Transcript generated from the episode’s audio. Speaker names are identified from the context of the conversation rather than from recorded speaker data, and automatic transcription may misspell names and terminology. Please refer to the video for the authoritative version.

David Raubach: I want to thank you guys for joining us on today’s episode of the Cancer Project podcast. We are really privileged to be joined by Dr. David Sandberg who’s a fellowship trained pediatric neurosurgeon and the former director of the pediatric neurosurgery program at McGovern Medical School at the University of Texas and an adjunct professor at the University of Texas Health Science Center. Dr. Sandberg is the recipient of numerous research grants and has pioneered novel treatment approaches for pediatric brain tumors and was a principal investigator of several clinical trials conducted at the McGovern Medical School and MD Anderson Cancer Center. But Dr. Sandberg has also just written a book and I have to say Dr. Sandberg this is one of the best books that I’ve ever read just relaying what it’s like to be a doctor.

David Raubach: This book, Brain and Heart: The Triumphs and Struggles of a Pediatric Neurosurgeon, was just released in May and you can find it, in hard copy form on Amazon and multiple other sites, but it’s also available on Audible as well, read by the author, Dr. Sandberg. So, thank you so much for joining us today.

David Sandberg: Thank you so much for having me on and thank you for your kind words about my book, too.

David Raubach: Yeah. So, Dr. Sandberg, tell us a little bit and I know you go into this in the book some, but tell us a little bit about your background and what led you to go into the field of medicine first and foremost, but then ultimately into the field of pediatric neurosurgery.

David Sandberg: So, it’s been a long journey. I grew up in South Florida. My father was a physician and he was kind of my idol. He was an ophthalmologist. When I was in high school in college, he took me on three medical mission trips, one to the Dominican Republic, one to Jamaica, and one to the island of Antigua where he was doing eye surgery. And patients had diseases that were so treatable like cataracts that they were blind from that would never happen in the United States. And he would do a simple operation and make a blind person see. And I was like, “Wow, I want to do something meaningful with my life.” So, I knew I was going to go to medical school. I was actually a history major in college.

David Sandberg: You know, some people decide they want to be a neurosurgeon when they come out of the womb. I was not one of those people. I approached medicine from a public health standpoint. I thought I would do something in primary care, maybe in an inner city. I wanted to help impoverished people especially. But once I started doing rotations in different specialties and I rotated through neurosurgery, I guess a flame was lit and a passion was ignited and I’ve never looked back from there.

David Raubach: And so you attended Harvard and then I believe you did your residency at Cornell, is that correct? And then fellowship at the Children’s Hospital in Los Angeles.

David Sandberg: Correct. Harvard for undergrad and then I went to Johns Hopkins for medical school and then residency at Cornell in New York.

David Raubach: So the history major was at Harvard then.

David Sandberg: Correct.

David Raubach: Okay, that’s great. I’m a history major myself, also working in the field of medicine. So there’s something I can appreciate the history of the field that we work in. So, you talk about this in your book, your time at UCLA and just or at the Children’s Hospital there in Los Angeles and just what it was like learning from other people in the field. What did what were some of the things or highlights that you took away from your time as a fellow?

David Sandberg: Yeah, fellowship is kind of like a transition between residency training and independent practice. You know, as a resident, you get graduatedly in, you know, increased responsibilities. By the time you finish residency, you should be a competent neurosurgeon. Fellowship is to, you know, try to make those skills even more, I guess, formed, you know, and, [clears throat] my fellowship was in the days before work restrictions. I took three days off the whole year.

David Raubach: Wow.

David Sandberg: I was on call every other night, taking first call but also I had attending privileges so I could do certain cases by myself. I did about 600 surgeries during that year.

David Raubach: Wow.

David Sandberg: I got very little sleep the entire year but I absolutely loved it. I had an incredible experience and you know I came out battle trained and ready to go.

David Raubach: Who were some of the people, or who was somebody that you remember from that time that really had a big influence on your career going forward?

David Sandberg: So the biggest influence in me becoming a pediatric neurosurgeon was Mark Souweidane, who is the director of pediatric neurosurgery and still is at Weill Cornell where I was a resident. He was such a spectacular surgeon. He had beautiful hands. And he was such a wonderful teacher and he was amazing with the patients and the kids and you know I was just looked at him and I was like I want to be like that guy. I’m still trying to be like that guy right now. And then in fellowship I had two wonderful mentors. Gordon McComb was the senior neurosurgeon there and Mark Krieger was the junior neurosurgeon. Both of them spectacular surgeons, teachers, you know, dear friends. I’ve learned so much from them and I’m so grateful.

David Raubach: So pediatric neurosurgery, I have worked in the field of oncology so I know what that means from an oncology standpoint, doing surgery on tumors, but you were doing a lot more than just oncology. Tell us what types of surgeries that you were doing or what it means broadly speaking to be a pediatric neurosurgeon.

David Sandberg: So in general neurosurgery has become very highly subspecialized. There are spine neurosurgeons who do almost exclusively spine. There are vascular neurosurgeons who take care of aneurysms and AVMs. There are epilepsy neurosurgeons, etc. There are multiple subspecialties. Pediatric neurosurgeons are because of the rarity of the diseases. You can’t really just do one diagnosis. So we’re the last kind of general neurosurgeons who do everything in the brain and spine in children. So congenital malformations of the spine such as spina bifida, tumors of the spine and brain, epilepsy surgery, hydrocephalus when there’s not proper fluid circulation in the brain, craniosynostosis when the bones of the skull don’t form properly, and many other things.

David Sandberg: So a lot of things I focus, so I did everything in pediatric [clears throat] neurosurgery but I had a specific focus both from a research and a clinical practice standpoint on brain tumors in children.

David Raubach: And what has changed over the years that you’ve seen, over the last few decades, with the treatment of cancerous tumors in children? What, and maybe what’s stayed the same, and what’s different, from an incidence rate or how we approach treatment or how we approach survivorship and rehabilitation?

David Sandberg: Yeah, I’m not an epidemiologist, but I’m told the incidence of pediatric brain tumors is rising. It’s the second most common tumor and the most common cause of cancer death in children. As far as the treatments, I would say some surgeries are exactly the same. If you have a big tumor in the back of the brain, the surgery that I would do now is very similar to the surgery I would do 20 years ago. For some operations, technology has made the surgery less invasive.

David Sandberg: So there are some operations where we used to have to do, you know, a big incision, take off a big piece of the skull, a huge operation lasting 4, 6, 8, 10 hours, where we can do a little incision without shaving any hair and do a little bur hole and accomplish the same thing with an endoscope or a laser or with other, you know, tools and toys.

David Raubach: So in the book, you talk about a couple of different types of surgeries or surgeries that you do. What did you find to be the most challenging as a surgeon? What describe the surgery itself and what was most challenging about the actual operation.

David Sandberg: Yeah. I never, I learned never to underestimate any surgery. Any surgery can become challenging with unexpected findings or complications. I was most passionate about very challenging deep tumors in the brain, tumors in the middle of the brain, in the pineal region, in the third ventricle, in the suprasellar space, the space, you know, up behind the nose and eyes, places that are difficult to get to where there are important structures that if you hurt those structures you can cause a patient to have a stroke or have an a very severe permanent problem. I love the technical challenge of those operations.

David Raubach: What, [clears throat] and one of the things that I love about the book is that you really talk about the fact that while you’re doing brain surgery, there’s this heart component to the process, and a lot of that is just the relational aspect that you develop with patients and then patients parents. Talk about why you titled the book Brain and Heart, and what you mean by that.

David Sandberg: Yeah. So there are kind of many meanings with the term heart. [clears throat] Mostly when I’m talking about the heart, I’m not talking about, of course, the organ that pumps blood, you know, through the body. I’m talking about the heart in the metaphysical sense as the center of our emotion or love. You know, brain surgery, we think of the brain as a very precise, amazing organ. It can do incredible things. It allows us to hear and think and see and feel and have complex emotions that are caused by transmissions of neurotransmitters very very rapidly through neurons and axons, etc.

David Sandberg: And you think of brain surgery as very precise and it is for the most part, but you would be amazed and the public should be slightly terrified by the fact that so much of what we do is not as precise and defined as you would want, and cannot be decided purely with our brains because there’s no published literature that clearly gives us the right pathway in every single case. If you show a single case to five pediatric neurosurgeons, you might get five different answers on whether the patient needs surgery or what surgery to do or what approach. And it’s not that anybody’s right or wrong. It’s just that it’s not well defined. So I found in my career that so many times, of course, I needed to use my brain, but I needed to use my gut and I need to use my heart.

David Sandberg: And the other, you know, [clears throat] thing with heart is there’s a lot of heartbreak in our field. You know, we’re dealing with, you know, great triumphs, amazing stories of success, but we also deal with tragedies. We deal with children who die. We deal with children who have brain tumors. You know, you can only imagine if you have children, you remember how upset you are when your kids are young and they have a cold or a cough and they have a fever and you can’t get them to go to sleep. Now, imagine if somebody would tell you that your child had a brain tumor. And now, you know, imagine if somebody would tell you that that brain tumor, that’s a cancer. Not only is your child going to need surgery, but they’re going to need radiation. They’re going to need chemotherapy.

David Sandberg: And they might not survive after all that. I mean, it is too much to bear for any one patient. So, it’s heartbreak.

David Raubach: You talked about how in the book you talked about how you approach those conversations with parents and the importance of having compassion but also honesty. Talk a little bit about how you did approach a conversation, especially those difficult conversations where maybe the outcome or the prognosis wasn’t necessarily going to be great for the child.

David Sandberg: Yeah, thanks for asking that. I think it’s one of the most important things I do and interestingly, you know, you would think that this is something that doctors would be trained to do. In my medical training, in medical school residency before beyond, I had zero minutes of instruction on how to give bad news to a family. And that may be different at some medical schools these days, but I think it’s undertaught everywhere, if taught at all. And it’s so important these conversations, you know, families remember them for the rest of their lives. I do think you need to be honest.

David Sandberg: I’ve seen a lot of mistakes made by other physicians where the truth is so hard to convey because it’s so painful that they don’t tell the truth, they don’t tell the family, that not only has the chemotherapy failed, but there’s no proven treatment for this disease. And you may want to just take your kid to Disney World or something else as opposed to trying something, they just can’t get those words out of their mouth. And it does a disservice to the family to not have the truth because they can’t make the best plans for their family. You have to listen. You know, you have to not just talk but listen, you know, answer the questions of the parents, of the other family members and be patient.

David Sandberg: You know, you might have 50 other patients waiting for you, but that patient is their whole world, and you got to listen and answer their questions well. And then you have to have compassion. I mean, you can imagine being on the other end. I’ve given horrible news hundreds, thousands of times. But I still, it’s hard to imagine being on the other news and hearing that news about my child. So you have to do your best to be empathetic.

David Raubach: How did you, over the years of having to deliver this bad news, how did you maintain that compassion and not become jaded or not let that create this hard surface as you continued to have to deliver bad news?

David Sandberg: It was easy because I always thought it was so important. It was something that was very, very meaningful to me. Because I know that even if I’m telling a family of that their child has died or is going to die, how I have that conversation will make a lasting impact. You can have it in a way that can leave really poor feelings that can last a long time and do damage, or you can leave it in a way that causes some degree of comfort or healing. Those conversations are incredibly important and I place the highest value in them. So I never needed to motivate myself to have those conversations in terms of the importance.

David Raubach: And I think one of the things that you did is partly what you’ve said earlier is you said I didn’t have necessarily this exposure or training in how to have these conversations with parents. And so you made it a point as you had residents come through and work with you that you required them to come to and have those conversations with you.

David Sandberg: Yeah. It’s just a reflex. Again, this is so important to me. Every time I was going to have one of these horrible conversations, I would look around and see who was near. And if it was a resident or a medical student, I would say, “Come with me.” And as we were walking quickly to tell the family, I would tell them what I was going to say. And I would tell them that this is important for their education. I wanted them to listen to how I did it. And then afterwards, I would check in with them to see if they were okay, cuz this is hard for everybody in the room. And I would ask them, you know, to consider the things I said.

David Sandberg: Some of them they might like and they might want to employ when they’re the ones giving the bad news one day and other things maybe I could do better and please give me suggestions if you have any and you know watch other people do it and take the best from every person who does it but these conversations are important.

David Raubach: One of the things you talk about in the book, Dr. Sandberg, is that it’s not normal to lose a child and so there’s no normal response to losing a child. Talk a little bit about the broad spectrum of emotions that you encountered as you were delivering tough news to parents about their child, whether it was the fact that their child had died or that their child maybe had suffered permanent brain damage.

David Sandberg: Yeah, I have seen absolutely every reaction in the book. You know, many families and parents of course are crying, right? Some don’t cry at all. They stare straight ahead and don’t say a word. I’ve seen patients, parents so emotional that they literally physically throw themselves on the floor and roll around and scream at the top of their lungs creating a scene in the hospital and people are looking like what’s going on? Is somebody being stabbed to death or something? And what I teach, you know, what I teach residents and medical students is that every single reaction is completely normal, you know, and that you should treat each reaction as normal, you know, and you shouldn’t judge anybody for that reaction because the news that these folks are receiving was so painful.

David Raubach: There’s a story that you tell in the book about a husband and wife that received bad news about their child and then they subsequently began to attack each other, and you talked about the fact that you actually intervened in that situation. What, maybe talk about that particular example in the book. And then maybe expand on that and talk about the advice that you would give to parents and how to approach a situation, especially as it related to their relationship.

David Sandberg: Yeah. I mean, having a child with a major illness or dying is a major stressor on any relationship, you know, and I just described in the book one scenario where a husband and wife were literally at each other’s throat in front of me. We were all embarrassed in the room and, you know, I tried to point them towards being kind to one another during a difficult time. I’m not a marital therapist and I don’t have any words of wisdom on that. But you know these are tough moments for couples.

David Raubach: You talk about your mom multiple times in the book. Will you just talk about, for our audience, just the impact that she had on your career?

David Sandberg: My mom, you know, there in our family we’re very focused on public service and I trace that to my mom and to her compassion. She’s, you know, was always the one to point out the person who was suffering, who was in need. And we kind of viewed it as our responsibility as a family to help others. We knew how lucky we were. You know, I did not experience poverty growing up. My father was a doctor. I had every advantage, you know, in terms of, of course, I worked hard to get where I am, but I also wouldn’t be there if not for the amazing parental support I had. My mom was into community service and helping others and I carry that with me.

David Raubach: So, you guys as a family, you mentioned and you talk about this in the book too, doing medical missions and going overseas and going to low income areas or areas of poverty or areas that have a lack of access to what we would think of as modern health care services. Why was that so important to you? And then what did you learn as you were going overseas about what it means to be a doctor?

David Sandberg: Yeah. I mean, I learned so much it’s hard to even put into words. I have a whole chapter on in the book. When I went overseas with my dad, it was amazing to see people blind from a curable problem that could take [clears throat] half an hour to fix. And after an operation, you know, they could see. And why were they blind all that time? Because they couldn’t have access to a half an hour operation. I’ve seen even worse in the field of neurosurgery over the course of my career. You know, I’ve gone to places that don’t even have a neurosurgeon, you know, and patients just die of the natural history of the diseases, or they don’t have one who’s adequately trained.

David Sandberg: That’s why I focus on training neurosurgeons in developing countries, you know, that kind of teach a man to fish concept rather than just doing surgeries. But as a neurosurgeon, you know, going down [clears throat] to Haiti, for example, I’ve been there 10 times. It’s the poorest country in our hemisphere, with poverty that is the same as the poverty in sub-Saharan Africa, the worst poverty in the world. You know, you basically play God and decide who should live and who should die, because there are so many patients that need surgery, you can’t help them all. It’s a devastating feeling, and these children are no less deserving of healthcare than my own kids are. It’s just they were unfortunate enough to be born into that environment.

David Raubach: Describe for us the scene of the surgeries itself and how that may contrast to what it looks like to go to a modern first world hospital in a Houston or Oklahoma City.

David Sandberg: Oh my god. You know, one of the reasons I love going down there is when I come back, you know, I don’t complain about this or that in the operating room because I remember how good I have it. You know, in the operating rooms that I work in, or worked in, I just retired, in the United States, you know, they’re all very similar. They’re big, beautiful rooms. They’re well lit. They have tons of technology for every aspect of the surgery. Great monitoring for anesthesia. You know, we’re doing surgeries with a high-powered operating microscope using frameless stereotaxy, which guides us, you know, [clears throat] million-dollar pieces of equipment, you know, to take out tumors there, endoscopes, various things.

David Sandberg: In Haiti, you’re happy if the electricity stays on for the whole case, because very frequently the lights would go out and we would be operating just with the light from our headlights, which was totally inadequate, but you get the job done. We have a fraction of the instruments, don’t have a microscope, so we just use surgical loupes, magnifying glasses. We do have endoscopes. The monitor sometimes wouldn’t work in the middle of the surgery. You’d have an instrument inside a child’s brain and the screen would go pitch black and you kind of gasp and hold steady and hope that somebody can fix the problem. It’s, you know, it’s very much not ideal, but it’s beautiful because it’s pure medicine. There are no insurance companies. There’s no money changing hands.

David Sandberg: It’s just a doctor and a patient trying to save a life, and we save many lives in that environment.

David Raubach: Well, and you talk in the book about the relationships that you developed with some of the patients and their families in places like Haiti. Talk about that, and especially as it ties back to the title of the book, Brain and Heart, because I think, you know, you really talked about how you felt the true heart of medicine being there in some of these settings.

David Sandberg: Yeah. I mean, truthfully, in terms of relationship forming, the relationships I formed were much more meaningful and deep in the United States because I’d follow the patients for a long time. I spoke their language. In Haiti, I don’t speak Creole. I learned a few words, like two or three words. And basically, I couldn’t communicate with the families. So, there’d be a translator who would get consent for the operations, but they had absolutely no understanding of what they were consenting for, the parents. These were very unsophisticated but loving individuals. Many of them were illiterate. We’re talking about complex brain surgeries and it was just something they couldn’t understand. They just knew that their kid’s head looked like a watermelon, was three times the size of, you know, all the other babies in the village.

David Sandberg: And then afterwards we would do our best to translate to them and tell them that the surgery went well and what to expect in the future. And we certainly experienced a lot of gratitude, you know, on the parts of those families, many of whom had traveled for days and waited for days for the opportunity for their child to have surgery, sleeping on sidewalks, sleeping outside the clinic on hard surfaces. So they’ll do, people will do anything for their child.

David Raubach: Yeah. Shifting gears a little bit and going back to something that you said at the beginning of the conversation, you talked about, and I’m going to paraphrase and maybe use my own words here, that we like to think of surgery, or broadly speaking the field of oncology, as a science, but there’s as much an art to it as a science. Talk about how you approach that, and especially as it pertains to situations where maybe you ran into things that you didn’t know what to do, and how you were willing to, talked about swallowing your pride in the book and being willing to call in colleagues for help.

David Sandberg: Yeah, there weren’t that many circumstances in the oncology realm that I was calling oncologists for help. There were more specific surgical circumstances where I wanted a second pair of eyes or another opinion and you have to have the humility to do that. It’s really important. In terms of oncology there is so much judgment, and, you know, my career was focused on children with brain tumors, and malignant brain tumors in children can be incredibly difficult to manage and difficult to cure. And some of the most difficult decisions are to be made in kids where there’s no cure. Right? An example that comes to mind is diffuse intrinsic pontine glioma, DIPG, which also goes these days more by diffuse midline glioma. This is the worst cancer. It’s, you know, people think of what’s the worst cancer? It’s pancreatic cancer, maybe, in adults.

David Sandberg: This is worse than pancreatic cancer because it has a worse prognosis and it’s in children, which makes it worse also. You know, kids present with various neurological findings. You get an imaging study, you find that their brain stem is completely expanded by tumor. It’s not amenable to surgery. It’s not amenable to chemotherapy. Radiation typically alleviates symptoms but only for a few months. And no chemotherapeutic agent, either alone or in combination, has ever made a dent in this disease. So kids typically get radiation therapy and then they go on clinical trials. And in my over two decade career, I never saw a single patient with a successful outcome from those clinical trials. And so, you know, what to advise those families? You know, how do you take away their hope, or maintain their hope, or what’s the right thing to do? Difficult conversations.

David Raubach: How do you balance that? Because I think hope is an important word, especially, well, in any situation, but in the field of oncology for sure. How do you balance providing hope for families, but being honest and realistic with them?

David Sandberg: Yeah, that very circumstance is the hardest one, because the honest truth is that there is no hope, right? There is none, because that child is going to die within a year and, or a few months thereafter, and is going to have a terrible death, and it’s going to be a horrible year for [snorts] that family. So I shift towards honesty and compassion rather than, I certainly don’t provide false hope. You know, I tell them what families choose to do. You know, that family, many families choose to do radiation therapy and then go on clinical trials. I tell them honestly the outcome of the clinical trials that have been performed to date, because I think they deserve that information.

David Sandberg: And this is one of the, you know, things that I think some doctors don’t do well, because, you know, there are some doctors who will see that same child with that same tumor and create a lot of confusion by going in and saying, “Okay, well, you know, you your child has this brain tumor and we’re going to treat him. We’re going to treat her with radiation therapy and then we’ll try some chemotherapy and hopefully it’ll work.” I mean, really, hopefully it’ll work. Nothing has ever worked on this disease, right? So I think framing it in that way and giving false hope to a family is unkind.

David Raubach: Why did you decide to write a book?

David Sandberg: Yeah, a lot of reasons. Number one is as I went through my career I accumulated amazing stories and I would sometimes write a few lines down. I had a Microsoft Word document that I would just write down a few things that I wanted to remember. You know, maybe one day I’m going to share this with somebody in some way, maybe for a talk, or maybe I’ll write something down. Who knows? But this is something I want to remember, a story that’s kind of incredible, and I see incredible stories actually all the time. The other is there are many books talking about the patient experience, which is so important, what it’s like to go through cancer treatment or so many other medical conditions.

David Sandberg: There are very few books that really allow you into the honest mind of your doctor, to know what he or she is thinking when they’re having those difficult conversations or when they have a complication or a problem. And you know, when I have these difficult conversations with families, I choose my words very carefully. And I’ve often thought to myself, it’s not like I’m hiding anything, but it would be interesting for families to know what I’m actually thinking, which may not be exactly word for word what I’m saying, because I’m trying to, you know, say what’s best for them to hear at that moment. But so that’s one of the reasons.

David Sandberg: The other is, you know, as I accumulated gray hair, I hope I’ve accumulated some wisdom, and particularly about the doctor patient relationship, because surgeons, you know, sometimes can be a little rough around the edges. So, you know, part of it was to educate the young generation. You know, kids in high school and college, do they want to become a doctor? Is this inspiring to them? This is what a day in my life actually looks like, for those who are considering a field such as, you know, neurosurgery, a challenging field physically, emotionally, you know, in every way, is this for you? Right? And then, you know, are you someone who’s built to have these conversations and give terrible news particularly about children?

David Sandberg: There are some who, you know, would say I can’t do that, that’s not for me, and that’s fine, and there are others who might say, you know, this is meaningful and this is my calling.

David Raubach: Was there a story in the book that, as you were going through the process of writing the book, really moved you again, a second time, just thinking back on the situation, or who was involved, or how things played out?

David Sandberg: I mean, there’s so many, you know, [clears throat] you know, I was moved by so many patients over the course of my career. One story that I relive over and over again is the story I tell in the book of Joselyn, and this has a specific message for doctors. I talked about wanting to convey some messages to doctors. I think, you know, the message is there’s a certain barrier between patients and doctors that is caused by an attempt on doctors to maintain a certain professionalism. Right? And it’s not something that’s necessarily taught with words, but it’s taught by watching how doctors interact with patients. And what I would encourage young doctors to do is to lose that quote unquote professionalism as much as possible and to show your emotions. And this is an example in which I showed my emotions, as a little girl, Joselyn.

David Sandberg: I use her name and all names with permission of the family, who came to Houston for one of our research trials. She had a recurrent malignant brain tumor, an ependymoma. Beautiful little girl. She had failed surgery multiple times, radiation therapy, chemotherapy, experimental chemotherapy, and our clinical trial, which we were infusing drugs in the brain, was her last hope, and we infused some drugs in her brain over a course of a few months. She seemed to be doing great, and then came the day of truth, the moment of truth, when we were going to get an MRI scan to see did this treatment work or not. And I describe in the book how I felt on that day. You know, normally I’m running from place to place doing 100 things at once, very busy.

David Sandberg: On that morning, I was so inefficient, which was atypical for me, because I couldn’t focus on anything else. And I kept refreshing the screen, hitting refresh, refresh, refresh. As I was waiting for the images to come up on the MRI, when the MRI images came up, what I saw was devastating. The tumor had dramatically increased in size. You know, it had laughed at my attempts to treat it.

David Raubach: Yeah.

David Sandberg: And now I had to go have that conversation with the parents and tell them that this, which was their last hope, has failed, and their daughter’s going to die. So how do you have that conversation? So normally, as I said, I walk fast from place to place, but I walked slowly that day. And when I sat with the parents in front of the computer and pulled up the images and showed them, I just started to cry. And I don’t mean like a couple tears rolling down my cheeks. I mean, like hard to, you know, choking on my words, hard to get them out. And I thought to myself at the time, how unprofessional is this of me? I’ve never seen a doctor do this. And, you know, who am I to share my grief, which is 1,000th of what the parents’ grief must be.

David Sandberg: How selfish of me. And, you know, years later, I had a conversation with the parents who I’m, you know, friend, close friend, friends with this to this day. And I said, you know, remember when we had that conversation? Of course they remember that conversation, you know. And I said, you know, you remember my emotions and I felt like I was really unprofessional and I’m sorry about that. And they said, no, no, they said, you know, what you did that day, you know, made us feel like you were really there with us, that you were in it with us. And so I learned something from that. I think we as patients or patients generally, they want to know that their doctor cares. And I think one of the ways that you feel that is by seeing that emotion from the doctor.

David Raubach: That’s, that’s again going back to the heart component of what you do. Are there, thinking back over your career, are there other moments that you wish you had actually showed more emotion, or did that kind of evolve over time where you felt more comfortable as you got older?

David Sandberg: That’s a hard question to ask. I mean, I think certainly that was an exception. That wasn’t the rule. I mean, there are other occasions where I’ve had a few tears rolling down my cheeks or choking on my words a little bit. Or might have cried alone, you know, in the car on the way home. But for the most part, I controlled my emotions. But I did my best to convey my compassion in every interaction. I didn’t get it perfectly all the time.

David Raubach: Yeah. One of the things that you talk about in the book, and I think that this is an important message for people that are thinking about being doctors or in residency, is managing that work life balance. And that’s something that you were cognizant of even as you were going through residency and fellowship and thinking about what is the life of a surgeon really look like. And so maybe start by describing what it’s like to be on call all the time, get phone calls in the middle of the night, and then how you manage to balance work and life.

David Sandberg: So when you’re a resident, you’re managing 50, 70 patients, you’ve got a long list of patients with stuff to be done. You’ve got a beeper or a cell phone that’s going off literally every 2 minutes. And when you’re on call, you don’t sleep at all in general. Back in the good old days, when I did residency before the era of work hour restrictions, you would then work the next day as if you weren’t up all night the next night. And, you know, sometimes a few nights in a row, as I describe in the book, it was kind of crazy. But I was crazy and I loved it. I, you know, I love the meaning of what I was doing. I’d love learning to do surgeries, as an attending once you’re finished with your training.

David Sandberg: You know, the nights, you know, you still get called and you sometimes have to go in in the middle of the night and do surgeries and work the next day. It’s not as hard as it is to be a resident, but it’s not an easy life. You know, I always was concerned. My dad is a phenomenal dad and was there with me throughout my childhood. He coached my basketball team and, you know, family is important to me and I wanted to be a good dad. That was important to me. So, that was a concern going into neurosurgery. You know, can I be a good father and also a good neurosurgeon? And the answer that I found is yes, you can, you know, you have more control over your schedule when you’re finished with your training. So, I can decide when to schedule surgeries.

David Sandberg: I can decide, you know, what days to be on call. If it’s my kids graduation ceremony of I’m not going to be on call that day and I’m not going to schedule surgeries, I’m going to make it to that graduation ceremony. But I have missed soccer games, other kids events. I have had days where I haven’t seen my kids all day, particularly when they were younger and they went to sleep earlier. Sometimes I would have emergencies and have to leave an event or at family dinner. But you know, I think the proof for me is I have two fabulous kids and they are very, you know, well adjusted and I feel very close with them. So, it’s all worked out.

David Raubach: What do you hope that a reader from the general public takes away from the book in terms of how to think about a doctor or the life of a doctor?

David Sandberg: Well, I think the reader will have a, you know, [clears throat] when they’re sitting and meeting a doctor face to face for the first time, when they’re going through something difficult and they’re seeking that doctor’s care, number one, they’ll have the background of what that doctor went to get to that moment where they’re on the other side. Number two, they’ll understand the uncertainty in the advice that that doctor gives. Number three, hopefully they’ll sense compassion from that doctor. And have a sense of what that doctor might be thinking that they’re not saying.

David Raubach: What? No, that’s a great answer. And what would you tell, because we run into this a lot, and I know you would have too, patients that are that want a different opinion or want a second opinion. You even talked about at the start of this interview the fact that you could talk to five different neurosurgeons about a specific case and get five different answers. What advice do you give to patients who maybe think, well, should I go get a second opinion?

David Sandberg: I think, you know, you need to feel comfortable with the person who’s taking care of your loved one. And if you feel uncomfortable with the first person you see, then you should get a second opinion or a third opinion or as many opinions as you need to feel comfortable that you’re getting the right advice. Sometimes, I mean, second opinions are costly, right? Not everybody has the luxury of doing that. And second opinions can create confusion, right? So there are many times where somebody has come to me for a second opinion and I’ve said, you know, I agree with the doctor you saw and you know, he or she is an excellent surgeon. If you want to go have your surgery there, go for it. And that’s fine.

David Sandberg: Some of them say, well, we’d rather stay with you and I get it’s their choice, whatever they want to do. Others go back from whence they came. And there are other situations where I say, “I disagree, you know, respectfully, and I actually don’t even think surgery’s needed, and you know, parents haven’t had surgery, or that doctor didn’t recommend surgery, and I do recommend surgery.” And then they’re like, “Huh, well, this guy said that and the other one said this.” Now, they go get a third opinion. It can create a lot of confusion. I think, you know, you need to feel comfortable and that’s an individual decision.

David Raubach: Is there, was there a chapter in the book that was hard for you to write?

David Sandberg: No, they were all independent subject matter that I had a lot to say on.

David Raubach: Yeah.

David Sandberg: And it wasn’t hard for me to write about it.

David Raubach: Yeah.

David Sandberg: None of the chapters.

David Raubach: Yeah. That’s, I mean that’s amazing. And I really appreciate the transparency again of just going into the mind of a doctor and what it’s like to deal with tragedy, what it’s like to deal with patients, what it’s like to deal with cases that maybe don’t go the way that you hope that they would have gone. And maybe talk a little bit about that, because you do address that in the book, of just what you had to do from a mental standpoint when a case didn’t necessarily go perfect.

David Sandberg: Yeah. So, you know, the fun part of neurosurgery or of surgical specialties is when things go perfectly. You know, you have a tragic situation, the family is terrified, you come out at the end of the surgery and you say, “Good news, the tumor’s out and Johnny woke up fine. He’s moving everything and he’s going to be okay,” and everybody cries and hugs and, you know, that’s super fun and super easy. The hard part is when you have a surgical complication. So, every surgeon has complications. The only surgeons that don’t are the ones that don’t do enough surgeries, right? And so the ones that you want to be operating on your loved one are the ones who have had complications, right? They take an emotional toll on the surgeon. And I get into that in great detail in the book.

David Sandberg: I think what I’ve learned in my career is that there are different extremes, neither of which is healthy, and there’s a middle ground, which is healthy. So on the one hand there are some surgeons, you know, I could say to myself if I have a complication, right, and to be clear, just sidetracking for a second, the brain is so unpredictable, I can take out a brain tumor in a child and everything go perfectly well and the patient wakes up great, and the next day I can do the same operation with the same technique in a similar child with a similar tumor, and the patient wakes up and isn’t moving the left side as well as the right, and that can be a permanent problem, and that’s devastating, right? So, and sometimes you why it happened. Sometimes you don’t know why it happened.

David Sandberg: So I could take the attitude when that happens. You know what? I’m an excellent pediatric neurosurgeon. I trained at the best institutions in the country. I’ve done this operation hundreds of times. I did the best I could. It’s not my fault, right? And many surgeons do that. And I think that they should not have the privilege of practicing medicine or being surgeons if they’re that flippant about it. On the other extreme, there are some surgeons who are so devastated by complications that they lose the ability to be effective. You know, they wonder, you know, if my mentor had done that surgery, or some other famous neurosurgeon, would this child be moving the left arm the way they are the right arm? Maybe not. So then the next time they have a brain tumor in that scenario, they don’t take out the whole tumor.

David Sandberg: They leave a part behind to try to not hurt the child, but then the tumor grows back and the kid needs a second brain surgery, right? So they haven’t done anybody any favors either, right? So I think the happy medium is, you know, I’ve lost a lot of sleep.

David Raubach: Yeah.

David Sandberg: When I have a surgical complication, night after night I can’t sleep. I think about it. I replay the events of that surgery in my mind. The conversation I had with the parents beforehand. Did I talk about the risks? Did I talk about the risk of the complication that actually happened in enough detail? The surgical technique, honestly, like no BS-ing. Is there anything I could have done differently at any phase in the operation? Is there anything I should have done differently in the post-operative care? And then you present that case to a morbidity and mortality conference. That’s always fun. You got 50 to 100 people in the room. And you present your worst day with slides and videos.

David Sandberg: Everybody gets to see, your boss is there, students are there, people you don’t know are there, and you talk about the cases, but they’re so important because I think everybody in the room learns, and hopefully patients get better care as a result.

David Raubach: Well, and I think, you’ve obviously done this with the book, but it seems like you’ve done this with your career, is that you were very willing to talk about those cases that didn’t go well and not try to gloss over or hide the fact if there was surgical complications or an outcome didn’t turn out exactly how you hoped. And I, this constant learning experience, and we can only learn by the things that we see other people do and the things that we do, but that information has to be disseminated to our colleagues. And so I think that’s, I love the fact that you do that. What, going forward, I mean, you’ve written this book, what are some of your goals, I guess, for this book?

David Raubach: Do you have another book planned, or are there more stories that you felt like didn’t make it into this book that you still want to tell?

David Sandberg: No. So, no more books planned. I think I captured everything I wanted to say. I’ve actually retired from pediatric neurosurgery prematurely due to a medical condition. I share it openly with people, so I’m happy to share it with you. I, you know.

David Raubach: Yeah. Talk a little bit about that if you don’t mind, and just, because that is probably things that other people are dealing with, and how have you dealt with that, and go into whatever detail you feel comfortable going into.

David Sandberg: Yeah. You know, life throws all of us curveballs. You know, I’m 54 years old. I stopped practicing in June at the age of 53, much younger than I anticipated retiring. I started developing, over the prior months, a tremor in my right hand. Not very profound. Actually wasn’t interfering with surgeries, cuz it’s a resting tremor. When my hand is still, it shakes a little bit. But when my hands are in motion, like when I’m doing surgery or under a microscope, nobody was noticing that I was having a tremor or problem.

David Sandberg: But I know the natural history, I was diagnosed with Parkinson’s disease, and I know the natural history of that condition, and you know, there are some folks who stick around too long, whether it be athletes on the playing field that you wish retired, you know, when they were in their prime, instead of you having to watch their later years, or surgeons who stick around too long, operating into their 70s and 80s, when they’re not as good as they used to be. I never wanted to be one of those individuals. And so I announced to the world in January that I had Parkinson’s disease and I’m going to retire from neurosurgery, and I told my family, and then I told my work colleagues, all at once. I kind of blew up my life all at once.

David Raubach: Wow.

David Sandberg: Told my work colleagues, told patients and families, many of whom were devastated, because, you know, their vision, which was mine, was that I would take care of their kid for many years to come. Right. So, I plan to have a second career focused on childhood poverty. You know, I want to do something that I can help kids. I if I wasn’t a neurosurgeon, I would continue doing whatever I’m doing, because all I have is a slight tremor. But I’m going to do something in the child poverty space, likely with homeless kids.

David Raubach: Wow, that’s amazing. What, how are you approaching this diagnosis as a patient now?

David Sandberg: Yeah, I mean, it and it’s very different having been on the other side. It’s better to be the doctor than the patient. I’ve learned that. But I kind of knew that. Kind of knew that already. I mean, look, I have a lot of gratitude, you know. I am grateful for so many things. I’m grateful that I had the opportunity to take care of thousands of children and form meaningful relationships with those families. Have the feeling of saving lives, going through the worst moments with families, creating meaning. I’m happy that this happened to me in my 50s instead of my 30s or 40s. I’ve given much worse news than I’ve received. I’m grateful that I don’t have cancer, that I have a normal life expectancy. I hope to have many more productive years. You know, I’ve learned so much from the bravery of my patients.

David Sandberg: And I’m trying to be brave and strong.

David Raubach: Yeah, that’s amazing. Well, it’s obviously a big loss for the surgical community not having you as a member, but if you’re able to do even half of what you’ve done in the surgical field with child poverty, then it’s you’re going to have a huge impact there. I really want to thank you for your time today, Dr. Sandberg. Is there any final thoughts? What, how do you want people to think of you? I mean, I know obviously the book says a lot about who you are, but even less as a surgeon, but as a person, how do you want people to think of you as a person?

David Sandberg: Well, I’ll leave everybody to form their own opinions. You know, I don’t, that’s not important to me. I hope there are some lessons that are valuable to patients and families and trainees in the book. And I hope they enjoy it. And I don’t want to speak further, by myself, and I don’t know.

David Raubach: Well, I will, and I think that your answer is perfect because humility is probably the biggest thing that I took away from the book. And I think that’s just an incredible thing to see in a doctor, and it must have been really special for patients who you dealt with to just see a doctor who brought to the table that just that humility, that even though you’re doing amazing things and saving lives, that you still brought this heart and this humbleness to what you were doing.

David Sandberg: Neurosurgery is a humbling profession. Yeah, it’s, you know, people think of neurosurgeons as they can be arrogant. The ones that I’ve know, you know, and I know so many, most of them, yeah, sure, they’re confident in their abilities, but they learn humility the hard way over the years because the brain is unpredictable and unforgiving.

David Raubach: Well, thank you so much for your time. I encourage everybody to go and check out the book, Dr. David Sandberg, Brain and Heart. It’s an incredible, incredible book. A great read, very well written, and those of you on who have Audible, great job narrating it as well. You said that you did have to try out to be the narrator of your own book.

David Sandberg: Exactly.

David Raubach: But again, thank you so much for your time today, Dr. Sandberg. I really enjoyed talking to you.

David Sandberg: Thank you for inviting me on your show and thanks for what you’re doing to educate families about, you know, what patients go through with cancer. And you know, I wish everybody the best.

David Raubach: Yeah, appreciate it. Thank you.

David Sandberg: Thank you.