September 27, 2024 • 66 mins
In this episode of Botox and Burpees, the surgical edition, we feature Dr. David Lawrence Brown, a seasoned plastic surgeon who recently transitioned from an academic career at the University of Michigan to private practice in St. Louis, Missouri. Drawing on over 26 years of experience in academia, Dr. Brown shares his journey of personal and professional growth, including the challenges of shifting from faculty to private practice.
Dr. Brown takes us through his extraordinary journey, sharing the highs and lows of his transition and his groundbreaking work in peripheral nerve surgery for chronic pain, revealing how this niche field can provide solutions for conditions like post-mastectomy pain, pain from knee and hip replacements, and shingles.
Dr. Brown outlines the evolution of surgical techniques, the importance of mentorship, and his vision for the future of nerve surgery.
Aspiring plastic surgeons will find his advice invaluable, particularly the importance of seizing opportunities and seeking mentorship in this niche but impactful specialty. Don't miss this inspiring episode packed with career evolution, medical innovation, and the relentless pursuit of improving patient outcomes.
#PlasticSurgery #MedicalPodcast #SurgicalLife #SurgeonSpotlight #HandSurgery #DoctorInterview #HealthcareHeroes #InspiringSurgeons #MedicalJourney #PodcastLife #SurgeryEducation #FutureSurgeons #BotoxAndBurpees #BotoxandBurpeesPodcast #LifeInMedicine
@michigan_surgery @umichplasticsurgery @umichmedicine
#chronicpain
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:04):
I just finished recording the podcast you're
about to watch and listen towith Dr David Lawrence Brown.
He was a newly minted attendingat the University of Michigan
when I started my plasticsurgery residency there over 20
years ago.
Maybe you've known someone whobecame a teacher at a school
that they were a student at andit's not easy to take on the
role of an attending after justbeing a fellow the week before.
(00:24):
But Dave took it in good strideand I watched him during my
residency become an accomplishedand seasoned attending over the
years.
Dave has a tremendousenthusiasm for everything he
does, as you can hear in thispodcast, but I never would have
expected him to have left theUniversity of Michigan so late
in his career.
After 26 years of faculty thereand as a tenured full professor
(00:44):
, he decided to leave Ann Arborfor private practice in St Louis
, missouri a couple months ago.
Now there are people that youknow at many institutions who
are lifers, and University ofMichigan is no exception.
People stay there for theirentire careers.
So to talk to Dave and find outwhy he decided to leave was an
absolutely fascinatingdiscussion.
I think it's absolutelyhilarious that he and Coach
Harba.
He decided to leave was anabsolutely fascinating
(01:04):
discussion.
I think it's absolutelyhilarious that he and Coach
Harbaugh decided to leaveMichigan at exactly the same
time but despite Dave's joke, heand Coach Harbaugh could not be
more different.
Probably the most interestinglyfuture forward part of our
discussion was the deepdiscussion we had about treating
chronic pain with peripheralnerve surgery, which is what his
(01:25):
specialty is now.
I believe it will work for manypatients in dire straits who
have no other solutions forexcruciating chronic pain.
I look forward to Dave's work inthe future and I believe that
many of us will benefit from thetechniques developed in the
small but growing field and, asI say at the end of the podcast,
(01:45):
I never would have imagined 20plus years ago that I would be
talking to Dave about a new job,new career and new surgical
specialty.
But you never know where theroad will take you and, as Dave
says, he took the one lesstraveled by and to steal from
Robert Frost.
I think it will have made allthe difference.
Thank you for watching andlistening.
(02:06):
All right, Welcome to anotheredition of Botox and Burpees,
the surgical edition.
I have with me a longtime friendand colleague and he was one of
my first attendings, actuallyas a plastic surgery resident Dr
David Brown, David LawrenceBrown, Because honestly there
are many David Brown's plasticsurgeons out there.
(02:28):
So make sure, if you're lookingfor the authentic, real David
Brown, it's got to be DavidLawrence Brown, who's currently
in St Louis, Missouri.
He was at Michigan for a verylong time.
Let's go through Dr Brown'straining a little bit so you
know who he is.
He graduated undergraduate atWittenberg University, which is
(02:49):
actually really pretty close tome because I grew up in Columbus
and then with a degree inchemistry.
And then you went to VanderbiltUniversity for your medical
school training or medicalschool, and you graduated there,
and then you did your generalsurgery residency at University
of Cincinnati.
So you're one of those oldschool guys who did a full
(03:11):
general surgery residency beforedoing your plastic surgery
training.
Speaker 2 (03:15):
Actually actually no, I left after four years.
Oh, that's right, you did four.
Speaker 1 (03:20):
So it was one of those quick jump tech things.
Speaker 2 (03:23):
That's an interesting story.
I can tell you about that later, if you want.
Speaker 1 (03:27):
Yeah, I have heard it , that's a good story.
And then you went to Michigan,university of Michigan where you
did your plastic surgeryresidency You're a fellow there,
yes.
And then you stayed on as a asfaculty, and I remember because
I just started my plasticsurgery residency there and you
(03:48):
were a brand new faculty member.
Pretty much that that first yearI started, yeah, and you got a
lot of crap because you knowit's kind of weird when you're a
fellow and then you suddenlybecome an attending and I
remember people sort of givingyou that the jibe the business
when you started.
But you stayed on for 26 yearsat University of Michigan and
(04:13):
you were a tenured professor inthe Department of Plastic
Surgery sorry, division ofPlastic Surgery but in January
of this past year you left after26 years and you are now at St
Louis, missouri, at NeuropaxClinic, where you specialize in
(04:35):
peripheral nerve injury and pain.
You have found the surgicaltreatment of chronic pain to be
the most rewarding due to theincredible results you've seen
with innovative techniques.
Your specialties include painfollowing mastectomy, knee and
hip replacement, shingles,hernia repair and abdominal
(04:55):
nerve pain, and you have a tonof accolades and awards.
You served as president of theASPN, the American Society of
Preferable Nerve, board ofdirectors of the American
Society of Plastic Surgeons,president of the Michigan
Academy of Plastic Surgeons andoral boards examiner for the
(05:16):
American Board of PlasticSurgery.
So welcome, dave, it's great totalk to you, thank you Steve.
And I really appreciate youcoming on to this podcast.
Speaker 2 (05:27):
Well, thank you.
I'm super honored to have youask.
It's been fun listening to manyof your past episodes and
hearing what other people had tosay, and I think this is an
awesome forum, so thanks forhaving me on.
Speaker 1 (05:43):
Thank you.
You represent someone that I'veknown for a really long time.
You are a Michigan lifer, andso your training really was
similar to mine, in the sensethat we had many of the same
faculty members and people thatwe worked with.
What was that like, though,coming from Cincinnati into
(06:06):
University of Michigan?
And, yeah, remind me again howyou managed to cut short your
general surgery residency andshort circuit that into plastic
surgery training at Michigan.
Sure, thank you.
Speaker 2 (06:19):
So you know, going into general surgery residency I
really thought I wanted to be avascular surgeon, do a vascular
surgery fellowship.
I found out in pretty shortorder.
I didn't really love thatspecialty and that's, you know,
a whole other story.
But people of yours and my kindof era, I think, know that
(06:42):
those are very difficult kind ofemotional patients to take care
of.
And when my thinking kind ofswitched to plastic surgery, as
you also might attest, plasticsurgeons were kind of persona
non grata to general surgery,especially the original kind of,
(07:03):
she said, hard, hardcoreprograms, of which Cincinnati
was certainly one.
And so I kind of had to applyto plastic surgery programs, I
guess not in secret, but withouttelling a whole lot of people.
And when I sent out my this wasback before online applications
(07:26):
.
And so when I sent out myrequest for paper applications,
I included a CV in every one.
And one night I was on call atthe VA and the program director
from Michigan actually paged methrough the hospital operator at
like 8 pm while I'm on call andsaid so what's your deal?
(07:48):
It was a very interesting phonecall.
You might imagine who that was.
Speaker 1 (07:53):
It was Garner, right yeah.
Speaker 2 (07:55):
It might have been and I love Warren, and you could
just tell from that firstmeeting of ours on the telephone
how it all went.
But he said you know, we canactually use somebody here in
about three months.
We had somebody leave theprogram and so, rather than
(08:18):
applying for a year and a halffrom now, I'd like you to think
about taking this job.
So I said, well, I really, oh.
And he said, you know, come upthis Wednesday for an interview.
Well, I couldn't just leave onany Wednesday.
And, um, I said I couldn't.
He says, well, that's too bad,we could have, we could have
liked having you here.
(08:38):
So, um, so anyway, I I talkedto the chief resident I was
working with at the time andI'll never forget her name was
Trish Abello, and I told her youknow kind of where I was with
the whole thing and I justremember Trish saying you know,
what doesn't matter, I willcover you.
You know, get there, do what youneed to do for you in your
(09:00):
career, and kind of the rest ishistory there.
You in your career, and kind ofthe rest is history there.
So I think some of those themesmaybe we'll talk about tonight
on the rest of this podcast, butI really remember that as being
a very pivotal time in my lifeand my career and a really
(09:22):
pivotal decision that Trish madeon the spur of the moment and I
don't know that, she knows thatand I have thought I should
tell her a million times, somaybe she'll see this podcast.
Speaker 1 (09:34):
You know, michigan does have a soft spot for people
like you and me who had abrupttransitions like that.
I had something similar comingfrom my program into Michigan
and Gardner was definitely apersonality and I had a similar
experience when he contacted meas well, so I can certainly
(09:57):
relate.
Very impactful.
It's funny how those littlecrossroads can really make a
ginormous decision and impact inour lives.
But let me ask you so, when youlook back at either your
general surgery training or yourplastic surgery training, was
there anything in there thatreally impacts you now or that
(10:19):
you even think of now as asurgeon?
Speaker 2 (10:27):
think of now as a surgeon.
Wow, that's hard to nail down.
I mean, I think we could spendprobably a whole podcast series.
We could do 10 episodes.
You know, I think and maybe wecan talk about this, because
I've heard you bring up thistheme on other podcasts you've
done kind of about serendipity,but also about mentors and
(10:50):
people who took the time atcertain points that you just
kind of remember little snippetsabout that helped you, either
guide you or bring you up orjust show you hey, listen,
here's a path to what you wantto do and you don't really
forget those things.
And the one thing, which maybesome of the things we'll talk
(11:15):
about are more that I should dowhat I say, because I do have a
few little, I guess, words ofwisdom I'd like to leave for any
other residents coming upbehind us, and one of them is to
remember those things and saythank you for them.
(11:36):
And so maybe I really shouldhave reached out to Trish before
now.
But you know, I reallyappreciated the way Warren
Garner taught me in theoperating room when I came to
Michigan.
When you asked you know whatwere the differences, I found
that I learned a lot at theUniversity of Cincinnati, I
(12:01):
learned a lot because I worked140 hours a week and there's
only 168 hours in a week and soit was hard not to, but the
learning was hands-on andpassive and it gave me a good
(12:22):
surgical foundation to know.
You know, I was responsible fora patient and I had to see that
through till the very end.
I couldn't go to bed or Icouldn't go home until things
were as good as I could makethem in somebody's health care
and but by the same token, right, it was a really hard system
(12:44):
and I know you've had podcastsabout that.
And when I got to Michigan toanswer your question, I found
people more focusing on me as alearner and as a developing
surgeon, with more dedicatedtime to teaching me things and
(13:07):
just a more active environment,and people like Ed Wilkins and
Steve Buckman and Paul Sedernaand those folks who really spent
a lot of time Hack Newmanworking with us as trainees.
I'll look back and reallyremember that fondly.
(13:29):
So those were several of thekind of main differences in that
period of time.
Speaker 1 (13:38):
They were and are awesome faculty members for sure
, and they did take an interestin our surgical education.
There was a lot of work.
Let's not cut it short.
I mean I know my generalsurgery sounds like your general
surgery.
Training was worse than mine.
Cincinnati was notoriouslybrutal, but it's changed
obviously a lot now.
(13:59):
Like none of what we sort ofexperienced is is the way
surgical residents and trainingis now, and you just recently
left Michigan.
So what you know, one of thosecompare and contrast type of
situations.
What what what would you say arethe biggest differences?
(14:20):
Both good and bad?
I don't want to be one of thoseGen Xers that say the Gen Z
people are all weak or whatever.
But what do you see that areboth good and bad?
Points to that.
Speaker 2 (14:32):
Great, great, great question.
We could go on for hours, butone of the things that when you
say, what is something Iremember.
I remember being a second yearresident and our chairman left a
copy of a newspaper article inall of our mailboxes for us to
read and to summarize it it wasfrom the New York Times and it
(14:55):
was about I believe it was aphysician who was saying you
know, my children don't need meto raise them and to know them,
and for them to know me, theyneed me to be the breadwinner
and a good role model.
And if I don't get home tillafter they're in bed or I sleep
(15:19):
all afternoon Sunday because I'mtired of working Sunday,
because I'm tired of working,that's really what they need and
that really summed up theentire kind of philosophy of
things and things were.
You know very much.
The reason they called usresidents is because we were
(15:39):
supposed to be resident of thehospital, right, sleeping there,
eating there, living there.
And, you're right, the plasticsurgery training wasn't
significantly easier, but thatwas really shocking to me at the
time to get that note from himand for him to be telling us
(16:00):
that this was a positive way toview our lives.
Again, I look back on thetraining that I got.
That was superb and gave megreat foundations that have
lasted this whole time.
But things needed to changeright.
I knew people who weren't therefor their children's births,
(16:24):
who weren't there for theirchildren's births, and I mean
you can say every familyoccasion or hospitalization or
surgery that somebody had andthey couldn't make it because
they were in the hospital andyou and I both know the kinds of
conditions that people trainedunder that just needed to change
(16:46):
, and they have.
They've changed a lot.
The question is, I think youknow, have they changed too much
?
Has this?
You know the pendulum usuallyswings and you know maybe then
finds that it's not at the rightapogee yet either and has to
come back so much.
(17:07):
And you know I'd posit to youthat maybe it swung too much.
It's hard to know and maybewe'll know in 10 or 15 or 20
years, maybe we won't.
Speaker 1 (17:18):
How?
So Let me know, Like what is itthat you see that might be a
little too much the other way,like example-wise for trainees.
Speaker 2 (17:27):
Well, sure, I mean, you know, I think what we want
out of our physicians and oursurgeons is somebody again who's
going to take care of usthrough an entire illness or
through our entire lives orwhatever the entire emergency
(17:48):
room visit, and that obviouslyisn't possible in all of
medicine.
It's not, especially notpossible today with different
work week hours and with, youknow, just being kinder to the
people who are delivering thatcare.
And you know, again, there arelots and lots of benefits to
(18:08):
what's happened.
Right, people aren't crashingtheir cars into the bridge
abutments on their way home froma long shift which happened to
one of my classmates, or youknow committing, you know,
medical errors because theyweren't getting enough sleep or
they didn't yell that too much,you know.
I think we do have to bemindful, though, about you know
(18:31):
how much we really take the jobas a shift work, what it looks
like when you turn over care toanother physician who's going to
assume the care of that patientfor you, and how that's done,
and be very mindful of that, andI think in many instances that
(18:55):
happens really, really well.
Obviously, there areopportunities, as these culture
shifts happen, for things to goa little too far and need to
come back.
You know, one of the originalcomplaints of long work hours in
the list of all the otherthings was the lack of time to
(19:18):
actually sit down and study,because learning is so much
about doing, but it's also aboutbeing taught, and it's about
teaching yourself.
And if you're up taking care ofpatients for the entire week,
you're not reading a book.
And there was an interestingstudy that came out, I don't
(19:39):
know, 10 years after the dutyhour work week changed.
That said that the number ofhours that residents were
reading was actually at or belowwhat it had been before the
duty hour change.
It's not entirely surprising.
I mean, you know you need sometime to live life and do your
(19:59):
laundry and, you know, get ahaircut, which there wasn't time
for.
But anyway, I don't have, Iguess, real criticisms.
I'm just saying I think we'restill figuring it out where that
best practice is.
Speaker 1 (20:21):
I might argue this is a permanent shift.
I know young surgeons comingout.
They don't go solo.
You can find a group where itis literally shift work, where
you are passing on and handingoff your care to someone else.
Then you go, you live your life, you come back, you pick up
(20:43):
wherever that other person leftoff or your group left off.
Oftentimes they're not incontrol of their own practice.
They are part of a largerorganization or administrative
group, a hospital.
So I think that this aspect ofsurgical culture where you have
(21:04):
a responsibility to a patient,may actually no longer exist in
10 to 15 to 20 years, or it'llbe the minority of us, because I
don't think people will see itas wrong to operate on a patient
.
Hand off that care to somebodyelse, let them manage that
patient.
Hand off that care to somebodyelse, let them manage that
(21:26):
patient.
When you come on, you might bemanaging somebody else's
post-operative care or patients,and it's just going to be
figuring out how to make thosetransitions less error-prone or
fraught with difficulty orproblem problems.
But there there, that might bea permanent culture shift at
(21:48):
this point, because I don't eversee us going back to the type
of training that we had where weliterally would stay up all
night taking care of somebodyand you know, and sort of seeing
the whole thing through.
Speaker 2 (22:03):
And I don't know if it's good or bad, I'm just
saying that.
Speaker 1 (22:06):
that's the way it's going to be.
Speaker 2 (22:07):
I don't disagree with you.
Again, there are certainelements that needed to change,
but hopefully we'll get smarterand better as this goes, Because
that's, I guess, why they callit a practice of medicine Right.
That's why they call it apractice of medicine right.
But you know, one of the thingsthat's been a little tough is,
(22:29):
honestly, the whole idea ofwellness and happiness.
Maybe that, what was that movieHappiness with a Y, right,
Right yeah, the pursuit ofhappiness.
Pursuit of happiness, and Ithink there's room to come back
(22:50):
and make gains in both ways.
Right, and most people I thinkmost of our trainees feel this
way and act this way, but Ithink there's an opportunity for
some to say you know what?
Yeah, wellness for me is notbeing at work, and I don't think
(23:14):
that's what that word in ourspecialty was really designed or
brought up for, right.
It doesn't mean that I justwork less hours, although I'm
not saying that we need to workmore hours.
I'm just saying that you haveto learn to be happy at work and
you have to learn to beefficient at work and you have
(23:36):
to learn to take good care ofpatients.
That makes you happy and youhave to seek out that happiness
in a system, in whatever way youdo that.
That involves your career andyour life and it isn't just well
, I'm, I'm happy when I'm notworking as an attitude, um and
(23:58):
and I that.
That, I guess, is maybe where Ithink we've swung a little far.
Uh and, and you know, maybesome of the hospital, when you,
when you read anything thesedays about burnout and about
administrative systems andthings that people would
generally complain about, it'smore about the systems and the
(24:22):
restrictions on how we practice.
That makes people less happywith their job and their career
at least the studies that I'veseen, as opposed to how many
hours I was at work or whatweeks of vacation I got,
although those are important.
Speaker 1 (24:43):
Well, all right, let's talk about your life then,
in terms of hours, weeks,career, happiness.
You spent 26 years atUniversity of Michigan as an
academician, as a faculty member, as a professor.
Now I spent five years inacademics and then I
(25:06):
transitioned out into privatepractice and I thought that was
one of the most jolting, weird,difficult transitions as a
physician and a surgeon that Ihad to make, and it's like mind
blown that after 26, that's whatyou're doing, having left
University of Michigan.
The same.
You're like Jim Harbaugh.
He was at Michigan last year,won a national championship,
(25:28):
took off, went to the pros.
You're sort of doing the samething.
Just about the time he left youyou're now at Neuropax, a
private practice with anothersurgeon no more academics, no
more provided secretaries, nomore salary, no more protected
(25:51):
time and vacation and all thissort of stuff.
Why, on God's green earth,after 26 years, would you leave
tenure to do this?
Speaker 2 (26:07):
So thank you for finally outing me.
I am Jim Harbaugh.
It is not a coincidence that weboth left the University of
Michigan at the same time.
I am his Clark Kent.
No, nothing could be furtherfrom the truth.
(26:32):
I really did love my time atMichigan.
It was actually really reallydifficult for me to leave and I
felt, as I was doing it, verysad about that, to be honest,
because of the people Imentioned and that really was my
(27:16):
and still is my family, andthat stuff's hard in life.
Those sorts of changes andtransitions are difficult.
But you know, I always had abit of a private practice
mindset, I think, and you know,one of the things that
highlights that is you know, Iused to complain quite a bit
about the state of ouroutpatient clinic, and so much
so that when it came time toname a medical director, when
they started doing those kind of, they started doing those kind
(27:36):
of administrative things acrossMichigan's outpatient clinics,
our chief at the time said hey,guess what you get to be the
medical director of theoutpatient clinics.
You know, careful, careful.
How much you complain aboutsomething, you'll be in charge
of fixing it.
Um, and and, and and.
I actually really liked that Idid that for 13 years, Um, I
(27:58):
finally stopped doing it, Um,when it became really difficult
to make those independentdecisions, or decisions with our
faculty, with our nurses, withour MAs, PAs, residents to do
(28:20):
what we thought was best to takecare of patients, and the
administration levels kind ofgrew, particularly in the last
few years, to the point that itbecame harder to make
independent decisions about whatwas good for plastic surgeons
and plastic surgery patients indeference to decisions that were
(28:42):
being made across, you know,big giant health systems.
And so I guess that brings meback to independent private
practice, and you know I'dalways had that is, the grass
greener kind of look over thefence mentality.
(29:04):
I did all I wanted to do at theUniversity of Michigan, Um, and
I just felt like it.
Either either I did somethingindependent um at this point in
my career or I wouldn't, becauseI, you know, maybe I have six
or eight years left to practice,Um, and I certainly wouldn't do
it with two or three years leftUm.
(29:27):
Rob Hagen, who's been a reallygood friend in the nerve society
, does a lot of the same thingsthat I do.
There are only, you know, adozen of us across the country
currently devoting our full-timepractices to peripheral nerve
surgery for treating chronicpain, and Rob's one of them.
(29:47):
And I wouldn't have left if ithadn't been for the right
opportunity and especially theright person.
Right, that's, that's what.
That's what drew me to Michigan, it's what brought me back when
you said, you know, after,after being a fellow there, and
I came back as junior faculty,Right, it was for those people,
(30:10):
and so I never would have leftthat if it didn't seem like a
really good match of people.
And Rob is a really good person, he's a great surgeon, he
actually writes a lot of papersand the two of us will continue
to do so.
So we're going to try to keepLee Dellin's saying alive about
(30:33):
privademics, which is some atleast still being somewhat
academic in a private practice,and to the point that we're even
going to have fellows, and wehave a fellow starting with us
here next year that I'm reallyexcited about.
So the transition's going well.
(30:54):
Uh, you know I'm I'm only a fewmonths into it, but, um, I'm,
I'm really, really enjoying, um,the setting and the ability to,
you know, do what I, do what Iwant to, to take care of
patients.
Um, and I I miss Michigan for,being honest, I miss the people.
(31:16):
But this is also very good andthat was one of the things that
I did want to talk about tonight, which is taking chances and
never passing up an opportunity,even though it looks hard.
And everybody I talk to haskind of the same attitude and
(31:37):
the same questions that you didfor me tonight and that is.
You know what were you thinking?
And fair enough, I mean, Iunderstand that question, but
maybe what was I thinking fiveyears ago or 10 years ago?
Or you know what would I bethinking five or 10 years from
(32:00):
now if I hadn't done it?
So you know, my excellentlong-term friend, mentor,
colleague and then finally bossat Michigan, Paul Sedernit, used
to always give me a little bitof a hard time because I'd
really get into hobbies and I'dget into scuba diving or flying
(32:24):
airplanes or sailing boatsaround different parts of the
world and just throw my wholeself into it for a while until
I'd kind of gotten all I wantedout of it and then pick up a new
hobby.
So I don't know that this is anew hobby, but it's just another
(32:46):
thing I wanted to tackle andsomething I just had to do
before I died, I guess it makessense.
Speaker 1 (32:56):
I applaud that, thinking that what you might see
yourself in five years, whetheryou would regret not taking
that chance, I think that'simportant.
You sort of pulled a reverse.
Bob Gilman he was the one whowas in private practice for a
long time and went to Michiganand you're flipping it now but
you're in a boutique-y kind ofspecialty, so most peripheral I
(33:17):
mean most plastic surgeons donot do peripheral nerve surgery
and even fewer do treat chronicpain by doing peripheral nerve
surgery.
So my and the ones who do are.
There are very few of them inthe country and world and
they're renowned for what theydo, like a Lee Dillon, for
(33:40):
example, and now.
Now, so you must probably drawfrom a very wide area, because
with the Internet, with peoplecommunicating, people must say I
have chronic pain from amastectomy.
Who do I see?
And they're like there arethese guys in St Louis, Doesn't
(34:01):
matter, if you're in LagunaBeach, California, you got to go
see these guys and they'll comeout and they'll see you.
You know, certain specialmedical conditions warrant
travel to specialists.
Speaker 2 (34:14):
Is that what?
Speaker 1 (34:14):
you're seeing in your practice and how do you manage
that sort of, you know, reallybroad, like a very niche
specialty, but drawing from avery broad geographic area?
Speaker 2 (34:27):
Sure, yeah, you couldn't be more right about
that, and I think that's one ofthe things.
That is really exciting to me.
You know the fat, so the fieldis taking small nerves, which
are, as you know, electricalwires in the body that carry
signals to the muscle to makethings work and then carry
(34:52):
signals from the skin and otherparts of us, our joints, to the
brain to tell us how those partsare feeling and their
sensations.
And many things like injury,accidents, surgery and just
sometimes life life as incompressions of nerves can leave
(35:15):
people with chronic pain andthe statistics are are
unbelievable and it's amazingthat we don't learn a lot about
pain in our in our medicaltraining, in our residencies,
even even in practice, otherthan and I always fell victim to
this that there are painmedicines which, as it turns out
, aren't really pain medicines,in opioids and other things, and
(35:41):
there are more people livingwith chronic pain than there are
with heart disease, diabetesand cancer combined diabetes and
cancer combined and they'vebeen absolutely the best
patients to take care of.
In all the things that I'vedone and I did a lot of Mohs,
(36:02):
facial cancer reconstruction, Idid lower extremity abdominal
wall, did a lot of breastreconstruction for a while, a
lot of hand trauma those wereall satisfying things to do.
This has just been for me.
It, just as my partner RobHagan now says it just pushes my
(36:22):
happy button.
I mean, these folks aremiserable.
This field is so new that notmany people know we exist.
I mean, I'm sure you feel thesame way that even just when
somebody says you say tosomebody I'm a plastic surgeon,
even probably people in yourclose family say couldn't really
(36:45):
describe what it is that you do.
Speaker 1 (36:48):
Right.
Well, they think I do lipo,which is kind of true.
Speaker 2 (36:51):
But whatever, go ahead, right, right and well,
they think I do lipo, which iskind of true, but whatever, go
ahead Right.
I mean there's a there's a verynarrow definition in society,
public opinion, about what aplastic surgeon is, despite the
fact that we do all kinds ofreconstruction and cosmetic
things, they don't can grasp.
So then, to add on to that,this little niche is it's hard
(37:15):
to get that information topatients.
But you're right, and I neverreally thought too much about
being at a big academic medicalcenter.
People would line up basicallydown the street right in terms
of booking appointments with you, so you never really needed to
try to get the word out about itvery much.
(37:36):
Our main goal now is just allthe time educating people about
what we do.
Excuse me, what can be done totry to get to those patients who
are sitting at home withchronic pain conditions and
nothing feels better than youknow a woman coming from New
(37:56):
York City to see me for chronicmastectomy pain from a bilateral
mastectomy eight years ago, andor a woman from Florida that I
treated last month for chronicneuropathic pain from shingles.
So that initial shinglesoutbreak right is so horrible.
(38:20):
Everybody talks about being oneof the worst painful things up
by next to kidney stones.
This is a condition where thenerves get so damaged you have
pain forever and there's neverbeen a solution, pain after
total knee replacements and allsorts of things.
So it's just been just anothergift.
(38:44):
That medicine's given me theability to interact with these
patients and help them.
And, um, and if we have twomore minutes in this kind of
vein, I'll tell you how, how Ifirst got into doing this.
I used to always tell patients,um, when they'd come back and
they'd say you know, my, mychest is hurting after having
(39:06):
had a breast reconstruction, andwe would always say, well, you
had surgery and now you knowthere's some pain that goes
along with that, and then youmight not see that patient again
.
Or you'd see them six monthslater and then not again.
And they went somewhere andthey lived their lives and they
went to many other doctorsunbeknownst to me to talk about
(39:28):
this horrible chronic pain thatthey had, so much that some
patients would come back to us,not infrequently, and say can,
can you know?
After all, they went throughhaving the breasts removed,
three or four operations to havethem reconstructed and they
would say just take them away, Idon't, I don't want this uh
anymore because they hurt and weknew that removing them wasn't
(39:53):
the answer right.
But sometimes you couldn't sayno because people were just in
such pain and were so insistent.
And I had one patient that Ialways tell was kind of my aha
moment.
She was very young, I don'tknow, early 30s, to have breast
cancer which, as you know, isusually more aggressive the
(40:15):
younger you are.
And she was so thin that sheneeded a muscle transfer, a
latissimus flap brought aroundto her chest to add to an
implant.
But we always did thatoperation with a couple days
hospital stay.
And she told me you know, Iwork on an assembly line, I'm
really tough, I'm not going tostay in the hospital and so well
(40:39):
you know it's really bad.
There's a lot of pain with this.
We need to admit you to thehospital a couple days.
She said no and in fact I willonly let you book my surgery at
the outpatient surgery center.
That's how confident I am thatI'm going home and you can't
make me stay in the hospital.
And we did and she did and Iwas very impressed by her
(41:04):
resolve and her ability to dothat and we got all through with
the reconstruction and it wentvery well.
And she came back and she saidyou know what?
The pain in my back that I'mhaving is unbelievable.
Take it rid of it.
It's horrible.
And you got to do somethingabout it.
And I'd heard that obviouslybefore.
(41:24):
We've all heard that, and to usin surgeons it was always a
thing about you know, I don'tknow how to help people who are
having pain, so they're, youknow, just aggravating to me and
them.
Anyway, I spent a lot of timelooking into it and found out
(41:45):
that, well, you know, anyoperation that you do can injure
little, tiny nerves that maybeyou don't even see during
surgery Usually you don't evensee during surgery Usually you
don't and you can cut them,stretch them, burn them.
They get caught up in scarafter surgery and she was so
definite about it hurts here andhere.
And we took her back to theoperating room and we opened up
(42:08):
those two little areas and wefound these big balls of nerve
tissue called neuromas and cutthem out.
And I don't know just at thatmoment that I said that is, just
for all the stuff I'd beendoing, really incredible and
that was kind of the tip of thaticeberg, so to speak.
Speaker 1 (42:33):
Working on patients who are in dire straits, such as
the ones that you have as asurgeon, it doesn't sound so
appealing to me on a couplelevels.
First of all, these arepatients that are very desperate
.
I would be worried that mysurgical procedure might not
(42:53):
work.
I might be concerned that Ihave to.
You know, pain is multimodal,so you have to do all sorts of
other things in addition to justoperating.
In terms of managing thesepatients, and as a surgeon I
would be like this does not seemlike the most fun to me.
It's a nebulous problem.
It's not always clear that youcan guarantee or have a high
(43:17):
likelihood that you woulddefinitely find a good outcome.
Pain is difficult sometimes, oralways, and so I would say why
would you encourage any surgeonto try to?
I mean, I understand the greatoutcomes are great outcomes, but
you know, as a batter, what areyou hitting here?
250, 300?
(43:38):
Like, is this a 90% likesuccess?
It's to me I would feel likeyou would pat yourself on the
back if you got maybe a quarterof these patients better.
Speaker 2 (43:50):
Um, I, I, I first say that you know, um, in all the
time I've known you, and so whathas it been?
20, we had to add it up, it'sbeen at least 20 years.
Yeah, More than that, probablyMore.
Yeah, you are one of the mostinsightful and most empathic
people that I've known, and Idon't know if I've gotten to
(44:12):
tell you that before, but no, Imean, and you're right, and so
that's another thing is, peopleare going so full professor, and
you left this to get what?
What are you thinking, right?
I mean anybody that I, that Itry to talk to about nerve
surgery, who's a surgeon, sayswait, you, you want a whole
clinic, you want to see 30patients in a day, all of whom
(44:34):
have pain.
That would be like two, itwould be bad for me.
And so that's basically whatyou just said.
The miracle comes when yourealize, actually, and even as I
started doing this, and even asI started doing this and in the
first 50 or 100 patients I tookcare of, that innate it's not
(44:58):
innate because it was ingrainedin us, I'm sure feeling of I'm
going to make it worse or I'mnot going to be able to fix it,
and then it's my fault,internalizing all those feelings
is there and just like anycomplication that you have, and
(45:19):
you feel absolutely horrible andcrushed about with anything
else, that's still true withthis, but it turns out that
these issues are mostly solvable.
So when you say, you know what'smy batting average?
Well, it's not perfect, butit's everything.
It was in hand surgery andcancer, reconstruction and
(45:45):
cosmetic surgery and so forthright, you have to understand
the problem really well and youhave to learn to diagnose B
(46:21):
nerve-related, and C treatable.
And it isn't what I thought itwould be.
That was so scary, which is,you know, I might have a whole
bunch of people that I can'thelp and a whole bunch of people
that have pain that's in theirhead and it's just really I
(46:47):
don't know.
It's really awesome.
Speaker 1 (46:50):
It's really an incredible thing when you do
these surgeries.
Now is the technical part of itthe most challenging, and what
kind of technologies can you usenow?
Like is it different doingthese surgeries now than it was,
say, 10 years ago?
Like there are a lot ofsurgeries where we don't do
anything the same that we did,say, 10 or 15 years ago.
(47:13):
So it's like what has changednow with this?
Or what's getting you jazzedabout this kind of surgery, the
new stuff?
Speaker 2 (47:21):
Sure, well, first of all, as we started the podcast
and I said that I originallywanted to go into vascular
surgery when I was a generalsurgeon.
Then, when I started atMichigan, I wanted to be a hand
surgeon, and I think the commontheme to those in peripheral
nerve surgery is detailedanatomy, and I love dissecting
(47:47):
out nerves, I love finding them.
You know, I think the residentshalf of them would think I kind
of lost it.
Every time we'd do a casetogether and we'd find the nerve
, even though we knew we'd findthe nerve, and I'd get all
excited and be like, hey, lookat this and I'm calling the
anesthesiologist to look overthe drapes.
Have you ever seen this nervethat goes here?
And it was a little silly, butit was really fun, and the
(48:12):
answer to your questionspecifically, though, is no,
it's just a new paradigm ofunderstanding.
In fact, the exam and the testsfor doing it are so
ridiculously simple.
Anybody could learn it in acouple of days.
(48:33):
The biggest thing you have todo, I think, is as my college
theater professor told me,because I went to liberal arts
school and I had to take atheater class this concept of
suspension, of disbelief, right,and so you know, when I trained
(48:57):
at Cincinnati, you, you, uh,you know, didn't let the patient
eat for five days after a bowelresection, because that's when
they got to eat, if for no otherreason, right, you didn't pull
the drain out until it was lessthan 30 cc's in a day, which
actually I still ascribe to.
(49:20):
And with peripheral nervesurgery for pain, first of all,
you have to start to believethat things can be possible that
you didn't think were possiblebefore, like, for example, that
you could do an operation on apatient with chronic pain from
(49:46):
post-herpetic neuralgia, whichis the term for chronic shingles
pain, when everybody has saidthat you're not going to help
that patient and the virus isstill in the nerve and it's up
in the dorsal horn and you'renot going to clear them of the
infection but in fact it curesthem of their pain.
You have to suspend yourdisbelief.
(50:09):
That where's my train ofthought?
That, oh, that you knowsomebody who gets a really bad
ankle sprain could havepermanent nerve pain from making
, and I, just in my own self, Iremember first time encountering
that thinking that's thesilliest thing I ever heard Like
(50:32):
, how are you hurting the nerve?
Right, but the nerve when itstretches across that fulcrum at
the angle when you have a badligament sprain, is stretched
beyond its capabilities tospring back and is broken inside
.
I describe it to patients likeone of those fiber optic light
(50:52):
cables and some of the cablesare all broken inside and you
see down it and patients come inwith healed orthopedic injuries
from that, but they havechronic burning pain on their
foot and it just goes on and onand on that list of things that
(51:13):
you have to tell yourself.
Well, I'm just going to applythese principles of how a
patient might have pain here,how it might be related to a
nerve, and then prove it is orit isn't, just like we do in all
of plastic surgery.
And this is people say to mehow do you do that?
How is a plastic surgeon doingthis?
(51:33):
And you know as well as anybodythat that's our specialty is
doing things with the softtissues all over the body and
being innovators in that space.
And I'm not in any way sayingI've done a lot of innovating in
this space.
I've certainly followed on thecoattails of several of the real
(51:57):
pioneers, but it is what ourspecialty does and it's just
been a real boon for me in thelast 10 years.
Speaker 1 (52:11):
Well, we definitely know the anatomy about the
entire body, I believe betterthan any other specialty out
there from head to toe.
I mean, we've had to operateliterally from head to toe as
surgeons.
So no doubt I think you'reright.
If anyone has to dig out nerves, identify them, identify what's
(52:32):
traumatized, that makes sense,you're right.
Some of the concepts you'resaying, as I'm listening to them
, blow my mind.
I've had shingles pain, one ofthe worst episodes I've ever had
.
To treat post-hepatic neuralgiawith surgery also blows my mind
.
Speaker 2 (52:45):
I'm going to be doing some uh Medline searches, uh,
after this podcast, just to tolearn a little bit more about it
and there's not much out thereabout it, um, which is, which is
you know the beauty of what, ofwhat we're doing?
Um, and I read, I read, so, oh,that's an awesome, interesting
(53:07):
story on how I came to do that.
So I had a patient come see meand he said you know, I had
shingles about eight years ago.
I've been in the same state ofpain for the whole eight years.
And I said, well, but I don'tknow how to help you with that.
(53:29):
And he said, well, here's ajournal article and if I'm not
mistaken it was Ivan Duchik'sabout a couple of patients he
treated this way.
And he said you know, I read apaper from you about how you're
treating post-mastectomy painwith nerve operations in the
(53:50):
chest.
And I had shingles on the chestand here's a paper about
treating shingles with nervesurgery.
And he taught me what to do tohim.
And he taught me what to do tohim and since that moment I've
tried to help anybody I can withthis issue.
(54:12):
I just got an email today fromsomebody in Australia.
These folks are, like you said,very, very desperate.
It's very hard to find anybodyto help them and hopefully we
can help this person, findsomeone in Australia to do it.
But you just have to take thosebuilding blocks and those
(54:38):
techniques and put them alltogether to solve these problems
.
Speaker 1 (54:42):
Do you do any other surgery at this point other than
peripheral nerve surgery?
Speaker 2 (54:54):
A little, not a lot, but then again, like I said,
I've been here three months butthat's what Rob Hagen and I is
our plan and to be two peoplewho he does a lot of headache
surgery, thoracic outlet, nervesurgery, upper extremity surgery
and some trunk, and I do trunkand groin and back and lower
(55:17):
extremity, so we overlap, but wecan cover from head to toe and
that's a unique thing, you know,I think.
Um, there are, there are clinicsfull of patients with back pain
and whatever can't be fixed byputting a rod and a screw, uh,
(55:41):
and doing some kind oflaminectomy, um, in the spinal
cord itself.
All those people get lumpedinto one category of low back
pain and there's no great answerfor them, right?
Or there's 50 great answers,which means there isn't a best
answer.
And our kind of next step,which we've already I've already
(56:03):
started doing, is operating onpeople for low back pain.
That I think we're going tofind out is 80% of the patients
who don't have a problem intheir spine itself.
We're going to be able to haveoperations to fix in the next
(56:27):
five years that people will bedoing all over the country to
fix all of these people with lowback pain.
Speaker 1 (56:36):
I think you're onto something intuitively.
There are a ton of people Iknow, because I know a lot of
athletes have had surgery forwhatever reason discs issues,
compression issues and they aretechnically or anatomically not
having anything pathologicallywrong, but they still have
(57:00):
issues.
And I do believe you are rightthere is some sort of peripheral
nerve issue, some other localnervous system issue which needs
to be addressed.
Speaker 2 (57:12):
There's a whole constellation of symptoms in the
lower back that we know ofalready right including the
facets, which are the joints ofthe spinal column, the bones and
their little nerves, and wewere just at one of the large
manufacturers of instruments.
(57:33):
So when you say, are there newtools out, we're learning to use
this minimally invasive tool togo and section or permanently
remove the nerves that go tothose joints.
So that's for facet arthropathy.
I've operated several timesmaybe 10 now on the superior
(57:57):
clunial nerves, which are theset of nerves that come out just
above the pelvis from the back,sensory nerves that run back
over the iliac crest, that canbe irritated there and it's, you
know, it's when you're grabbingyour back and saying I'm having
, you know, low back pain rightthere at your upper part of your
pelvis, and those are solvableproblems.
(58:21):
The sacroiliac joint is a verycommon source for inflammation
and low back pain, of which Iwas unaware five years ago but
is getting a lot of attentionnow for both denervation
techniques but also fusiontechniques.
So all of these things in thelower back, I think, are going
(58:44):
to combine to be able to treatalmost all these patients that
haven't had any good answersforever.
Speaker 1 (58:51):
What do you think about non-invasive treatments
like acupuncture?
Do you think that they're sortof modulating this sort of
peripheral nerve pain in someway to help afford some relief
in some of these patients?
Is that one of the modalitieshow these pain treatments are
working?
Or EMG, for example?
Are you just likeelectrostimulating some of these
(59:12):
peripheral nerve issues as well?
Speaker 2 (59:15):
Sure, that's a long, complicated answer and I don't
want anybody to mistake anythingI'd say in that space because
it's there's a lot of nuances tothat.
But I will say that you know,as a surgery resident, as a
young faculty surgeon, I wouldhave thought acupuncture and
(59:40):
massage therapy and differentthings couldn't possibly be as
therapeutic as they were beingtouted.
Again, I think you have to havean open mind to at least listen
to the arguments and thereasoning behind it and look and
(01:00:02):
see what patients are gettingtreated out there, because when
the general medical communitysays, well, that's not how we do
it and we need published datauntil we all start doing it,
there's still a lot of patientsthat aren't being treated for
whatever reason.
(01:00:23):
So I'm sure and I don't knowanything about acupuncture, but
I'm sure it helps a lot ofpatients.
Speaker 1 (01:00:33):
Okay, so I think you already answered my next
question, which is where do yousee yourself in the future?
And a lot of it is sort ofdelineating a lot of these
techniques, expanding, like yousaid, the indications treating a
wider range of patients.
I mean chronic low back pain.
If you can treat a large subsetof those patients, that would
(01:00:55):
be humongous, like we would seeyou literally on the front page
of a newspaper or newspapers orTikTok.
Speaker 2 (01:01:03):
now I guess you know of a newspaper or newspapers or
tick tock now I guess, um, youknow sort of.
Speaker 1 (01:01:09):
I hope I don't wind up on it, you will, I guess I
bet you if you were to figurethis stuff out.
Is this?
Speaker 2 (01:01:14):
uh, I'm I'm going to admit something to you, sam I
what I.
I was addicted to tick tockWere you, I was I, I uh, just
let me guess what came up?
Speaker 1 (01:01:24):
It was uh videos, cute dogs and I don't know movie
clips.
Is that what came up on yourtake?
I, I, I had.
Speaker 2 (01:01:35):
I had tick tock for a total of one week and my my
wife would attest I could notbelieve I was blown away at how
talented and funny.
Believe I was blown away at howtalented and funny millions of
people are.
Hundreds of thousands that poston that medium and I could just
scroll it for hours.
I stayed up till two, three inthe morning for a week watching
(01:01:57):
that stuff.
I finally had to just go coldturkey and turn it off.
But what so?
What am I?
Um, what am I gonna?
Is that?
That was kind of your question.
Speaker 1 (01:02:10):
Yeah, is this your last stand at this point, cause
you've done all the other stuff,you like?
You said you really get intosomething for a while.
Is this the last thing, atleast professionally, that David
Lawrence Brown is going to getinto before he, like, figures
out something else?
Speaker 2 (01:02:22):
uh, like sort of end of career type stuff.
That's that's.
I think that's my plan.
Yes, that's that's my plan.
Now, whether that comes tofruition, I don't know.
Maybe something, some othershiny thing will make me look
and say squirrel, but um, I, Ithat that that is.
My plan is to, um, take care ofas many patients with chronic
(01:02:45):
nerve pain in as good a way as Ican while I still have this
ability.
Speaker 1 (01:02:53):
And if somebody is listening to this and says you
know what I want to do this asmy job or profession.
This appeals to me.
I am a young person and this iswhat I want to do.
What is the advice you'd givethem in order to become you?
Speaker 2 (01:03:10):
Is this person already a young plastic surgeon?
Speaker 1 (01:03:13):
Either way younger than that or at that level
either way.
Speaker 2 (01:03:17):
Well, I guess I'd say you know there's a lot of
prerequisites and one thing I'dsay is, in as much as you can,
choose the harder, moredifficult route, because then it
leaves you more options openlater.
(01:03:40):
And I guess my piece of advicethere is that you don't know
what it is, you don't know whoyou're going to be in five years
and what that person is goingto have as desires and
motivations and so forth, andthe more you leave options open,
(01:04:00):
I think is the better.
If you're already a plasticsurgeon, then I think there are
a number.
Or if you're a plastic surgeryresident, there are a number of
great opportunities forfellowships around the country
in peripheral nerve surgery, acouple that are more heavily
(01:04:21):
weighted on neuropathic pain.
And if you are a plastic surgeonand want to start doing it,
there are lots, lots of peoplewho just love doing it to teach
you.
And if you don't readily findthem, email me and we'll get get
(01:04:41):
you started.
I mean I got lots of great helpfrom Lee Dellen and Tim
Tolstrup and Eric Williams andRob Hagan and the people who are
doing it really well JohnWinograd, susan McKinnon and
(01:05:04):
it's a really great, tight,small and any of us would be
happy to help.
Speaker 1 (01:05:29):
Dave, it's been eye-opening on so many levels
for me to hear.
I certainly want more people tohear about what you do.
I think there are a lot ofpeople that can benefit and I
appreciate you taking the timeto share.
I never would have thought 20years ago or 25 years ago that
we'd be here talking and you'dbe so enthusiastic about
(01:05:50):
peripheral nerve surgery.
But yet here we are.
And it's absolutely amazing.
I love it.
Speaker 2 (01:05:57):
Thank you.
Thank you, sam.
It's really great to have beenasked to do this.
I think it's an incrediblething you're doing.
It's amazingly time-consumingand I'm sure, but I think you're
reaching a group of people thatis very unique.
Maybe like peripheral nervesurgery, you know it's really
(01:06:22):
specialized, but it's reallyinteresting and I've had a lot
of fun listening to all of yourpodcasts since you asked me to
be on this recently and I reallyappreciate being one of the
people that you did ask.
Thank you so much, dave.
Appreciate it All right, thanks, sam.
I just finished recording the podcast you're
about to watch and listen towith Dr David Lawrence Brown.
He was a newly minted attendingat the University of Michigan
when I started my plasticsurgery residency there over 20
years ago.
Maybe you've known someone whobecame a teacher at a school
that they were a student at andit's not easy to take on the
role of an attending after justbeing a fellow the week before.
(00:24):
But Dave took it in good strideand I watched him during my
residency become an accomplishedand seasoned attending over the
years.
Dave has a tremendousenthusiasm for everything he
does, as you can hear in thispodcast, but I never would have
expected him to have left theUniversity of Michigan so late
in his career.
After 26 years of faculty thereand as a tenured full professor
(00:44):
, he decided to leave Ann Arborfor private practice in St Louis
, missouri a couple months ago.
Now there are people that youknow at many institutions who
are lifers, and University ofMichigan is no exception.
People stay there for theirentire careers.
So to talk to Dave and find outwhy he decided to leave was an
absolutely fascinatingdiscussion.
I think it's absolutelyhilarious that he and Coach
Harba.
He decided to leave was anabsolutely fascinating
(01:04):
discussion.
I think it's absolutelyhilarious that he and Coach
Harbaugh decided to leaveMichigan at exactly the same
time but despite Dave's joke, heand Coach Harbaugh could not be
more different.
Probably the most interestinglyfuture forward part of our
discussion was the deepdiscussion we had about treating
chronic pain with peripheralnerve surgery, which is what his
(01:25):
specialty is now.
I believe it will work for manypatients in dire straits who
have no other solutions forexcruciating chronic pain.
I look forward to Dave's work inthe future and I believe that
many of us will benefit from thetechniques developed in the
small but growing field and, asI say at the end of the podcast,
(01:45):
I never would have imagined 20plus years ago that I would be
talking to Dave about a new job,new career and new surgical
specialty.
But you never know where theroad will take you and, as Dave
says, he took the one lesstraveled by and to steal from
Robert Frost.
I think it will have made allthe difference.
Thank you for watching andlistening.
(02:06):
All right, Welcome to anotheredition of Botox and Burpees,
the surgical edition.
I have with me a longtime friendand colleague and he was one of
my first attendings, actuallyas a plastic surgery resident Dr
David Brown, David LawrenceBrown, Because honestly there
are many David Brown's plasticsurgeons out there.
(02:28):
So make sure, if you're lookingfor the authentic, real David
Brown, it's got to be DavidLawrence Brown, who's currently
in St Louis, Missouri.
He was at Michigan for a verylong time.
Let's go through Dr Brown'straining a little bit so you
know who he is.
He graduated undergraduate atWittenberg University, which is
(02:49):
actually really pretty close tome because I grew up in Columbus
and then with a degree inchemistry.
And then you went to VanderbiltUniversity for your medical
school training or medicalschool, and you graduated there,
and then you did your generalsurgery residency at University
of Cincinnati.
So you're one of those oldschool guys who did a full
(03:11):
general surgery residency beforedoing your plastic surgery
training.
Speaker 2 (03:15):
Actually actually no, I left after four years.
Oh, that's right, you did four.
Speaker 1 (03:20):
So it was one of those quick jump tech things.
Speaker 2 (03:23):
That's an interesting story.
I can tell you about that later, if you want.
Speaker 1 (03:27):
Yeah, I have heard it , that's a good story.
And then you went to Michigan,university of Michigan where you
did your plastic surgeryresidency You're a fellow there,
yes.
And then you stayed on as a asfaculty, and I remember because
I just started my plasticsurgery residency there and you
(03:48):
were a brand new faculty member.
Pretty much that that first yearI started, yeah, and you got a
lot of crap because you knowit's kind of weird when you're a
fellow and then you suddenlybecome an attending and I
remember people sort of givingyou that the jibe the business
when you started.
But you stayed on for 26 yearsat University of Michigan and
(04:13):
you were a tenured professor inthe Department of Plastic
Surgery sorry, division ofPlastic Surgery but in January
of this past year you left after26 years and you are now at St
Louis, missouri, at NeuropaxClinic, where you specialize in
(04:35):
peripheral nerve injury and pain.
You have found the surgicaltreatment of chronic pain to be
the most rewarding due to theincredible results you've seen
with innovative techniques.
Your specialties include painfollowing mastectomy, knee and
hip replacement, shingles,hernia repair and abdominal
(04:55):
nerve pain, and you have a tonof accolades and awards.
You served as president of theASPN, the American Society of
Preferable Nerve, board ofdirectors of the American
Society of Plastic Surgeons,president of the Michigan
Academy of Plastic Surgeons andoral boards examiner for the
(05:16):
American Board of PlasticSurgery.
So welcome, dave, it's great totalk to you, thank you Steve.
And I really appreciate youcoming on to this podcast.
Speaker 2 (05:27):
Well, thank you.
I'm super honored to have youask.
It's been fun listening to manyof your past episodes and
hearing what other people had tosay, and I think this is an
awesome forum, so thanks forhaving me on.
Speaker 1 (05:43):
Thank you.
You represent someone that I'veknown for a really long time.
You are a Michigan lifer, andso your training really was
similar to mine, in the sensethat we had many of the same
faculty members and people thatwe worked with.
What was that like, though,coming from Cincinnati into
(06:06):
University of Michigan?
And, yeah, remind me again howyou managed to cut short your
general surgery residency andshort circuit that into plastic
surgery training at Michigan.
Sure, thank you.
Speaker 2 (06:19):
So you know, going into general surgery residency I
really thought I wanted to be avascular surgeon, do a vascular
surgery fellowship.
I found out in pretty shortorder.
I didn't really love thatspecialty and that's, you know,
a whole other story.
But people of yours and my kindof era, I think, know that
(06:42):
those are very difficult kind ofemotional patients to take care
of.
And when my thinking kind ofswitched to plastic surgery, as
you also might attest, plasticsurgeons were kind of persona
non grata to general surgery,especially the original kind of,
(07:03):
she said, hard, hardcoreprograms, of which Cincinnati
was certainly one.
And so I kind of had to applyto plastic surgery programs, I
guess not in secret, but withouttelling a whole lot of people.
And when I sent out my this wasback before online applications
(07:26):
.
And so when I sent out myrequest for paper applications,
I included a CV in every one.
And one night I was on call atthe VA and the program director
from Michigan actually paged methrough the hospital operator at
like 8 pm while I'm on call andsaid so what's your deal?
(07:48):
It was a very interesting phonecall.
You might imagine who that was.
Speaker 1 (07:53):
It was Garner, right yeah.
Speaker 2 (07:55):
It might have been and I love Warren, and you could
just tell from that firstmeeting of ours on the telephone
how it all went.
But he said you know, we canactually use somebody here in
about three months.
We had somebody leave theprogram and so, rather than
(08:18):
applying for a year and a halffrom now, I'd like you to think
about taking this job.
So I said, well, I really, oh.
And he said, you know, come upthis Wednesday for an interview.
Well, I couldn't just leave onany Wednesday.
And, um, I said I couldn't.
He says, well, that's too bad,we could have, we could have
liked having you here.
(08:38):
So, um, so anyway, I I talkedto the chief resident I was
working with at the time andI'll never forget her name was
Trish Abello, and I told her youknow kind of where I was with
the whole thing and I justremember Trish saying you know,
what doesn't matter, I willcover you.
You know, get there, do what youneed to do for you in your
(09:00):
career, and kind of the rest ishistory there.
You in your career, and kind ofthe rest is history there.
So I think some of those themesmaybe we'll talk about tonight
on the rest of this podcast, butI really remember that as being
a very pivotal time in my lifeand my career and a really
(09:22):
pivotal decision that Trish madeon the spur of the moment and I
don't know that, she knows thatand I have thought I should
tell her a million times, somaybe she'll see this podcast.
Speaker 1 (09:34):
You know, michigan does have a soft spot for people
like you and me who had abrupttransitions like that.
I had something similar comingfrom my program into Michigan
and Gardner was definitely apersonality and I had a similar
experience when he contacted meas well, so I can certainly
(09:57):
relate.
Very impactful.
It's funny how those littlecrossroads can really make a
ginormous decision and impact inour lives.
But let me ask you so, when youlook back at either your
general surgery training or yourplastic surgery training, was
there anything in there thatreally impacts you now or that
(10:19):
you even think of now as asurgeon?
Speaker 2 (10:27):
think of now as a surgeon.
Wow, that's hard to nail down.
I mean, I think we could spendprobably a whole podcast series.
We could do 10 episodes.
You know, I think and maybe wecan talk about this, because
I've heard you bring up thistheme on other podcasts you've
done kind of about serendipity,but also about mentors and
(10:50):
people who took the time atcertain points that you just
kind of remember little snippetsabout that helped you, either
guide you or bring you up orjust show you hey, listen,
here's a path to what you wantto do and you don't really
forget those things.
And the one thing, which maybesome of the things we'll talk
(11:15):
about are more that I should dowhat I say, because I do have a
few little, I guess, words ofwisdom I'd like to leave for any
other residents coming upbehind us, and one of them is to
remember those things and saythank you for them.
(11:36):
And so maybe I really shouldhave reached out to Trish before
now.
But you know, I reallyappreciated the way Warren
Garner taught me in theoperating room when I came to
Michigan.
When you asked you know whatwere the differences, I found
that I learned a lot at theUniversity of Cincinnati, I
(12:01):
learned a lot because I worked140 hours a week and there's
only 168 hours in a week and soit was hard not to, but the
learning was hands-on andpassive and it gave me a good
(12:22):
surgical foundation to know.
You know, I was responsible fora patient and I had to see that
through till the very end.
I couldn't go to bed or Icouldn't go home until things
were as good as I could makethem in somebody's health care
and but by the same token, right, it was a really hard system
(12:44):
and I know you've had podcastsabout that.
And when I got to Michigan toanswer your question, I found
people more focusing on me as alearner and as a developing
surgeon, with more dedicatedtime to teaching me things and
(13:07):
just a more active environment,and people like Ed Wilkins and
Steve Buckman and Paul Sedernaand those folks who really spent
a lot of time Hack Newmanworking with us as trainees.
I'll look back and reallyremember that fondly.
(13:29):
So those were several of thekind of main differences in that
period of time.
Speaker 1 (13:38):
They were and are awesome faculty members for sure
, and they did take an interestin our surgical education.
There was a lot of work.
Let's not cut it short.
I mean I know my generalsurgery sounds like your general
surgery.
Training was worse than mine.
Cincinnati was notoriouslybrutal, but it's changed
obviously a lot now.
(13:59):
Like none of what we sort ofexperienced is is the way
surgical residents and trainingis now, and you just recently
left Michigan.
So what you know, one of thosecompare and contrast type of
situations.
What what what would you say arethe biggest differences?
(14:20):
Both good and bad?
I don't want to be one of thoseGen Xers that say the Gen Z
people are all weak or whatever.
But what do you see that areboth good and bad?
Points to that.
Speaker 2 (14:32):
Great, great, great question.
We could go on for hours, butone of the things that when you
say, what is something Iremember.
I remember being a second yearresident and our chairman left a
copy of a newspaper article inall of our mailboxes for us to
read and to summarize it it wasfrom the New York Times and it
(14:55):
was about I believe it was aphysician who was saying you
know, my children don't need meto raise them and to know them,
and for them to know me, theyneed me to be the breadwinner
and a good role model.
And if I don't get home tillafter they're in bed or I sleep
(15:19):
all afternoon Sunday because I'mtired of working Sunday,
because I'm tired of working,that's really what they need and
that really summed up theentire kind of philosophy of
things and things were.
You know very much.
The reason they called usresidents is because we were
(15:39):
supposed to be resident of thehospital, right, sleeping there,
eating there, living there.
And, you're right, the plasticsurgery training wasn't
significantly easier, but thatwas really shocking to me at the
time to get that note from himand for him to be telling us
(16:00):
that this was a positive way toview our lives.
Again, I look back on thetraining that I got.
That was superb and gave megreat foundations that have
lasted this whole time.
But things needed to changeright.
I knew people who weren't therefor their children's births,
(16:24):
who weren't there for theirchildren's births, and I mean
you can say every familyoccasion or hospitalization or
surgery that somebody had andthey couldn't make it because
they were in the hospital andyou and I both know the kinds of
conditions that people trainedunder that just needed to change
(16:46):
, and they have.
They've changed a lot.
The question is, I think youknow, have they changed too much
?
Has this?
You know the pendulum usuallyswings and you know maybe then
finds that it's not at the rightapogee yet either and has to
come back so much.
(17:07):
And you know I'd posit to youthat maybe it swung too much.
It's hard to know and maybewe'll know in 10 or 15 or 20
years, maybe we won't.
Speaker 1 (17:18):
How?
So Let me know, Like what is itthat you see that might be a
little too much the other way,like example-wise for trainees.
Speaker 2 (17:27):
Well, sure, I mean, you know, I think what we want
out of our physicians and oursurgeons is somebody again who's
going to take care of usthrough an entire illness or
through our entire lives orwhatever the entire emergency
(17:48):
room visit, and that obviouslyisn't possible in all of
medicine.
It's not, especially notpossible today with different
work week hours and with, youknow, just being kinder to the
people who are delivering thatcare.
And you know, again, there arelots and lots of benefits to
(18:08):
what's happened.
Right, people aren't crashingtheir cars into the bridge
abutments on their way home froma long shift which happened to
one of my classmates, or youknow committing, you know,
medical errors because theyweren't getting enough sleep or
they didn't yell that too much,you know.
I think we do have to bemindful, though, about you know
(18:31):
how much we really take the jobas a shift work, what it looks
like when you turn over care toanother physician who's going to
assume the care of that patientfor you, and how that's done,
and be very mindful of that, andI think in many instances that
(18:55):
happens really, really well.
Obviously, there areopportunities, as these culture
shifts happen, for things to goa little too far and need to
come back.
You know, one of the originalcomplaints of long work hours in
the list of all the otherthings was the lack of time to
(19:18):
actually sit down and study,because learning is so much
about doing, but it's also aboutbeing taught, and it's about
teaching yourself.
And if you're up taking care ofpatients for the entire week,
you're not reading a book.
And there was an interestingstudy that came out, I don't
(19:39):
know, 10 years after the dutyhour work week changed.
That said that the number ofhours that residents were
reading was actually at or belowwhat it had been before the
duty hour change.
It's not entirely surprising.
I mean, you know you need sometime to live life and do your
(19:59):
laundry and, you know, get ahaircut, which there wasn't time
for.
But anyway, I don't have, Iguess, real criticisms.
I'm just saying I think we'restill figuring it out where that
best practice is.
Speaker 1 (20:21):
I might argue this is a permanent shift.
I know young surgeons comingout.
They don't go solo.
You can find a group where itis literally shift work, where
you are passing on and handingoff your care to someone else.
Then you go, you live your life, you come back, you pick up
(20:43):
wherever that other person leftoff or your group left off.
Oftentimes they're not incontrol of their own practice.
They are part of a largerorganization or administrative
group, a hospital.
So I think that this aspect ofsurgical culture where you have
(21:04):
a responsibility to a patient,may actually no longer exist in
10 to 15 to 20 years, or it'llbe the minority of us, because I
don't think people will see itas wrong to operate on a patient
.
Hand off that care to somebodyelse, let them manage that
patient.
Hand off that care to somebodyelse, let them manage that
(21:26):
patient.
When you come on, you might bemanaging somebody else's
post-operative care or patients,and it's just going to be
figuring out how to make thosetransitions less error-prone or
fraught with difficulty orproblem problems.
But there there, that might bea permanent culture shift at
(21:48):
this point, because I don't eversee us going back to the type
of training that we had where weliterally would stay up all
night taking care of somebodyand you know, and sort of seeing
the whole thing through.
Speaker 2 (22:03):
And I don't know if it's good or bad, I'm just
saying that.
Speaker 1 (22:06):
that's the way it's going to be.
Speaker 2 (22:07):
I don't disagree with you.
Again, there are certainelements that needed to change,
but hopefully we'll get smarterand better as this goes, Because
that's, I guess, why they callit a practice of medicine Right.
That's why they call it apractice of medicine right.
But you know, one of the thingsthat's been a little tough is,
(22:29):
honestly, the whole idea ofwellness and happiness.
Maybe that, what was that movieHappiness with a Y, right,
Right yeah, the pursuit ofhappiness.
Pursuit of happiness, and Ithink there's room to come back
(22:50):
and make gains in both ways.
Right, and most people I thinkmost of our trainees feel this
way and act this way, but Ithink there's an opportunity for
some to say you know what?
Yeah, wellness for me is notbeing at work, and I don't think
(23:14):
that's what that word in ourspecialty was really designed or
brought up for, right.
It doesn't mean that I justwork less hours, although I'm
not saying that we need to workmore hours.
I'm just saying that you haveto learn to be happy at work and
you have to learn to beefficient at work and you have
(23:36):
to learn to take good care ofpatients.
That makes you happy and youhave to seek out that happiness
in a system, in whatever way youdo that.
That involves your career andyour life and it isn't just well
, I'm, I'm happy when I'm notworking as an attitude, um and
(23:58):
and I that.
That, I guess, is maybe where Ithink we've swung a little far.
Uh and, and you know, maybesome of the hospital, when you,
when you read anything thesedays about burnout and about
administrative systems andthings that people would
generally complain about, it'smore about the systems and the
(24:22):
restrictions on how we practice.
That makes people less happywith their job and their career
at least the studies that I'veseen, as opposed to how many
hours I was at work or whatweeks of vacation I got,
although those are important.
Speaker 1 (24:43):
Well, all right, let's talk about your life then,
in terms of hours, weeks,career, happiness.
You spent 26 years atUniversity of Michigan as an
academician, as a faculty member, as a professor.
Now I spent five years inacademics and then I
(25:06):
transitioned out into privatepractice and I thought that was
one of the most jolting, weird,difficult transitions as a
physician and a surgeon that Ihad to make, and it's like mind
blown that after 26, that's whatyou're doing, having left
University of Michigan.
The same.
You're like Jim Harbaugh.
He was at Michigan last year,won a national championship,
(25:28):
took off, went to the pros.
You're sort of doing the samething.
Just about the time he left youyou're now at Neuropax, a
private practice with anothersurgeon no more academics, no
more provided secretaries, nomore salary, no more protected
(25:51):
time and vacation and all thissort of stuff.
Why, on God's green earth,after 26 years, would you leave
tenure to do this?
Speaker 2 (26:07):
So thank you for finally outing me.
I am Jim Harbaugh.
It is not a coincidence that weboth left the University of
Michigan at the same time.
I am his Clark Kent.
No, nothing could be furtherfrom the truth.
(26:32):
I really did love my time atMichigan.
It was actually really reallydifficult for me to leave and I
felt, as I was doing it, verysad about that, to be honest,
because of the people Imentioned and that really was my
(27:16):
and still is my family, andthat stuff's hard in life.
Those sorts of changes andtransitions are difficult.
But you know, I always had abit of a private practice
mindset, I think, and you know,one of the things that
highlights that is you know, Iused to complain quite a bit
about the state of ouroutpatient clinic, and so much
so that when it came time toname a medical director, when
they started doing those kind of, they started doing those kind
(27:36):
of administrative things acrossMichigan's outpatient clinics,
our chief at the time said hey,guess what you get to be the
medical director of theoutpatient clinics.
You know, careful, careful.
How much you complain aboutsomething, you'll be in charge
of fixing it.
Um, and and, and and.
I actually really liked that Idid that for 13 years, Um, I
(27:58):
finally stopped doing it, Um,when it became really difficult
to make those independentdecisions, or decisions with our
faculty, with our nurses, withour MAs, PAs, residents to do
(28:20):
what we thought was best to takecare of patients, and the
administration levels kind ofgrew, particularly in the last
few years, to the point that itbecame harder to make
independent decisions about whatwas good for plastic surgeons
and plastic surgery patients indeference to decisions that were
(28:42):
being made across, you know,big giant health systems.
And so I guess that brings meback to independent private
practice, and you know I'dalways had that is, the grass
greener kind of look over thefence mentality.
(29:04):
I did all I wanted to do at theUniversity of Michigan, Um, and
I just felt like it.
Either either I did somethingindependent um at this point in
my career or I wouldn't, becauseI, you know, maybe I have six
or eight years left to practice,Um, and I certainly wouldn't do
it with two or three years leftUm.
(29:27):
Rob Hagen, who's been a reallygood friend in the nerve society
, does a lot of the same thingsthat I do.
There are only, you know, adozen of us across the country
currently devoting our full-timepractices to peripheral nerve
surgery for treating chronicpain, and Rob's one of them.
(29:47):
And I wouldn't have left if ithadn't been for the right
opportunity and especially theright person.
Right, that's, that's what.
That's what drew me to Michigan, it's what brought me back when
you said, you know, after,after being a fellow there, and
I came back as junior faculty,Right, it was for those people,
(30:10):
and so I never would have leftthat if it didn't seem like a
really good match of people.
And Rob is a really good person, he's a great surgeon, he
actually writes a lot of papersand the two of us will continue
to do so.
So we're going to try to keepLee Dellin's saying alive about
(30:33):
privademics, which is some atleast still being somewhat
academic in a private practice,and to the point that we're even
going to have fellows, and wehave a fellow starting with us
here next year that I'm reallyexcited about.
So the transition's going well.
(30:54):
Uh, you know I'm I'm only a fewmonths into it, but, um, I'm,
I'm really, really enjoying, um,the setting and the ability to,
you know, do what I, do what Iwant to, to take care of
patients.
Um, and I I miss Michigan for,being honest, I miss the people.
(31:16):
But this is also very good andthat was one of the things that
I did want to talk about tonight, which is taking chances and
never passing up an opportunity,even though it looks hard.
And everybody I talk to haskind of the same attitude and
(31:37):
the same questions that you didfor me tonight and that is.
You know what were you thinking?
And fair enough, I mean, Iunderstand that question, but
maybe what was I thinking fiveyears ago or 10 years ago?
Or you know what would I bethinking five or 10 years from
(32:00):
now if I hadn't done it?
So you know, my excellentlong-term friend, mentor,
colleague and then finally bossat Michigan, Paul Sedernit, used
to always give me a little bitof a hard time because I'd
really get into hobbies and I'dget into scuba diving or flying
(32:24):
airplanes or sailing boatsaround different parts of the
world and just throw my wholeself into it for a while until
I'd kind of gotten all I wantedout of it and then pick up a new
hobby.
So I don't know that this is anew hobby, but it's just another
(32:46):
thing I wanted to tackle andsomething I just had to do
before I died, I guess it makessense.
Speaker 1 (32:56):
I applaud that, thinking that what you might see
yourself in five years, whetheryou would regret not taking
that chance, I think that'simportant.
You sort of pulled a reverse.
Bob Gilman he was the one whowas in private practice for a
long time and went to Michiganand you're flipping it now but
you're in a boutique-y kind ofspecialty, so most peripheral I
(33:17):
mean most plastic surgeons donot do peripheral nerve surgery
and even fewer do treat chronicpain by doing peripheral nerve
surgery.
So my and the ones who do are.
There are very few of them inthe country and world and
they're renowned for what theydo, like a Lee Dillon, for
(33:40):
example, and now.
Now, so you must probably drawfrom a very wide area, because
with the Internet, with peoplecommunicating, people must say I
have chronic pain from amastectomy.
Who do I see?
And they're like there arethese guys in St Louis, Doesn't
(34:01):
matter, if you're in LagunaBeach, California, you got to go
see these guys and they'll comeout and they'll see you.
You know, certain specialmedical conditions warrant
travel to specialists.
Speaker 2 (34:14):
Is that what?
Speaker 1 (34:14):
you're seeing in your practice and how do you manage
that sort of, you know, reallybroad, like a very niche
specialty, but drawing from avery broad geographic area?
Speaker 2 (34:27):
Sure, yeah, you couldn't be more right about
that, and I think that's one ofthe things.
That is really exciting to me.
You know the fat, so the fieldis taking small nerves, which
are, as you know, electricalwires in the body that carry
signals to the muscle to makethings work and then carry
(34:52):
signals from the skin and otherparts of us, our joints, to the
brain to tell us how those partsare feeling and their
sensations.
And many things like injury,accidents, surgery and just
sometimes life life as incompressions of nerves can leave
(35:15):
people with chronic pain andthe statistics are are
unbelievable and it's amazingthat we don't learn a lot about
pain in our in our medicaltraining, in our residencies,
even even in practice, otherthan and I always fell victim to
this that there are painmedicines which, as it turns out
, aren't really pain medicines,in opioids and other things, and
(35:41):
there are more people livingwith chronic pain than there are
with heart disease, diabetesand cancer combined diabetes and
cancer combined and they'vebeen absolutely the best
patients to take care of.
In all the things that I'vedone and I did a lot of Mohs,
(36:02):
facial cancer reconstruction, Idid lower extremity abdominal
wall, did a lot of breastreconstruction for a while, a
lot of hand trauma those wereall satisfying things to do.
This has just been for me.
It, just as my partner RobHagan now says it just pushes my
(36:22):
happy button.
I mean, these folks aremiserable.
This field is so new that notmany people know we exist.
I mean, I'm sure you feel thesame way that even just when
somebody says you say tosomebody I'm a plastic surgeon,
even probably people in yourclose family say couldn't really
(36:45):
describe what it is that you do.
Speaker 1 (36:48):
Right.
Well, they think I do lipo,which is kind of true.
Speaker 2 (36:51):
But whatever, go ahead, right, right and well,
they think I do lipo, which iskind of true, but whatever, go
ahead Right.
I mean there's a there's a verynarrow definition in society,
public opinion, about what aplastic surgeon is, despite the
fact that we do all kinds ofreconstruction and cosmetic
things, they don't can grasp.
So then, to add on to that,this little niche is it's hard
(37:15):
to get that information topatients.
But you're right, and I neverreally thought too much about
being at a big academic medicalcenter.
People would line up basicallydown the street right in terms
of booking appointments with you, so you never really needed to
try to get the word out about itvery much.
(37:36):
Our main goal now is just allthe time educating people about
what we do.
Excuse me, what can be done totry to get to those patients who
are sitting at home withchronic pain conditions and
nothing feels better than youknow a woman coming from New
(37:56):
York City to see me for chronicmastectomy pain from a bilateral
mastectomy eight years ago, andor a woman from Florida that I
treated last month for chronicneuropathic pain from shingles.
So that initial shinglesoutbreak right is so horrible.
(38:20):
Everybody talks about being oneof the worst painful things up
by next to kidney stones.
This is a condition where thenerves get so damaged you have
pain forever and there's neverbeen a solution, pain after
total knee replacements and allsorts of things.
So it's just been just anothergift.
(38:44):
That medicine's given me theability to interact with these
patients and help them.
And, um, and if we have twomore minutes in this kind of
vein, I'll tell you how, how Ifirst got into doing this.
I used to always tell patients,um, when they'd come back and
they'd say you know, my, mychest is hurting after having
(39:06):
had a breast reconstruction, andwe would always say, well, you
had surgery and now you knowthere's some pain that goes
along with that, and then youmight not see that patient again
.
Or you'd see them six monthslater and then not again.
And they went somewhere andthey lived their lives and they
went to many other doctorsunbeknownst to me to talk about
(39:28):
this horrible chronic pain thatthey had, so much that some
patients would come back to us,not infrequently, and say can,
can you know?
After all, they went throughhaving the breasts removed,
three or four operations to havethem reconstructed and they
would say just take them away, Idon't, I don't want this uh
anymore because they hurt and weknew that removing them wasn't
(39:53):
the answer right.
But sometimes you couldn't sayno because people were just in
such pain and were so insistent.
And I had one patient that Ialways tell was kind of my aha
moment.
She was very young, I don'tknow, early 30s, to have breast
cancer which, as you know, isusually more aggressive the
(40:15):
younger you are.
And she was so thin that sheneeded a muscle transfer, a
latissimus flap brought aroundto her chest to add to an
implant.
But we always did thatoperation with a couple days
hospital stay.
And she told me you know, Iwork on an assembly line, I'm
really tough, I'm not going tostay in the hospital and so well
(40:39):
you know it's really bad.
There's a lot of pain with this.
We need to admit you to thehospital a couple days.
She said no and in fact I willonly let you book my surgery at
the outpatient surgery center.
That's how confident I am thatI'm going home and you can't
make me stay in the hospital.
And we did and she did and Iwas very impressed by her
(41:04):
resolve and her ability to dothat and we got all through with
the reconstruction and it wentvery well.
And she came back and she saidyou know what?
The pain in my back that I'mhaving is unbelievable.
Take it rid of it.
It's horrible.
And you got to do somethingabout it.
And I'd heard that obviouslybefore.
(41:24):
We've all heard that, and to usin surgeons it was always a
thing about you know, I don'tknow how to help people who are
having pain, so they're, youknow, just aggravating to me and
them.
Anyway, I spent a lot of timelooking into it and found out
(41:45):
that, well, you know, anyoperation that you do can injure
little, tiny nerves that maybeyou don't even see during
surgery Usually you don't evensee during surgery Usually you
don't and you can cut them,stretch them, burn them.
They get caught up in scarafter surgery and she was so
definite about it hurts here andhere.
And we took her back to theoperating room and we opened up
(42:08):
those two little areas and wefound these big balls of nerve
tissue called neuromas and cutthem out.
And I don't know just at thatmoment that I said that is, just
for all the stuff I'd beendoing, really incredible and
that was kind of the tip of thaticeberg, so to speak.
Speaker 1 (42:33):
Working on patients who are in dire straits, such as
the ones that you have as asurgeon, it doesn't sound so
appealing to me on a couplelevels.
First of all, these arepatients that are very desperate
.
I would be worried that mysurgical procedure might not
(42:53):
work.
I might be concerned that Ihave to.
You know, pain is multimodal,so you have to do all sorts of
other things in addition to justoperating.
In terms of managing thesepatients, and as a surgeon I
would be like this does not seemlike the most fun to me.
It's a nebulous problem.
It's not always clear that youcan guarantee or have a high
(43:17):
likelihood that you woulddefinitely find a good outcome.
Pain is difficult sometimes, oralways, and so I would say why
would you encourage any surgeonto try to?
I mean, I understand the greatoutcomes are great outcomes, but
you know, as a batter, what areyou hitting here?
250, 300?
(43:38):
Like, is this a 90% likesuccess?
It's to me I would feel likeyou would pat yourself on the
back if you got maybe a quarterof these patients better.
Speaker 2 (43:50):
Um, I, I, I first say that you know, um, in all the
time I've known you, and so whathas it been?
20, we had to add it up, it'sbeen at least 20 years.
Yeah, More than that, probablyMore.
Yeah, you are one of the mostinsightful and most empathic
people that I've known, and Idon't know if I've gotten to
(44:12):
tell you that before, but no, Imean, and you're right, and so
that's another thing is, peopleare going so full professor, and
you left this to get what?
What are you thinking, right?
I mean anybody that I, that Itry to talk to about nerve
surgery, who's a surgeon, sayswait, you, you want a whole
clinic, you want to see 30patients in a day, all of whom
(44:34):
have pain.
That would be like two, itwould be bad for me.
And so that's basically whatyou just said.
The miracle comes when yourealize, actually, and even as I
started doing this, and even asI started doing this and in the
first 50 or 100 patients I tookcare of, that innate it's not
(44:58):
innate because it was ingrainedin us, I'm sure feeling of I'm
going to make it worse or I'mnot going to be able to fix it,
and then it's my fault,internalizing all those feelings
is there and just like anycomplication that you have, and
(45:19):
you feel absolutely horrible andcrushed about with anything
else, that's still true withthis, but it turns out that
these issues are mostly solvable.
So when you say, you know what'smy batting average?
Well, it's not perfect, butit's everything.
It was in hand surgery andcancer, reconstruction and
(45:45):
cosmetic surgery and so forthright, you have to understand
the problem really well and youhave to learn to diagnose B
(46:21):
nerve-related, and C treatable.
And it isn't what I thought itwould be.
That was so scary, which is,you know, I might have a whole
bunch of people that I can'thelp and a whole bunch of people
that have pain that's in theirhead and it's just really I
(46:47):
don't know.
It's really awesome.
Speaker 1 (46:50):
It's really an incredible thing when you do
these surgeries.
Now is the technical part of itthe most challenging, and what
kind of technologies can you usenow?
Like is it different doingthese surgeries now than it was,
say, 10 years ago?
Like there are a lot ofsurgeries where we don't do
anything the same that we did,say, 10 or 15 years ago.
(47:13):
So it's like what has changednow with this?
Or what's getting you jazzedabout this kind of surgery, the
new stuff?
Speaker 2 (47:21):
Sure, well, first of all, as we started the podcast
and I said that I originallywanted to go into vascular
surgery when I was a generalsurgeon.
Then, when I started atMichigan, I wanted to be a hand
surgeon, and I think the commontheme to those in peripheral
nerve surgery is detailedanatomy, and I love dissecting
(47:47):
out nerves, I love finding them.
You know, I think the residentshalf of them would think I kind
of lost it.
Every time we'd do a casetogether and we'd find the nerve
, even though we knew we'd findthe nerve, and I'd get all
excited and be like, hey, lookat this and I'm calling the
anesthesiologist to look overthe drapes.
Have you ever seen this nervethat goes here?
And it was a little silly, butit was really fun, and the
(48:12):
answer to your questionspecifically, though, is no,
it's just a new paradigm ofunderstanding.
In fact, the exam and the testsfor doing it are so
ridiculously simple.
Anybody could learn it in acouple of days.
(48:33):
The biggest thing you have todo, I think, is as my college
theater professor told me,because I went to liberal arts
school and I had to take atheater class this concept of
suspension, of disbelief, right,and so you know, when I trained
(48:57):
at Cincinnati, you, you, uh,you know, didn't let the patient
eat for five days after a bowelresection, because that's when
they got to eat, if for no otherreason, right, you didn't pull
the drain out until it was lessthan 30 cc's in a day, which
actually I still ascribe to.
(49:20):
And with peripheral nervesurgery for pain, first of all,
you have to start to believethat things can be possible that
you didn't think were possiblebefore, like, for example, that
you could do an operation on apatient with chronic pain from
(49:46):
post-herpetic neuralgia, whichis the term for chronic shingles
pain, when everybody has saidthat you're not going to help
that patient and the virus isstill in the nerve and it's up
in the dorsal horn and you'renot going to clear them of the
infection but in fact it curesthem of their pain.
You have to suspend yourdisbelief.
(50:09):
That where's my train ofthought?
That, oh, that you knowsomebody who gets a really bad
ankle sprain could havepermanent nerve pain from making
, and I, just in my own self, Iremember first time encountering
that thinking that's thesilliest thing I ever heard Like
(50:32):
, how are you hurting the nerve?
Right, but the nerve when itstretches across that fulcrum at
the angle when you have a badligament sprain, is stretched
beyond its capabilities tospring back and is broken inside
.
I describe it to patients likeone of those fiber optic light
(50:52):
cables and some of the cablesare all broken inside and you
see down it and patients come inwith healed orthopedic injuries
from that, but they havechronic burning pain on their
foot and it just goes on and onand on that list of things that
(51:13):
you have to tell yourself.
Well, I'm just going to applythese principles of how a
patient might have pain here,how it might be related to a
nerve, and then prove it is orit isn't, just like we do in all
of plastic surgery.
And this is people say to mehow do you do that?
How is a plastic surgeon doingthis?
(51:33):
And you know as well as anybodythat that's our specialty is
doing things with the softtissues all over the body and
being innovators in that space.
And I'm not in any way sayingI've done a lot of innovating in
this space.
I've certainly followed on thecoattails of several of the real
(51:57):
pioneers, but it is what ourspecialty does and it's just
been a real boon for me in thelast 10 years.
Speaker 1 (52:11):
Well, we definitely know the anatomy about the
entire body, I believe betterthan any other specialty out
there from head to toe.
I mean, we've had to operateliterally from head to toe as
surgeons.
So no doubt I think you'reright.
If anyone has to dig out nerves, identify them, identify what's
(52:32):
traumatized, that makes sense,you're right.
Some of the concepts you'resaying, as I'm listening to them
, blow my mind.
I've had shingles pain, one ofthe worst episodes I've ever had
.
To treat post-hepatic neuralgiawith surgery also blows my mind
.
Speaker 2 (52:45):
I'm going to be doing some uh Medline searches, uh,
after this podcast, just to tolearn a little bit more about it
and there's not much out thereabout it, um, which is, which is
you know the beauty of what, ofwhat we're doing?
Um, and I read, I read, so, oh,that's an awesome, interesting
(53:07):
story on how I came to do that.
So I had a patient come see meand he said you know, I had
shingles about eight years ago.
I've been in the same state ofpain for the whole eight years.
And I said, well, but I don'tknow how to help you with that.
(53:29):
And he said, well, here's ajournal article and if I'm not
mistaken it was Ivan Duchik'sabout a couple of patients he
treated this way.
And he said you know, I read apaper from you about how you're
treating post-mastectomy painwith nerve operations in the
(53:50):
chest.
And I had shingles on the chestand here's a paper about
treating shingles with nervesurgery.
And he taught me what to do tohim.
And he taught me what to do tohim and since that moment I've
tried to help anybody I can withthis issue.
(54:12):
I just got an email today fromsomebody in Australia.
These folks are, like you said,very, very desperate.
It's very hard to find anybodyto help them and hopefully we
can help this person, findsomeone in Australia to do it.
But you just have to take thosebuilding blocks and those
(54:38):
techniques and put them alltogether to solve these problems
.
Speaker 1 (54:42):
Do you do any other surgery at this point other than
peripheral nerve surgery?
Speaker 2 (54:54):
A little, not a lot, but then again, like I said,
I've been here three months butthat's what Rob Hagen and I is
our plan and to be two peoplewho he does a lot of headache
surgery, thoracic outlet, nervesurgery, upper extremity surgery
and some trunk, and I do trunkand groin and back and lower
(55:17):
extremity, so we overlap, but wecan cover from head to toe and
that's a unique thing, you know,I think.
Um, there are, there are clinicsfull of patients with back pain
and whatever can't be fixed byputting a rod and a screw, uh,
(55:41):
and doing some kind oflaminectomy, um, in the spinal
cord itself.
All those people get lumpedinto one category of low back
pain and there's no great answerfor them, right?
Or there's 50 great answers,which means there isn't a best
answer.
And our kind of next step,which we've already I've already
(56:03):
started doing, is operating onpeople for low back pain.
That I think we're going tofind out is 80% of the patients
who don't have a problem intheir spine itself.
We're going to be able to haveoperations to fix in the next
(56:27):
five years that people will bedoing all over the country to
fix all of these people with lowback pain.
Speaker 1 (56:36):
I think you're onto something intuitively.
There are a ton of people Iknow, because I know a lot of
athletes have had surgery forwhatever reason discs issues,
compression issues and they aretechnically or anatomically not
having anything pathologicallywrong, but they still have
(57:00):
issues.
And I do believe you are rightthere is some sort of peripheral
nerve issue, some other localnervous system issue which needs
to be addressed.
Speaker 2 (57:12):
There's a whole constellation of symptoms in the
lower back that we know ofalready right including the
facets, which are the joints ofthe spinal column, the bones and
their little nerves, and wewere just at one of the large
manufacturers of instruments.
(57:33):
So when you say, are there newtools out, we're learning to use
this minimally invasive tool togo and section or permanently
remove the nerves that go tothose joints.
So that's for facet arthropathy.
I've operated several timesmaybe 10 now on the superior
(57:57):
clunial nerves, which are theset of nerves that come out just
above the pelvis from the back,sensory nerves that run back
over the iliac crest, that canbe irritated there and it's, you
know, it's when you're grabbingyour back and saying I'm having
, you know, low back pain rightthere at your upper part of your
pelvis, and those are solvableproblems.
(58:21):
The sacroiliac joint is a verycommon source for inflammation
and low back pain, of which Iwas unaware five years ago but
is getting a lot of attentionnow for both denervation
techniques but also fusiontechniques.
So all of these things in thelower back, I think, are going
(58:44):
to combine to be able to treatalmost all these patients that
haven't had any good answersforever.
Speaker 1 (58:51):
What do you think about non-invasive treatments
like acupuncture?
Do you think that they're sortof modulating this sort of
peripheral nerve pain in someway to help afford some relief
in some of these patients?
Is that one of the modalitieshow these pain treatments are
working?
Or EMG, for example?
Are you just likeelectrostimulating some of these
(59:12):
peripheral nerve issues as well?
Speaker 2 (59:15):
Sure, that's a long, complicated answer and I don't
want anybody to mistake anythingI'd say in that space because
it's there's a lot of nuances tothat.
But I will say that you know,as a surgery resident, as a
young faculty surgeon, I wouldhave thought acupuncture and
(59:40):
massage therapy and differentthings couldn't possibly be as
therapeutic as they were beingtouted.
Again, I think you have to havean open mind to at least listen
to the arguments and thereasoning behind it and look and
(01:00:02):
see what patients are gettingtreated out there, because when
the general medical communitysays, well, that's not how we do
it and we need published datauntil we all start doing it,
there's still a lot of patientsthat aren't being treated for
whatever reason.
(01:00:23):
So I'm sure and I don't knowanything about acupuncture, but
I'm sure it helps a lot ofpatients.
Speaker 1 (01:00:33):
Okay, so I think you already answered my next
question, which is where do yousee yourself in the future?
And a lot of it is sort ofdelineating a lot of these
techniques, expanding, like yousaid, the indications treating a
wider range of patients.
I mean chronic low back pain.
If you can treat a large subsetof those patients, that would
(01:00:55):
be humongous, like we would seeyou literally on the front page
of a newspaper or newspapers orTikTok.
Speaker 2 (01:01:03):
now I guess you know of a newspaper or newspapers or
tick tock now I guess, um, youknow sort of.
Speaker 1 (01:01:09):
I hope I don't wind up on it, you will, I guess I
bet you if you were to figurethis stuff out.
Is this?
Speaker 2 (01:01:14):
uh, I'm I'm going to admit something to you, sam I
what I.
I was addicted to tick tockWere you, I was I, I uh, just
let me guess what came up?
Speaker 1 (01:01:24):
It was uh videos, cute dogs and I don't know movie
clips.
Is that what came up on yourtake?
I, I, I had.
Speaker 2 (01:01:35):
I had tick tock for a total of one week and my my
wife would attest I could notbelieve I was blown away at how
talented and funny.
Believe I was blown away at howtalented and funny millions of
people are.
Hundreds of thousands that poston that medium and I could just
scroll it for hours.
I stayed up till two, three inthe morning for a week watching
(01:01:57):
that stuff.
I finally had to just go coldturkey and turn it off.
But what so?
What am I?
Um, what am I gonna?
Is that?
That was kind of your question.
Speaker 1 (01:02:10):
Yeah, is this your last stand at this point, cause
you've done all the other stuff,you like?
You said you really get intosomething for a while.
Is this the last thing, atleast professionally, that David
Lawrence Brown is going to getinto before he, like, figures
out something else?
Speaker 2 (01:02:22):
uh, like sort of end of career type stuff.
That's that's.
I think that's my plan.
Yes, that's that's my plan.
Now, whether that comes tofruition, I don't know.
Maybe something, some othershiny thing will make me look
and say squirrel, but um, I, Ithat that that is.
My plan is to, um, take care ofas many patients with chronic
(01:02:45):
nerve pain in as good a way as Ican while I still have this
ability.
Speaker 1 (01:02:53):
And if somebody is listening to this and says you
know what I want to do this asmy job or profession.
This appeals to me.
I am a young person and this iswhat I want to do.
What is the advice you'd givethem in order to become you?
Speaker 2 (01:03:10):
Is this person already a young plastic surgeon?
Speaker 1 (01:03:13):
Either way younger than that or at that level
either way.
Speaker 2 (01:03:17):
Well, I guess I'd say you know there's a lot of
prerequisites and one thing I'dsay is, in as much as you can,
choose the harder, moredifficult route, because then it
leaves you more options openlater.
(01:03:40):
And I guess my piece of advicethere is that you don't know
what it is, you don't know whoyou're going to be in five years
and what that person is goingto have as desires and
motivations and so forth, andthe more you leave options open,
(01:04:00):
I think is the better.
If you're already a plasticsurgeon, then I think there are
a number.
Or if you're a plastic surgeryresident, there are a number of
great opportunities forfellowships around the country
in peripheral nerve surgery, acouple that are more heavily
(01:04:21):
weighted on neuropathic pain.
And if you are a plastic surgeonand want to start doing it,
there are lots, lots of peoplewho just love doing it to teach
you.
And if you don't readily findthem, email me and we'll get get
(01:04:41):
you started.
I mean I got lots of great helpfrom Lee Dellen and Tim
Tolstrup and Eric Williams andRob Hagan and the people who are
doing it really well JohnWinograd, susan McKinnon and
(01:05:04):
it's a really great, tight,small and any of us would be
happy to help.
Speaker 1 (01:05:29):
Dave, it's been eye-opening on so many levels
for me to hear.
I certainly want more people tohear about what you do.
I think there are a lot ofpeople that can benefit and I
appreciate you taking the timeto share.
I never would have thought 20years ago or 25 years ago that
we'd be here talking and you'dbe so enthusiastic about
(01:05:50):
peripheral nerve surgery.
But yet here we are.
And it's absolutely amazing.
I love it.
Speaker 2 (01:05:57):
Thank you.
Thank you, sam.
It's really great to have beenasked to do this.
I think it's an incrediblething you're doing.
It's amazingly time-consumingand I'm sure, but I think you're
reaching a group of people thatis very unique.
Maybe like peripheral nervesurgery, you know it's really
(01:06:22):
specialized, but it's reallyinteresting and I've had a lot
of fun listening to all of yourpodcasts since you asked me to
be on this recently and I reallyappreciate being one of the
people that you did ask.
Thank you so much, dave.
Appreciate it All right, thanks, sam.
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