Botox and Burpees
Botox and Burpees
S04E87 From Academia to Private Practice: Dr. David L. Brown's Journey in Treating Chronic Pain
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
I just finished recording the podcast you're about to watch and listen to with Dr David Lawrence Brown. He was a newly minted attending at the University of Michigan when I started my plastic surgery residency there over 20 years ago. Maybe you've known someone who became a teacher at a school that they were a student at and it's not easy to take on the role of an attending after just being a fellow the week before. But Dave took it in good stride and I watched him during my residency become an accomplished and seasoned attending over the years. Dave has a tremendous enthusiasm for everything he does, as you can hear in this podcast, but I never would have expected him to have left the University of Michigan so late in his career. After 26 years of faculty there and as a tenured full professor, he decided to leave Ann Arbor for private practice in St Louis, missouri a couple months ago.
Speaker 1:Now there are people that you know at many institutions who are lifers, and University of Michigan is no exception. People stay there for their entire careers. So to talk to Dave and find out why he decided to leave was an absolutely fascinating discussion. I think it's absolutely hilarious that he and Coach Harba. He decided to leave was an absolutely fascinating discussion. I think it's absolutely hilarious that he and Coach Harbaugh decided to leave Michigan at exactly the same time but despite Dave's joke, he and Coach Harbaugh could not be more different. Probably the most interestingly future forward part of our discussion was the deep discussion we had about treating chronic pain with peripheral nerve surgery, which is what his specialty is now. I believe it will work for many patients in dire straits who have no other solutions for excruciating chronic pain.
Speaker 1:I look forward to Dave's work in the future and I believe that many of us will benefit from the techniques developed in the small but growing field and, as I say at the end of the podcast, I never would have imagined 20 plus years ago that I would be talking to Dave about a new job, new career and new surgical specialty. But you never know where the road will take you and, as Dave says, he took the one less traveled by and to steal from Robert Frost. I think it will have made all the difference. Thank you for watching and listening. All right, Welcome to another edition of Botox and Burpees, the surgical edition.
Speaker 1:I have with me a longtime friend and colleague and he was one of my first attendings, actually as a plastic surgery resident Dr David Brown, David Lawrence Brown, Because honestly there are many David Brown's plastic surgeons out there. So make sure, if you're looking for the authentic, real David Brown, it's got to be David Lawrence Brown, who's currently in St Louis, Missouri. He was at Michigan for a very long time. Let's go through Dr Brown's training a little bit so you know who he is. He graduated undergraduate at Wittenberg University, which is actually really pretty close to me because I grew up in Columbus and then with a degree in chemistry. And then you went to Vanderbilt University for your medical school training or medical school, and you graduated there, and then you did your general surgery residency at University of Cincinnati.
Speaker 1:So you're one of those old school guys who did a full general surgery residency before doing your plastic surgery training.
Speaker 2:Actually actually no, I left after four years. Oh, that's right, you did four.
Speaker 1:So it was one of those quick jump tech things.
Speaker 2:That's an interesting story. I can tell you about that later, if you want.
Speaker 1:Yeah, I have heard it, that's a good story. And then you went to Michigan, university of Michigan where you did your plastic surgery residency You're a fellow there, yes. And then you stayed on as a as faculty, and I remember because I just started my plastic surgery residency there and you were a brand new faculty member.
Speaker 1:Pretty much that that first year I started, yeah, and you got a lot of crap because you know it's kind of weird when you're a fellow and then you suddenly become an attending and I remember people sort of giving you that the jibe the business when you started.
Speaker 1:But you stayed on for 26 years at University of Michigan and you were a tenured professor in the Department of Plastic Surgery sorry, division of Plastic Surgery but in January of this past year you left after 26 years and you are now at St Louis, missouri, at Neuropax Clinic, where you specialize in peripheral nerve injury and pain. You have found the surgical treatment of chronic pain to be the most rewarding due to the incredible results you've seen with innovative techniques. Your specialties include pain following mastectomy, knee and hip replacement, shingles, hernia repair and abdominal nerve pain, and you have a ton of accolades and awards. You served as president of the ASPN, the American Society of Preferable Nerve, board of directors of the American Society of Plastic Surgeons, president of the Michigan Academy of Plastic Surgeons and oral boards examiner for the American Board of Plastic Surgery. So welcome, dave, it's great to talk to you, thank you Steve.
Speaker 1:And I really appreciate you coming on to this podcast.
Speaker 2:Well, thank you. I'm super honored to have you ask. It's been fun listening to many of your past episodes and hearing what other people had to say, and I think this is an awesome forum, so thanks for having me on.
Speaker 1:Thank you. You represent someone that I've known for a really long time. You are a Michigan lifer, and so your training really was similar to mine, in the sense that we had many of the same faculty members and people that we worked with. What was that like, though, coming from Cincinnati into University of Michigan? And, yeah, remind me again how you managed to cut short your general surgery residency and short circuit that into plastic surgery training at Michigan. Sure, thank you.
Speaker 2:So you know, going into general surgery residency I really thought I wanted to be a vascular surgeon, do a vascular surgery fellowship. I found out in pretty short order. I didn't really love that specialty and that's, you know, a whole other story. But people of yours and my kind of era, I think, know that those are very difficult kind of emotional patients to take care of.
Speaker 2:And when my thinking kind of switched to plastic surgery, as you also might attest, plastic surgeons were kind of persona non grata to general surgery, especially the original kind of, she said, hard, hardcore programs, of which Cincinnati was certainly one. And so I kind of had to apply to plastic surgery programs, I guess not in secret, but without telling a whole lot of people. And when I sent out my this was back before online applications. And so when I sent out my request for paper applications, I included a CV in every one. And one night I was on call at the VA and the program director from Michigan actually paged me through the hospital operator at like 8 pm while I'm on call and said so what's your deal? It was a very interesting phone call. You might imagine who that was.
Speaker 1:It was Garner, right yeah.
Speaker 2:It might have been and I love Warren, and you could just tell from that first meeting of ours on the telephone how it all went. But he said you know, we can actually use somebody here in about three months. We had somebody leave the program and so, rather than applying for a year and a half from now, I'd like you to think about taking this job. So I said, well, I really, oh. And he said, you know, come up this Wednesday for an interview. Well, I couldn't just leave on any 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. So, um, so anyway, I I talked to the chief resident I was working with at the time and I'll never forget her name was Trish Abello, and I told her you know kind of where I was with the whole thing and I just remember Trish saying you know, what doesn't matter, I will cover you.
Speaker 2:You know, get there, do what you need to do for you in your career, and kind of the rest is history there. You in your career, and kind of the rest is history there. So I think some of those themes maybe we'll talk about tonight on the rest of this podcast, but I really remember that as being a very pivotal time in my life and my career and a really pivotal decision that Trish made on the spur of the moment and I don't know that, she knows that and I have thought I should tell her a million times, so maybe she'll see this podcast.
Speaker 1:You know, michigan does have a soft spot for people like you and me who had abrupt transitions like that. I had something similar coming from my program into Michigan and Gardner was definitely a personality and I had a similar experience when he contacted me as well, so I can certainly relate. Very impactful. It's funny how those little crossroads can really make a ginormous decision and impact in our lives. But let me ask you so, when you look back at either your general surgery training or your plastic surgery training, was there anything in there that really impacts you now or that you even think of now as a surgeon?
Speaker 2:think of now as a surgeon. Wow, that's hard to nail down. I mean, I think we could spend probably a whole podcast series. We could do 10 episodes.
Speaker 2:You know, I think and maybe we can talk about this, because I've heard you bring up this theme on other podcasts you've done kind of about serendipity, but also about mentors and people who took the time at certain points that you just kind of remember little snippets about that helped you, either guide you or bring you up or just show you hey, listen, here's a path to what you want to do and you don't really forget those things. And the one thing, which maybe some of the things we'll talk about are more that I should do what I say, because I do have a few little, I guess, words of wisdom I'd like to leave for any other residents coming up behind us, and one of them is to remember those things and say thank you for them. And so maybe I really should have reached out to Trish before now. But you know, I really appreciated the way Warren Garner taught me in the operating room when I came to Michigan. When you asked you know what were the differences, I found that I learned a lot at the University of Cincinnati, I learned a lot because I worked 140 hours a week and there's only 168 hours in a week and so it was hard not to, but the learning was hands-on and passive and it gave me a good surgical foundation to know.
Speaker 2:You know, I was responsible for a patient and I had to see that through till the very end. I couldn't go to bed or I couldn't go home until things were as good as I could make them in somebody's health care and but by the same token, right, it was a really hard system and I know you've had podcasts about that. And when I got to Michigan to answer your question, I found people more focusing on me as a learner and as a developing surgeon, with more dedicated time to teaching me things and just a more active environment, and people like Ed Wilkins and Steve Buckman and Paul Sederna and those folks who really spent a lot of time Hack Newman working with us as trainees. I'll look back and really remember that fondly. So those were several of the kind of main differences in that period of time.
Speaker 1:They were and are awesome faculty members for sure, and they did take an interest in our surgical education. There was a lot of work. Let's not cut it short. I mean I know my general surgery sounds like your general surgery. Training was worse than mine. Cincinnati was notoriously brutal, but it's changed obviously a lot now. Like none of what we sort of experienced is is the way surgical residents and training is now, and you just recently left Michigan. So what you know, one of those compare and contrast type of situations.
Speaker 1:What what what would you say are the biggest differences? Both good and bad? I don't want to be one of those Gen Xers that say the Gen Z people are all weak or whatever. But what do you see that are both good and bad? Points to that.
Speaker 2:Great, great, great question. We could go on for hours, but one of the things that when you say, what is something I remember. I remember being a second year resident and our chairman left a copy of a newspaper article in all of our mailboxes for us to read and to summarize it it was from the New York Times and it was about I believe it was a physician who was saying you know, my children don't need me to raise them and to know them, and for them to know me, they need me to be the breadwinner and a good role model. And if I don't get home till after they're in bed or I sleep all afternoon Sunday because I'm tired of working Sunday, because I'm tired of working, that's really what they need and that really summed up the entire kind of philosophy of things and things were. You know very much. The reason they called us residents is because we were supposed to be resident of the hospital, right, sleeping there, eating there, living there. And, you're right, the plastic surgery training wasn't significantly easier, but that was really shocking to me at the time to get that note from him and for him to be telling us that this was a positive way to view our lives. Again, I look back on the training that I got. That was superb and gave me great foundations that have lasted this whole time.
Speaker 2:But things needed to change right. I knew people who weren't there for their children's births, who weren't there for their children's births, and I mean you can say every family occasion or hospitalization or surgery that somebody had and they couldn't make it because they were in the hospital and you and I both know the kinds of conditions that people trained under that just needed to change, and they have. They've changed a lot. The question is, I think you know, have they changed too much? Has this? You know the pendulum usually swings and you know maybe then finds that it's not at the right apogee yet either and has to come back so much. And you know I'd posit to you that maybe it swung too much. It's hard to know and maybe we'll know in 10 or 15 or 20 years, maybe we won't.
Speaker 1:How? So Let me know, Like what is it that you see that might be a little too much the other way, like example-wise for trainees.
Speaker 2:Well, sure, I mean, you know, I think what we want out of our physicians and our surgeons is somebody again who's going to take care of us through an entire illness or through our entire lives or whatever the entire emergency room visit, and that obviously isn't possible in all of medicine. It's not, especially not possible today with different work week hours and with, you know, just being kinder to the people who are delivering that care. And you know, again, there are lots and lots of benefits to what's happened. Right, people aren't crashing their cars into the bridge abutments on their way home from a long shift which happened to one of my classmates, or you know committing, you know, medical errors because they weren't getting enough sleep or they didn't yell that too much, you know. I think we do have to be mindful, though, about you know how much we really take the job as a shift work, what it looks like when you turn over care to another physician who's going to assume the care of that patient for you, and how that's done, and be very mindful of that, and I think in many instances that happens really, really well. Obviously, there are opportunities, as these culture shifts happen, for things to go a little too far and need to come back.
Speaker 2:You know, one of the original complaints of long work hours in the list of all the other things was the lack of time to actually sit down and study, because learning is so much about doing, but it's also about being taught, and it's about teaching yourself. And if you're up taking care of patients for the entire week, you're not reading a book. And there was an interesting study that came out, I don't know, 10 years after the duty hour work week changed. That said that the number of hours that residents were reading was actually at or below what it had been before the duty hour change. It's not entirely surprising. I mean, you know you need some time to live life and do your laundry and, you know, get a haircut, which there wasn't time for. But anyway, I don't have, I guess, real criticisms. I'm just saying I think we're still figuring it out where that best practice is.
Speaker 1:I might argue this is a permanent shift. I know young surgeons coming out. They don't go solo. You can find a group where it is literally shift work, where you are passing on and handing off your care to someone else. Then you go, you live your life, you come back, you pick up wherever that other person left off or your group left off. Oftentimes they're not in control of their own practice. They are part of a larger organization or administrative group, a hospital.
Speaker 1:So I think that this aspect of surgical culture where you have a responsibility to a patient, may actually no longer exist in 10 to 15 to 20 years, or it'll be the minority of us, because I don't think people will see it as wrong to operate on a patient. Hand off that care to somebody else, let them manage that patient. Hand off that care to somebody else, let them manage that patient. When you come on, you might be managing somebody else's post-operative care or patients, and it's just going to be figuring out how to make those transitions less error-prone or fraught with difficulty or problem problems. But there there, that might be a permanent culture shift at this point, because I don't ever see us going back to the type of training that we had where we literally would stay up all night taking care of somebody and you know, and sort of seeing the whole thing through.
Speaker 2:And I don't know if it's good or bad, I'm just saying that.
Speaker 1:that's the way it's going to be.
Speaker 2:I don't disagree with you. Again, there are certain elements that needed to change, but hopefully we'll get smarter and better as this goes, Because that's, I guess, why they call it a practice of medicine Right. That's why they call it a practice of medicine right. But you know, one of the things that's been a little tough is, honestly, the whole idea of wellness and happiness. Maybe that, what was that movie Happiness with a Y, right, Right yeah, the pursuit of happiness.
Speaker 2:Pursuit of happiness, and I think there's room to come back and make gains in both ways. Right, and most people I think most of our trainees feel this way and act this way, but I think there's an opportunity for some to say you know what? Yeah, wellness for me is not being at work, and I don't think that's what that word in our specialty was really designed or brought up for, right. It doesn't mean that I just work less hours, although I'm not saying that we need to work more hours. I'm just saying that you have to learn to be happy at work and you have to learn to be efficient at work and you have to learn to take good care of patients.
Speaker 2:That makes you happy and you have to seek out that happiness in a system, in whatever way you do that. That involves your career and your life and it isn't just well, I'm, I'm happy when I'm not working as an attitude, um and and I that. That, I guess, is maybe where I think we've swung a little far. Uh and, and you know, maybe some of the hospital, when you, when you read anything these days about burnout and about administrative systems and things that people would generally complain about, it's more about the systems and the restrictions on how we practice. That makes people less happy with their job and their career at least the studies that I've seen, as opposed to how many hours I was at work or what weeks of vacation I got, although those are important.
Speaker 1:Well, all right, let's talk about your life then, in terms of hours, weeks, career, happiness. You spent 26 years at University of Michigan as an academician, as a faculty member, as a professor. Now I spent five years in academics and then I transitioned out into private practice and I thought that was one of the most jolting, weird, difficult transitions as a physician and a surgeon that I had to make, and it's like mind blown that after 26, that's what you're doing, having left University of Michigan. The same. You're like Jim Harbaugh. He was at Michigan last year, won a national championship, took off, went to the pros. You're sort of doing the same thing. Just about the time he left you you're now at Neuropax, a private practice with another surgeon no more academics, no more provided secretaries, no more salary, no more protected time and vacation and all this sort of stuff. Why, on God's green earth, after 26 years, would you leave tenure to do this?
Speaker 2:So thank you for finally outing me. I am Jim Harbaugh. It is not a coincidence that we both left the University of Michigan at the same time. I am his Clark Kent. No, nothing could be further from the truth.
Speaker 2:I really did love my time at Michigan. It was actually really really difficult for me to leave and I felt, as I was doing it, very sad about that, to be honest, because of the people I mentioned and that really was my and still is my family, and that stuff's hard in life. Those sorts of changes and transitions are difficult. But you know, I always had a bit of a private practice mindset, I think, and you know, one of the things that highlights that is you know, I used to complain quite a bit about the state of our outpatient clinic, and so much so that when it came time to name a medical director, when they started doing those kind of, they started doing those kind of administrative things across Michigan's outpatient clinics, our chief at the time said hey, guess what you get to be the medical director of the outpatient clinics. You know, careful, careful. How much you complain about something, you'll be in charge of fixing it. Um, and and, and and. I actually really liked that I did that for 13 years, Um, I finally stopped doing it, Um, when it became really difficult to make those independent decisions, or decisions with our faculty, with our nurses, with our MAs, PAs, residents to do what we thought was best to take care of patients, and the administration levels kind of grew, particularly in the last few years, to the point that it became harder to make independent decisions about what was good for plastic surgeons and plastic surgery patients in deference to decisions that were being made across, you know, big giant health systems. And so I guess that brings me back to independent private practice, and you know I'd always had that is, the grass greener kind of look over the fence mentality. I did all I wanted to do at the University of Michigan, Um, and I just felt like it. Either either I did something independent um at this point in my career or I wouldn't, because I, 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 left Um.
Speaker 2:Rob Hagen, who's been a really good friend in the nerve society, does a lot of the same things that I do. There are only, you know, a dozen of us across the country currently devoting our full-time practices to peripheral nerve surgery for treating chronic pain, and Rob's one of them. And I wouldn't have left if it hadn't been for the right opportunity and especially the right 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, and so I never would have left that 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 papers and the two of us will continue to do so. So we're going to try to keep Lee Dellin's saying alive about privademics, which is some at least still being somewhat academic in a private practice, and to the point that we're even going to have fellows, and we have a fellow starting with us here next year that I'm really excited about. So the transition's going well.
Speaker 2:Uh, you know I'm I'm only a few months 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 I want to, to take care of patients. Um, and I I miss Michigan for, being honest, I miss the people. But this is also very good and that 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 has kind of the same attitude and the same questions that you did for me tonight and that is. You know what were you thinking?
Speaker 2:And fair enough, I mean, I understand that question, but maybe what was I thinking five years ago or 10 years ago? Or you know what would I be thinking five or 10 years from now if I hadn't done it? So you know, my excellent long-term friend, mentor, colleague and then finally boss at Michigan, Paul Sedernit, used to always give me a little bit of a hard time because I'd really get into hobbies and I'd get into scuba diving or flying airplanes or sailing boats around different parts of the world and just throw my whole self into it for a while until I'd kind of gotten all I wanted out of it and then pick up a new hobby. So I don't know that this is a new hobby, but it's just another thing I wanted to tackle and something I just had to do before I died, I guess it makes sense.
Speaker 1:I applaud that, thinking that what you might see yourself in five years, whether you would regret not taking that chance, I think that's important. You sort of pulled a reverse. Bob Gilman he was the one who was in private practice for a long time and went to Michigan and you're flipping it now but you're in a boutique-y kind of specialty, so most peripheral I mean most plastic surgeons do not do peripheral nerve surgery and even fewer do treat chronic pain by doing peripheral nerve surgery.
Speaker 1:So my and the ones who do are. There are very few of them in the country and world and they're renowned for what they do, like a Lee Dillon, for example, and now. Now, so you must probably draw from a very wide area, because with the Internet, with people communicating, people must say I have chronic pain from a mastectomy. Who do I see? And they're like there are these guys in St Louis, Doesn't matter, if you're in Laguna Beach, California, you got to go see these guys and they'll come out and they'll see you. You know, certain special medical conditions warrant travel to specialists.
Speaker 2:Is that what?
Speaker 1:you're seeing in your practice and how do you manage that sort of, you know, really broad, like a very niche specialty, but drawing from a very broad geographic area?
Speaker 2:Sure, yeah, you couldn't be more right about that, and I think that's one of the things.
Speaker 2:That is really exciting to me. You know the fat, so the field is taking small nerves, which are, as you know, electrical wires in the body that carry signals to the muscle to make things work and then carry signals from the skin and other parts of us, our joints, to the brain to tell us how those parts are feeling and their sensations. And many things like injury, accidents, surgery and just sometimes life life as in compressions of nerves can leave people with chronic pain and the statistics are are unbelievable and it's amazing that we don't learn a lot about pain in our in our medical training, in our residencies, even even in practice, other than and I always fell victim to this that there are pain medicines which, as it turns out, aren't really pain medicines, in opioids and other things, and there are more people living with chronic pain than there are with heart disease, diabetes and cancer combined diabetes and cancer combined and they've been absolutely the best patients to take care of. In all the things that I've done and I did a lot of Mohs, facial cancer reconstruction, I did lower extremity abdominal wall, did a lot of breast reconstruction for a while, a lot of hand trauma those were all satisfying things to do.
Speaker 2:This has just been for me. It, just as my partner Rob Hagan now says it just pushes my happy button. I mean, these folks are miserable. This field is so new that not many people know we exist. I mean, I'm sure you feel the same way that even just when somebody says you say to somebody I'm a plastic surgeon, even probably people in your close family say couldn't really describe what it is that you do.
Speaker 1:Right. Well, they think I do lipo, which is kind of true.
Speaker 2:But whatever, go ahead, right, right and well, they think I do lipo, which is kind of true, but whatever, go ahead Right. I mean there's a there's a very narrow definition in society, public opinion, about what a plastic surgeon is, despite the fact that we do all kinds of reconstruction and cosmetic things, they don't can grasp. So then, to add on to that, this little niche is it's hard to get that information to patients. But you're right, and I never really thought too much about being at a big academic medical center. People would line up basically down the street right in terms of booking appointments with you, so you never really needed to try to get the word out about it very much.
Speaker 2:Our main goal now is just all the time educating people about what we do. Excuse me, what can be done to try to get to those patients who are sitting at home with chronic pain conditions and nothing feels better than you know a woman coming from New York City to see me for chronic mastectomy pain from a bilateral mastectomy eight years ago, and or a woman from Florida that I treated last month for chronic neuropathic pain from shingles. So that initial shingles outbreak right is so horrible. Everybody talks about being one of the worst painful things up by next to kidney stones. This is a condition where the nerves get so damaged you have pain forever and there's never been a solution, pain after total knee replacements and all sorts of things. So it's just been just another gift. That medicine's given me the ability to interact with these patients and help them. And, um, and if we have two more minutes in this kind of vein, I'll tell you how, how I first got into doing this.
Speaker 2:I used to always tell patients, um, when they'd come back and they'd say you know, my, my chest is hurting after having had a breast reconstruction, and we would always say, well, you had surgery and now you know there's some pain that goes along with that, and then you might not see that patient again. Or you'd see them six months later and then not again. And they went somewhere and they lived their lives and they went to many other doctors unbeknownst to me to talk about this horrible chronic pain that they had, so much that some patients would come back to us, not infrequently, and say can, can you know? After all, they went through having the breasts removed, three or four operations to have them reconstructed and they would say just take them away, I don't, I don't want this uh anymore because they hurt and we knew that removing them wasn't the answer right. But sometimes you couldn't say no because people were just in such pain and were so insistent.
Speaker 2:And I had one patient that I always tell was kind of my aha moment. She was very young, I don't know, early 30s, to have breast cancer which, as you know, is usually more aggressive the younger you are. And she was so thin that she needed a muscle transfer, a latissimus flap brought around to her chest to add to an implant. But we always did that operation with a couple days hospital stay. And she told me you know, I work on an assembly line, I'm really tough, I'm not going to stay in the hospital and so well you know it's really bad. There's a lot of pain with this. We need to admit you to the hospital a couple days. She said no and in fact I will only let you book my surgery at the outpatient surgery center. That's how confident I am that I'm going home and you can't make me stay in the hospital. And we did and she did and I was very impressed by her resolve and her ability to do that and we got all through with the reconstruction and it went very well.
Speaker 2:And she came back and she said you know what? The pain in my back that I'm having is unbelievable. Take it rid of it. It's horrible. And you got to do something about it.
Speaker 2:And I'd heard that obviously before. We've all heard that, and to us in surgeons it was always a thing about you know, I don't know how to help people who are having pain, so they're, you know, just aggravating to me and them. Anyway, I spent a lot of time looking into it and found out that, well, you know, any operation that you do can injure little, tiny nerves that maybe you don't even see during surgery Usually you don't even see during surgery Usually you don't and you can cut them, stretch them, burn them. They get caught up in scar after surgery and she was so definite about it hurts here and here. And we took her back to the operating room and we opened up those two little areas and we found these big balls of nerve tissue called neuromas and cut them out. And I don't know just at that moment that I said that is, just for all the stuff I'd been doing, really incredible and that was kind of the tip of that iceberg, so to speak.
Speaker 1:Working on patients who are in dire straits, such as the ones that you have as a surgeon, it doesn't sound so appealing to me on a couple levels. First of all, these are patients that are very desperate. I would be worried that my surgical procedure might not work. I might be concerned that I have to. You know, pain is multimodal, so you have to do all sorts of other things in addition to just operating. In terms of managing these patients, and as a surgeon I would be like this does not seem like the most fun to me. It's a nebulous problem. It's not always clear that you can guarantee or have a high likelihood that you would definitely find a good outcome.
Speaker 1:Pain is difficult sometimes, or always, and so I would say why would you encourage any surgeon to try to? I mean, I understand the great outcomes are great outcomes, but you know, as a batter, what are you hitting here? 250, 300? Like, is this a 90% like success? It's to me I would feel like you would pat yourself on the back if you got maybe a quarter of these patients better.
Speaker 2:Um, I, I, I first say that you know, um, in all the time I've known you, and so what has it been? 20, we had to add it up, it's been at least 20 years. Yeah, More than that, probably More. Yeah, you are one of the most insightful and most empathic people that I've known, and I don't know if I've gotten to tell you that before, but no, I mean, and you're right, and so that's another thing is, people are going so full professor, and you left this to get what? What are you thinking, right? I mean anybody that I, that I try to talk to about nerve surgery, who's a surgeon, says wait, you, you want a whole clinic, you want to see 30 patients in a day, all of whom have pain. That would be like two, it would be bad for me. And so that's basically what you just said.
Speaker 2:The miracle comes when you realize, actually, and even as I started doing this, and even as I started doing this and in the first 50 or 100 patients I took care of, that innate it's not innate because it was ingrained in us, I'm sure feeling of I'm going to make it worse or I'm not going to be able to fix it, and then it's my fault, internalizing all those feelings is there and just like any complication that you have, and you feel absolutely horrible and crushed about with anything else, that's still true with this, but it turns out that these issues are mostly solvable.
Speaker 2:So when you say, you know what's my batting average? Well, it's not perfect, but it's everything. It was in hand surgery and cancer, reconstruction and cosmetic surgery and so forth right, you have to understand the problem really well and you have to learn to diagnose B nerve-related, and C treatable. And it isn't what I thought it would be. That was so scary, which is, you know, I might have a whole bunch of people that I can't help and a whole bunch of people that have pain that's in their head and it's just really I don't know. It's really awesome.
Speaker 1:It's really an incredible thing when you do these surgeries. Now is the technical part of it the most challenging, and what kind of technologies can you use now? Like is it different doing these surgeries now than it was, say, 10 years ago? Like there are a lot of surgeries where we don't do anything the same that we did, say, 10 or 15 years ago. So it's like what has changed now with this? Or what's getting you jazzed about this kind of surgery, the new stuff?
Speaker 2:Sure, well, first of all, as we started the podcast and I said that I originally wanted to go into vascular surgery when I was a general surgeon. Then, when I started at Michigan, I wanted to be a hand surgeon, and I think the common theme to those in peripheral nerve surgery is detailed anatomy, and I love dissecting out nerves, I love finding them. You know, I think the residents half of them would think I kind of lost it. Every time we'd do a case together and we'd find the nerve, even though we knew we'd find the nerve, and I'd get all excited and be like, hey, look at this and I'm calling the anesthesiologist to look over the drapes. Have you ever seen this nerve that goes here? And it was a little silly, but it was really fun, and the answer to your question specifically, though, is no, it's just a new paradigm of understanding. In fact, the exam and the tests for doing it are so ridiculously simple. Anybody could learn it in a couple of days. The biggest thing you have to do, I think, is as my college theater professor told me, because I went to liberal arts school and I had to take a theater class this concept of suspension, of disbelief, right, and so you know, when I trained at Cincinnati, you, you, uh, you know, didn't let the patient eat for five days after a bowel resection, because that's when they got to eat, if for no other reason, right, you didn't pull the drain out until it was less than 30 cc's in a day, which actually I still ascribe to.
Speaker 2:And with peripheral nerve surgery for pain, first of all, you have to start to believe that things can be possible that you didn't think were possible before, like, for example, that you could do an operation on a patient with chronic pain from post-herpetic neuralgia, which is the term for chronic shingles pain, when everybody has said that you're not going to help that patient and the virus is still in the nerve and it's up in the dorsal horn and you're not going to clear them of the infection but in fact it cures them of their pain. You have to suspend your disbelief. That where's my train of thought? That, oh, that you know somebody who gets a really bad ankle sprain could have permanent nerve pain from making, and I, just in my own self, I remember first time encountering that thinking that's the silliest thing I ever heard Like, how are you hurting the nerve? Right, but the nerve when it stretches across that fulcrum at the angle when you have a bad ligament sprain, is stretched beyond its capabilities to spring back and is broken inside.
Speaker 2:I describe it to patients like one of those fiber optic light cables and some of the cables are all broken inside and you see down it and patients come in with healed orthopedic injuries from that, but they have chronic burning pain on their foot and it just goes on and on and on that list of things that you have to tell yourself.
Speaker 2:Well, I'm just going to apply these principles of how a patient might have pain here, how it might be related to a nerve, and then prove it is or it isn't, just like we do in all of plastic surgery. And this is people say to me how do you do that? How is a plastic surgeon doing this? And you know as well as anybody that that's our specialty is doing things with the soft tissues all over the body and being innovators in that space. And I'm not in any way saying I've done a lot of innovating in this space. I've certainly followed on the coattails of several of the real pioneers, but it is what our specialty does and it's just been a real boon for me in the last 10 years.
Speaker 1:Well, we definitely know the anatomy about the entire body, I believe better than any other specialty out there from head to toe. I mean, we've had to operate literally from head to toe as surgeons. So no doubt I think you're right. If anyone has to dig out nerves, identify them, identify what's traumatized, that makes sense, you're right. Some of the concepts you're saying, as I'm listening to them, blow my mind. I've had shingles pain, one of the worst episodes I've ever had. To treat post-hepatic neuralgia with surgery also blows my mind.
Speaker 2:I'm going to be doing some uh Medline searches, uh, after this podcast, just to to learn a little bit more about it and there's not much out there about it, um, which is, which is you know the beauty of what, of what we're doing? Um, and I read, I read, so, oh, that's an awesome, interesting story on how I came to do that. So I had a patient come see me and he said you know, I had shingles about eight years ago. I've been in the same state of pain for the whole eight years. And I said, well, but I don't know how to help you with that.
Speaker 2:And he said, well, here's a journal article and if I'm not mistaken it was Ivan Duchik's about a couple of patients he treated this way. And he said you know, I read a paper from you about how you're treating post-mastectomy pain with nerve operations in the chest. And I had shingles on the chest and here's a paper about treating shingles with nerve surgery. And he taught me what to do to him. And he taught me what to do to him and since that moment I've tried to help anybody I can with this issue. I just got an email today from somebody in Australia. These folks are, like you said, very, very desperate. It's very hard to find anybody to help them and hopefully we can help this person, find someone in Australia to do it. But you just have to take those building blocks and those techniques and put them all together to solve these problems.
Speaker 1:Do you do any other surgery at this point other than peripheral nerve surgery?
Speaker 2:A little, not a lot, but then again, like I said, I've been here three months but that's what Rob Hagen and I is our plan and to be two people who he does a lot of headache surgery, thoracic outlet, nerve surgery, upper extremity surgery and some trunk, and I do trunk and groin and back and lower extremity, so we overlap, but we can cover from head to toe and that's a unique thing, you know, I think.
Speaker 2:Um, there are, there are clinics full of patients with back pain and whatever can't be fixed by putting a rod and a screw, uh, and doing some kind of laminectomy, um, in the spinal cord itself. All those people get lumped into one category of low back pain and there's no great answer for 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 started doing, is operating on people for low back pain. That I think we're going to find out is 80% of the patients who don't have a problem in their spine itself. We're going to be able to have operations to fix in the next five years that people will be doing all over the country to fix all of these people with low back pain.
Speaker 1:I think you're onto something intuitively. There are a ton of people I know, because I know a lot of athletes have had surgery for whatever reason discs issues, compression issues and they are technically or anatomically not having anything pathologically wrong, but they still have issues. And I do believe you are right there is some sort of peripheral nerve issue, some other local nervous system issue which needs to be addressed.
Speaker 2:There's a whole constellation of symptoms in the lower back that we know of already right including the facets, which are the joints of the spinal column, the bones and their little nerves, and we were just at one of the large manufacturers of instruments.
Speaker 2:So when you say, are there new tools out, we're learning to use this minimally invasive tool to go and section or permanently remove the nerves that go to those joints. So that's for facet arthropathy. I've operated several times maybe 10 now on the superior clunial nerves, which are the set of nerves that come out just above the pelvis from the back, sensory nerves that run back over the iliac crest, that can be irritated there and it's, you know, it's when you're grabbing your back and saying I'm having, you know, low back pain right there at your upper part of your pelvis, and those are solvable problems. The sacroiliac joint is a very common source for inflammation and low back pain, of which I was unaware five years ago but is getting a lot of attention now for both denervation techniques but also fusion techniques. So all of these things in the lower back, I think, are going to combine to be able to treat almost all these patients that haven't had any good answers forever.
Speaker 1:What do you think about non-invasive treatments like acupuncture? Do you think that they're sort of modulating this sort of peripheral nerve pain in some way to help afford some relief in some of these patients? Is that one of the modalities how these pain treatments are working? Or EMG, for example? Are you just like electrostimulating some of these peripheral nerve issues as well?
Speaker 2:Sure, that's a long, complicated answer and I don't want anybody to mistake anything I'd say in that space because it's there's a lot of nuances to that. But I will say that you know, as a surgery resident, as a young faculty surgeon, I would have thought acupuncture and massage therapy and different things couldn't possibly be as therapeutic as they were being touted. Again, I think you have to have an open mind to at least listen to the arguments and the reasoning behind it and look and see what patients are getting treated out there, because when the general medical community says, well, that's not how we do it and we need published data until we all start doing it, there's still a lot of patients that aren't being treated for whatever reason. So I'm sure and I don't know anything about acupuncture, but I'm sure it helps a lot of patients.
Speaker 1:Okay, so I think you already answered my next question, which is where do you see yourself in the future? And a lot of it is sort of delineating a lot of these techniques, expanding, like you said, the indications treating a wider range of patients. I mean chronic low back pain. If you can treat a large subset of those patients, that would be humongous, like we would see you literally on the front page of a newspaper or newspapers or TikTok.
Speaker 2:now I guess you know of a newspaper or newspapers or tick tock now I guess, um, you know sort of.
Speaker 1:I hope I don't wind up on it, you will, I guess I bet you if you were to figure this stuff out. Is this?
Speaker 2:uh, I'm I'm going to admit something to you, sam I what I. I was addicted to tick tock Were you, I was I, I uh, just let me guess what came up?
Speaker 1:It was uh videos, cute dogs and I don't know movie clips. Is that what came up on your take? I, I, I had.
Speaker 2:I had tick tock for a total of one week and my my wife would attest I could not believe I was blown away at how talented and funny. Believe I was blown away at how talented and funny millions of people are. Hundreds of thousands that post on that medium and I could just scroll it for hours. I stayed up till two, three in the morning for a week watching that stuff. I finally had to just go cold turkey 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:Yeah, is this your last stand at this point, cause you've done all the other stuff, you like? You said you really get into something for a while. Is this the last thing, at least professionally, that David Lawrence Brown is going to get into before he, like, figures out something else?
Speaker 2: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 to fruition, I don't know. Maybe something, some other shiny thing will make me look and say squirrel, but um, I, I that that that is. My plan is to, um, take care of as many patients with chronic nerve pain in as good a way as I can while I still have this ability.
Speaker 1:And if somebody is listening to this and says you know what I want to do this as my job or profession. This appeals to me. I am a young person and this is what I want to do. What is the advice you'd give them in order to become you?
Speaker 2:Is this person already a young plastic surgeon?
Speaker 1:Either way younger than that or at that level either way.
Speaker 2:Well, I guess I'd say you know there's a lot of prerequisites and one thing I'd say is, in as much as you can, choose the harder, more difficult route, because then it leaves you more options open later. And I guess my piece of advice there is that you don't know what it is, you don't know who you're going to be in five years and what that person is going to have as desires and motivations and so forth, and the more you leave options open, I think is the better. If you're already a plastic surgeon, then I think there are a number. Or if you're a plastic surgery resident, there are a number of great opportunities for fellowships around the country in peripheral nerve surgery, a couple that are more heavily weighted on neuropathic pain.
Speaker 2:And if you are a plastic surgeon and want to start doing it, there are lots, lots of people who just love doing it to teach you. And if you don't readily find them, email me and we'll get get you started. I mean I got lots of great help from Lee Dellen and Tim Tolstrup and Eric Williams and Rob Hagan and the people who are doing it really well John Winograd, susan McKinnon and it's a really great, tight, small and any of us would be happy to help.
Speaker 1:Dave, it's been eye-opening on so many levels for me to hear. I certainly want more people to hear about what you do. I think there are a lot of people that can benefit and I appreciate you taking the time to share. I never would have thought 20 years ago or 25 years ago that we'd be here talking and you'd be so enthusiastic about peripheral nerve surgery. But yet here we are. And it's absolutely amazing. I love it.
Speaker 2:Thank you. Thank you, sam. It's really great to have been asked to do this. I think it's an incredible thing you're doing. It's amazingly time-consuming and I'm sure, but I think you're reaching a group of people that is very unique. Maybe like peripheral nerve surgery, you know it's really specialized, but it's really interesting and I've had a lot of fun listening to all of your podcasts since you asked me to be on this recently and I really appreciate being one of the people that you did ask. Thank you so much, dave. Appreciate it All right, thanks, sam.