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Peter Vajkoczy heads Germany’s largest and most advanced neurosurgical centre. His book —recently published in Hungarian as well—has introduced tens of thousands of readers to the world of neurosurgery, and he has made it his mission to demystify his profession. We spoke with the Hungarian-origin professor working at Berlin’s Charité about difficult, often tragic cases, the present and future of neurosurgery, and we also learned what kind of music plays in the operating theatre.

Written by Miklós Stemler

Dr. Peter Vajkoczy gave a lecture at the Medical School in Pécs for hundreds of Hungarian and international medical students, who, in addition to heading the neurosurgery clinic at Berlin’s Charité—one of Europe’s leading hospitals and medical research centres—, is also a bestselling author. All the more remarkable given that Professor Vajkoczy never planned to write a book.

“A good friend of mine, Michael Tsokos, kept nudging me that I had so many interesting stories, I should write a book about them. For my part, though, I felt that I would just end up making my colleagues hate me, and the whole thing would be pathetic—not to mention that I did not really have the time for it either. Eventually, I let myself be talked into it on the condition that a co-writer would assist me, and I was promised I would only have to meet with him a few times. That turned into more than six months of intense work, and then he wrote the first draft, which was terrible. Pathetic, self-centred, show-offy—exactly what I had feared. So, I threw the entire draft out. But after a year and a half, I realised that writing a book is a unique opportunity, and it would be arrogant to turn it down. I have to accept the challenge, write the book, but the way I like it.”

The result is a rather unconventional and candid book.

“It was important to me that my colleagues be credited by name and receive the recognition they deserve for their work. I also wanted a book from which laypeople could learn something about anatomy and the development of neuroscience; a book with an educational focus, or, to use a trendy term, edutainment. Most importantly, the patient had to be the hero. As doctors, we rarely get to know the people we treat during their care, and I was very interested in their backstories. And to be honest, all of this was also a kind of self-therapy for me, because I also write about cases where patients die, or the outcome of the surgery is not positive, or where I made a bad decision. It helped me process those experiences.”

Although some of Peter Vajkoczy’s colleagues were not pleased that he was writing a book, its success and impact outweighed their opinion. The book made it onto the bestseller lists and, with only a slight exaggeration, introduced the entire country to the work of neurosurgeons.

“To this day, high school students write to me saying that my book inspired them to consider a career in medicine, and medical students contact me to say that it is why they want to choose neurosurgery. A neurosurgeon colleague of mine in Pécs just told me how great this is for promoting our profession, since it is a very niche field, and we have to compete with other medical specialties for the best students.”

Part of the book’s impact comes from the fact that, alongside the successes, the book also highlights the darker side of neurosurgery: those cases where a single unfortunate accident is enough for a doctor to lose a patient in a matter of seconds, or where, even if the procedure is successful, the patient leaves the operating theatre with permanent damage.

“I never wanted to romanticise my profession; on the contrary, my goal was to demystify the field. The generation before me, whether in Hungary or Germany, had mysticised neurosurgery. I believe it is crucial for the field’s development to dispel this mystique and democratise neurosurgery. Young people can easily lose their motivation and courage if they constantly hear from their older colleagues that only they are capable of performing a certain procedure. It is important to strike a balance because neurosurgery is indeed a complex and exciting field of medicine, but it should not be portrayed as overly mysterious. That is exactly why I also write about things like what kind of music we listen to during surgery—Depeche Mode is a big favourite of mine—just as I speak honestly about complications, those cases when everything goes wrong.”

One of the beauties, and at the same time, one of the risks of neurosurgery is precisely that even cases that seem simple and obvious can take unexpected turns, since every brain is slightly different, not to mention the fact that there is still so much we do not know about how our brain and nervous system work.

“It is a very intriguing question whether it is the brain that is unique, or whether it is the person behind the brain. From a neuroanatomical perspective, there are no major differences: the motor cortex is always located in the same place, as are the cranial nerves. Of course, there are functional aspects that are highly unique, but the anatomy is quite standardised. A brain tumour, however, always results in unique situations, since individual areas shift as brain plasticity attempts to compensate for lost functions.

In addition, every brain surgery poses a challenge, as we still do not fully understand 80 percent of brain functions and localisations, nor the compensatory mechanisms. Currently, we are happy if the patient can speak or move after the procedure. But we also know that neurocognition and higher-order brain functions involve much more than just speech. Today, we are trying to understand these higher functions and how to preserve them. So a neurosurgeon’s work never gets boring, and it never becomes a routine.”

This is clearly illustrated by the changing goals of neurosurgery. While a few decades ago, the patient’s survival or the prolongation of their life was considered a major achievement, today the primary goal is to preserve the patient’s quality of life to the greatest extent possible, that is, to ensure that the patient can speak and move just as well after the procedure. Peter Vajkoczy has witnessed this revolutionary change throughout his own career.

“The most significant advances have occurred in areas where neurosurgery has become less invasive. My specialty is vascular surgery, and a major breakthrough here has been the endovascular revolution involving catheter techniques, stents, and coils. In the case of the spine, it was crucial that neurosurgeons understood the concepts of orthopaedic biomechanics and learned when to use maximally invasive and when to use minimally invasive strategies. In addition, interdisciplinarity has brought about tremendous development in this field, as neurosurgeons, traumatologists, and orthopaedic surgeons have joined forces and learned from one another.

The greatest advance in brain surgery has been the localisation of specific brain functions, which allows us to prevent permanent damage and complications with increasing effectiveness. Before Harvey Cushing, one of the pioneers of neurosurgery, only about 10 percent of patients survived surgery; today, a significant proportion of those who undergo surgery can return to normal life. And then there are new areas, such as the treatment of movement disorders in Parkinson’s disease, where we use neuromodulation to counteract the destruction of nerve cells. Another relatively new field is radiosurgery, where we use precise radiation to destroy tumours located in areas that are too risky for surgery. The future lies in reconstructive neurosurgery, that is, how we can restore lost functions following a stroke, spinal cord injury, or nerve damage.”

Various technological advances can accelerate this development. Neurosurgery has benefited greatly from the revolution in medical imaging, and computer-assisted surgical planning, for example, first emerged in this field. Now the age of artificial intelligence is here, though even experts do not yet know exactly what form it will take.

“I have been thinking about integrating new technological possibilities for years, but I would not claim to have a definitive answer. It is a fact that neurosurgery is the most digitised surgical specialty, where so-called neuronavigation and computer-assisted surgery have long been standard procedures. We use a variety of imaging technologies that can be linked. We use various solutions based on mixed reality and virtual reality. Robotic surgery is currently being introduced, although the robots are still controlled by surgeons.

My big dream in Berlin is to create a new operating theatre environment that could represent the next level in neurosurgical operating theatres. Artificial intelligence will certainly be a part of this, with AI assisting in the decision-making process. The operating theatres will be interconnected for teleconsultation, and AI will help beginners acquire knowledge more quickly. In addition, operating theatres specialised in specific subfields will emerge. In neuro-oncology operating theatres, an entire robotic system, intraoperative molecular diagnostics, and intraoperative imaging will be available. There will be local therapeutic operating theatres equipped with every strategy for local, minimally invasive treatment of brain diseases. This means that technology will increasingly change the way operating theatres function and the course of individual procedures, just as it has done in recent years.”

Of course, the question is what role doctors and nurses will play in this system. Peter Vajkoczy does not consider a future reminiscent of science fiction to be at all unimaginable, but in the shorter term, everyday reality will likely override techno-optimistic predictions.

“I do not think the role of humans in neurosurgery will fundamentally change over the next 20 years. There will still be surgical teams supported by AI-based technology, rather than replaced by it. But beyond that timeframe, I believe robots will assist with patient positioning and movement. It is possible that nursing care will be partially replaced or supported by robots. Then the time will come when everything except the surgeon will be automated, and perhaps in more than 30–40 years, robots will replace surgeons as well. According to Elon Musk, of course, all of this could happen even within five years, but I do not see it that way: today’s everyday clinical reality is much more about the fact that even if you have an idea for a digital development, there is no funding for it. So, the future envisioned by AI companies is one thing, and the reality of it is something else entirely.”

The ongoing discourse on artificial intelligence is also rife with predictions that have aged rather poorly, such as Nobel Prize-winning AI researcher Geoffrey Hinton’s 2016 statement that radiologists would no longer be needed within a decade. According to Peter Vajkoczy, it is worth treating such grandiose statements with caution, as they can cause actual harm.

“I see a significant risk that such predictions will deter motivated and intelligent students from choosing a career in medicine, and if these predictions prove to be wrong, there will be a shortage of qualified professionals. In my opinion, anyone interested in medicine should continue studying to become a doctor. They should specialise, learn to apply new technologies in their fields, and not be afraid of being replaced in the foreseeable future.”

Affinity for technology is therefore an important requirement for the neurosurgeons of the future, but according to the chief neurosurgeon at Charité, human values are far more important than that.

“I have not been hiring people based on their talent, but on their character for quite some time now. Manual skills and theoretical knowledge can be taught, but I cannot change someone’s character. I believe that traditional values will also remain the most important in the future: honesty, dignity, patience, teamwork, humility in the face of complications, but also the courage to try new things and develop them. In addition, I strongly believe in the close connection between clinical work and basic research. I encourage everyone to be not only a good clinician but also a good researcher. Neurosurgery departments of the future will also need specialists who are highly skilled in digital technology and AI. Traditional medical training does not teach students programming or the use of AI, which is why this additional skill is so important.”

Neurosurgeons will also be needed for quite some time to come because in the case of a significant number of serious neurological disorders, we still know too little about the causes that lead to their development, and thus, no effective prevention strategies exist either.

“I believe the first step must be early detection, which alone could lead to a huge improvement in the outcome of brain tumours. I can imagine a world where we wear such wearable devices that detect even the slightest abnormalities. This would allow pathological changes to be detected at a very early stage, potentially increasing the success of treatments.

The next step is prevention, which requires understanding the genetic causes of the disease, and we still have a great deal of work to do in this area in the case of neurological disorders. I believe that the first key area for prevention will be dementia and Alzheimer’s disease. If we understand the genetics and molecular subtypes, we can identify at-risk groups. Then we can apply preventive treatments, such as gene or cell therapy. Understanding genetics, effective screening, and then intervention—such as implanting cells or genes into the brain. This could be the future.”

The Hungarian trio

“Genetically, I am 100 percent Hungarian,” says Peter Vajkoczy about his heritage; he was born in Munich in 1968 after his Hungarian parents emigrated to Germany. He inherited his love of medicine from his father, a thoracic surgeon; he graduated from the medical school in Munich and went on to work in the United States, among other places, before being appointed director of the neurosurgery clinic at Charité in 2007. In addition, he maintains close ties with the Hungarian neurosurgery community and Hungarian specialists working abroad, as he also mentions in his book regarding the “Hungarian trio” performing a complex procedure. “I am constantly learning from my Hungarian colleagues because they studied neurosurgery under different circumstances than I did and adhere to different philosophies. There are many masters of my profession in whose presence I feel like a student, and more than one of them is Hungarian."

Photos:

Dávid Verébi (UP MS)

This article was originally published on Pulzus.