughter’s fever tonight due to acute tonsillitis? I treasure—probably more than the average person—when that black and blue mark goes away and when the fever breaks in the morning. I don’t fear death at all. I fear a devastating sickness in my family.
J.P.: Greatest moment of your career? Lowest?
J.B.: I don’t really have an answer for the greatest yet.
I think the lowest point of my career was when I was named in a lawsuit by a patient who I not only trusted but I thought that I had done a terrific operation on. She had come in with a terrible spinal tumor and I had removed it safely and she now leads a normal life. During the trial, I felt that the plaintiff misrepresented my relationship with the patient, the goals of the surgery, the outcome, etc. This was my only experience with a malpractice trial and it was rather demoralizing. I felt like the villain during the trial despite my very best efforts to help the patient. Fortunately the jury agreed with my efforts and ruled in favor of me and my defense. However, those experiences in medicine can leave an awfully bitter taste in doctors mouths.
J.P.: One of your bios reads, “Dr. Boockvar directs the Brain Tumor Biotech Center at the Institute that seeks to bridge the translational gap between basic and clinical science for patients with malignant brain tumors.” I wonder if there’s more to this than that sentence contains. What I mean is, how complicated is it to bridge that gap? And, when you’re someone who’s deep into the clinical world (and jargon), is it sometimes easy to forget that the guy sitting across from you doesn’t know glioblastoma from Jason Giambi?
J.B.: The translational gap or divide is a big problem for all of us. What it means simply is that it takes an extraordinary amount of time (10 years or more) and money ($1 billion or more) to take a good idea (piece of intellectual property) from the laboratory bench and bring it into the clinic for a patient at the bedside. We developed the Brain Tumor Biotech Center at the Feinstein Institute to help shorten the time it takes and the amount of money required to bring a drug or device from the bench to the bedside for our patients with brain tumors.
J.P.: OK, so in 2008 you operated on Alcides Moreno, a 37-year-old window washer who fell FORTY SEVEN stories. I wanna say that again—FORTY SEVEN stories. John, are you a magician? Isn’t that automatic death 99.9 percent of the time?
J.B.: That is truly an unbelievable story. I am no magician. The entire trauma team including the neurosurgery team worked quickly to save that young man. I believe it is the largest survived fall in the United States.
J.P.: This might sound weird, but you do incredibly important work. You save lives, you develop life-saving techniques. Big, big, important stuff. So it’s the weekend, and you’re at the pool, and your kid is crying because his ice cream fell. Or Joe Loud Yapper is bragging about his golf score. Or your neighbor is telling you about his big day as a branch division manager something for Citicorp. How are you not like, “Dude, I’ve got bigger fish to fry?” How do you turn on and off your work?
J.B.: I am very humbled by the work that I do. I never compare being a brain surgeon to anyone. I treat so many great men and women who do important work for society, whether they are policemen, drive a school bus or teach our children. My parents instilled in me great humility. The job itself brings with it great humility. When I am at home with the family, I am just a goofy dad trying to help my kids enjoy life and stay safe.
J.P.: What do you remember from your first huge operating room moment? What happened? What were your nerves like?
J.B.: One of the best first memories I had was my very first surgery as an attending neurosurgeon in New York. They warn you in residency that when you are done with your training, the first 10 operations you do as an attending should be simple ones. Not in my case. A young man came into the emergency room with blockage of the spinal fluid in his brain from a cyst formed from a parasite. I had to operate and remove the parasite from the brain. As I did the surgery, I had some trouble finding the cyst. I became increasingly nervous that I may have been in the wrong part of the brain. However, soon enough I found the cyst, removed it, held it up and said, “I can do this.”
QUAZ EXPRESS WITH DR. JOHN BOOCKVAR:
• Rank in order (favorite to least): Walter Payton, Nathan’s French fries, gorgonzola turkey sliders, Superselective Intraarterial Cerebral Infusion, the iPad, hamsters, Dexy’s Midnight Runners, Wrigley Field, Stairway to Heaven, denim, Chris Farley: the iPad, Superselective Intraarterial Cerebral Infusion, Nathan’s French fries, Walter Payton, Chris Farley, Stairway to Heaven, denim, gorgonzola, turkey sliders, Wrigley Field, hamsters, Dexy’s Midnight Runners.
• Ever thought you were about to die in a plane crash? If so, what do you recall?: I hate flying in general. I have so much to lose now. I hate relinquishing control and I don’t like not knowing how planes work and how to fly them and land them. I only think about my wife and children when I am in turbulence.
• How has the Affordable Care Act impacted your world?: In sum: More low paying patients. Less reimbursement. Tighter operating margins. Less time for physicians to conduct research. Less money for research. In short, we have to do more with less.
• Is twirling a sport?: Yes.
• Celine Dion calls and offers you $30 million to be her Las Vegas physician for the next two years. She demands daily checkups and that you get a tattoo on your shoulder than reads, “Jack+Rose=4Ever.” You in?: Yes, if the $30 million is tax free.
• Should marijuana be legalized? Why or why not?: Yes. Medical marijuana has import. Patients with many conditions including cancer, psychiatric disorders, seizures could benefit from medicinal marijuana.
• What interesting thing can you tell me about my wife’s childhood?: It was with Cathy that I had Korean food for the very first time and grilled artichokes. She was the very first kid who “moved to the city.” She grew up faster than the rest of us. However, she somehow remained the sweet girl from the Five Towns of Long Island.
• The greatest meal you ever had was where?: Martha’s Place in Montgomery, Alabama.
• Do you think cell phones hurt the brain in ways we should be concerned about?: Yes. They are incredible distractions while driving. This is a grave concern.
• You have a twin brother. Please tell me you had a funny moment when you pretended to be one another …: In seventh grade, we were playing seven minutes in heaven (not with your wife—I promise). My brother went in with the girl Melissa first, came out halfway, I stepped in for the final few minutes …