Looking Back…Moving Forward: The Heart of a Pediatric Neurosurgeon
As we continue our interview series in commemoration of our 30th anniversary, Dr. Harold L. Rekate, Director of the Chiari Institute in New York, sits down and shares a personal account of what inspired him to become a neurosurgeon, a career shaped by hydrocephalus and its patients, and his relationship with the Hydrocephalus Association.
In retrospect, I feel that I must have been destined to become a pediatric neurosurgeon and to study hydrocephalus. Few young people who have not had personal experiences with this very small specialty would feel drawn to it. In my own case, I have been certain that I wanted to be a physician since the age of 12. This goal derived from my feelings for my own pediatrician, Dr. Brisco in Annapolis, MD. From that point until my first clinical rotation in medical school at the Medical College of Virginia in Richmond I knew that I wanted to be a pediatrician. Because I had expressed this goal, my first assignment as a third-year medical student was on pediatrics. During those three months, I found that I was not particularly excited about the subjects that I was studying or the disease processes that I was learning to treat. It was a bit deflating.
My next rotation was on surgery. I was amazed at how exciting every aspect of that rotation was. The faculty was replete with dynamic, dedicated faculty, and the residents were great teachers. During that rotation we had four one-week rotations on surgical specialties, including one week on neurosurgery. On my first day on the service I was met by Dr. David Silver, who at the time was a mid-level resident. We spent the next 21 hours together doing neurological exams, going to the emergency room and seeing head-injured patients, and working in the ICU. The first neurosurgical operation I saw lasted 14 hours and demonstrated the intellectual and technical challenges of neurosurgery. At 3 o’clock in the morning, I was disappointed to realize that the day was over. I was hooked. The neurologic examination was elegant, the disease processes were challenging, the surgical procedures were demanding, and the results were often immediate. I had found my calling. My fellow students were incredulous. I was committing myself to years of every other night call, long hours, and challenging procedures. The most important part of that decision was that my wife, Mary, was so excited for me. She could sense the way I felt and desired only the best for me. We have now been married for 46 years and she still supports me in this way.
In 1970, neurosurgery residencies were very competitive (as they are today). The resident match, which was actually for a general surgical internship, brought us to Cleveland to train at Case Western Reserve University (CWRU). The chairman at the time was Professor Frank E. Nulsen. Dr. Nulsen was instrumental in the development of the first effective valves to treat hydrocephalus. When he came to Case in 1953 as chairman of the newly created neurosurgical section, he began doing shunts and set up a clinic for the multidisciplinary care of children born with hydrocephalus and spina bifida. By the time I moved to Cleveland, this clinic served hundreds of children and young adults who had been cared for in this clinic since birth. Records and X-ray studies were compulsively maintained on all of these patients. Surgical procedures were documented in handwritten log books dating back to the first day of a patient’s arrival. The population of Cleveland was very stable, and the majority of those patients were still available for examination and study. It was an extraordinary living laboratory and documented the life history of the treatment of hydrocephalus almost from the invention of the shunt.
As had been done by Case residents who had preceded me, I began to study this population with a view to writing papers and making presentations at meetings. I found much about hydrocephalus and its treatment confusing. There was so much that required study. My first epiphany regarding hydrocephalus came in 1973 when I was able to attend a meeting of the American Association of Neurological Surgeons (AANS) and listened to a presentation by Professor Fred Epstein in which he described the treatment of hydrocephalus in premature infants by wrapping the head with an elastic bandage. This was the first time that I realized that hydrocephalus wasn’t an all-or-none phenomenon. Just because you could see the ventricles were too large did not necessarily mean that the patient needed a shunt. What was this thing called hydrocephalus?
With almost two years to go in my residency and in recognition of my interest in following up on the patients who were so important for the program and for Dr. Nulsen specifically, I was asked to remain at Case after residency and to become a pediatric neurosurgeon. I had come full circle from pediatrics to neurosurgery to pediatric neurosurgery. It felt like it was my destiny.
The intellectual environment at Case was quite remarkable. Dr. Nulsen demanded a great deal of the residents and we were constantly anxious because we knew that we were going to be asked question after question until we could not answer or got the wrong answer. You were never able to finish a session with him on a winning note. The anxiety drove me to be more prepared for discussions than I had ever been and probably more than I have ever been since. From him I learned what was important about the examination of a patient and the thought process leading to treatment decisions. While not always pleasant, it was always educational.
Dr. Joseph Foley was the director of the neurology department. Watching him do a neurologic examination was quite an experience. I was amazed at what could be gleaned from careful examination and thorough discussions with patients. This was at a time prior to the invention of CT scans or MRI scans. Many of the faculty members at Case were inspiring to me at that time and my experiences there will stay with me forever.
As a resident and a junior faculty member at Case, it is essential that an academic neurosurgeon be a “triple threat.” He or she must establish himself or herself in clinical neurosurgery, teaching, and basic science research. Based on my experiences in medical school, I attempted to concentrate my research on brain tumors and, especially, the immunological aspects of brain tumor treatment. It soon became obvious that keeping up with two rapidly evolving areas of science without a great deal of overlap would be nearly an impossible task. At that time, the engineering school at CWRU was developing exciting relationships with clinical departments of the medical school. Professor Wen Ko of the Electronics Design Center had invented an implantable device to measure intracranial pressure telemetrically. The importance of such a device for hydrocephalus was immediately obvious. This relationship led to a lifelong study of hydrocephalus. Dr. Ko and I and a third player, Dr. Howard Chizeck of the Department of Systems and Design Engineering, established a program to study hydrocephalus from a biomechanical point of view. It took us two years of meeting for three hours per week to be able to even speak the same language. This work resulted in research that was funded by the National Institutes of Health and NASA. It also developed into a unique approach to the clinical study of hydrocephalus that has guided my thinking ever since. It has taken decades to see the full effect of these thought processes and observations. Unexpected results of treatment and complicated problems of hydrocephalus become understandable when the biophysics are analyzed.
I first became aware of the existence of the Hydrocephalus Association in 1988 when I was approached by two absolutely driven women, Cynthia Solomon and Emily Fudge. They were the founders of a patient support group in the San-Francisco Bay area and wanted to make the pediatric neurosurgical community aware of their existence and to create supportive bonds between the organization and the neurosurgeons who treat their children. That year I was the host of the 17th meeting of the Joint Section on Pediatric Neurosurgery that was held in December in Scottsdale, AZ. The two of them were supplied with a small booth and brought educational brochures and tremendous energy to Scottsdale. I physically and verbally brought as many attendees to the booth as I could and that was the beginning of a joint effort creating a vibrant coalition of searching families and willing teachers that was at the core of the Association in the early days.
Soon thereafter I was invited to give a few lectures at their biannual meeting in Monterrey, CA. It was truly exciting. Seeing all those people with their probing questions and energy for learning has to be inspiring to a physician interested in education. My most vivid memories of my participation with HA relates to several of the lectures given at the meetings. Once in a while, after completing the lectures, I was deluged with a line of people seeking clarification and more information to the point that we had to be driven from the room so the next session could start. How could anything be more life affirming?
The next step was meeting Pip Marks in her role as director of patient outreach and who was always found at the biannual meetings running hither and thither to make certain everything went smoothly and everyone was where they needed to be. While these three remarkable women have been for me at the heart of the association, I have benefited from enduring relationships with many related to working with HA.
I have been on the Medical Advisory Board (MAB) for many years and it has been an honor for me to serve and learn. I have recently resigned from the board so that younger energetic interested persons can share the energy that exists at the table with the MAB. I am still in active practice at the Chiari Institute and hope to remain a resource for the Association in any way that they desire. Nothing pleases me more than to be called for advice for management or help people who are desperately seeking answers to complicated problems.
In 2002 I was honored by the AANS/CNS Young Neurosurgeons and was asked to give a talk at their meeting. The title of my talk was “Who are our teachers?” This talk dealt with the issues discussed here. Where did I get my inspiration? I gave credit to the individuals listed above for being important in my development as well as to a few others who have shaped my thoughts and actions. I then concentrated on those whom I have learned the most from; I have learned the most from my patients. I have had the opportunity to care for a large number of patients from their first day of life into adulthood. I have learned about the effects of intervention on these people decades later. From them I have learned how much of a burden we are capable of shouldering. I have a new definition of courage involving the ability to accept what cannot be changed and the willingness to take risks in the hope for a better life. Each of my patients has benefited from my previous experiences with the patients and families who have come before. The British poet Gerard Manley Hopkins said, “What I do is who I am. It is why I’ve come.” For me this has been a calling as I believe it is for the majority of pediatric neurosurgeons.
Congratulations to the Hydrocephalus Association for their 30 years of success in helping patients, their families and also those of us who are dedicated to finding answers and treating individuals touched by hydrocephalus.