MedicalPhysician Q&A

Q&A with Dr. James Doty, Neurosurgeon, CCARE Director

James R. Doty M.D., is a Professor of Neurosurgery and the founder and director of the Center for Compassion and Altruism Research and Education (CCARE) at Stanford University.

He is also a philanthropist serving on the board of a number of non-profits; an investor and consultant to a number of medical device and biomedical companies; a venture partner in the medical device industry; and an entrepreneur. He is the former CEO of Accuray, manufacturer of the CyberKnife, that went public in 2007 with a valuation of $1.3 billion.

Dr. Doty, obtained his BS in Biological Sciences from UC Irvine before studying medicine at Tulane University School of Medicine (1981). He trained in neurosurgery at Walter Reed Army Medical Center in Washington, DC and spent 9 years on active duty service in the US Army.

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Dr. Doty was previously chief of pediatric neurosurgery at Children’s Hospital in Orange County and chief of the complex spine and minimally invasive spine surgery service at Stanford. He has been honoured multiple times as a one of “America’s Top Surgeons” by the Consumers’ Research Council, and one of the “Best Doctors in America” by Best Doctors.

He is the New York Times bestselling author of “Into the Magic Shop: A Neurosurgeon’s Quest to Discover the Mysteries of the Brain and the Secrets of the Heart” that has been translated into 31 languages. He also the senior editor of the recently-released “The Oxford Handbook of Compassion Science” (2017).

When did you first decide to become a doctor? Why?
In fourth grade, and it was following a visit at my school by a pediatrician. He so impressed me that I decided to become a physician.

How/why did you choose the medical school you attended?
It’s the one I was accepted to!

First of all, my background was such that I grew up in poverty. My father was an alcoholic, and my mother was chronically depressed and had attempted suicide multiple times. We were on public assistance my entire life. The reason I bring this up is because the normal trajectory of someone from that background is not typically to become a doctor. So when I went off to college, I did not perform well and had a very low grade point as a result of having been ill-prepared for college, working, and having to leave multiple times as a result of family crises. The idea of going to medical school with that was thought to be completely unrealistic. That being said, I had an absolute belief that I was going to be accepted and I was. The details are much more complex and are discussed in my memoir.

What surprised you the most about your medical studies?
It’s very hard to truly understand what it means to be a doctor. As an example, I thought that I wanted to be a family practitioner. I was enamored by the idea of taking care of delivering babies, and taking care of children, families, and elderly people. It was a very naive perception. At least in the United States, the only way to do all of this is if you’re in the most rural of areas where they don’t have any specialists. The other problem in the States is that oftentimes family practitioners end up being individuals who simply see people with colds, indigestion, and minor illnesses. While they may have a lot of information about a lot of things, it’s limited information.

Why did you decide to specialize in neurosurgery?
I found that my personality and mindset were more attuned to being a surgeon and to being in a demanding high-level specialty. After I realized this, I initially thought I would become a plastic surgeon who focused on cranial-facial disorders in children. In the US, you have to do a surgical residency before you can go on to do a plastic surgery fellowship, followed by a craniofacial fellowship. During my internship I rotated on general surgery, and I realized that I disliked it.

Right after that, I rotated on neurosurgery and recognized it was very demanding, and intellectually very interesting. So I decided I would do neurosurgery, then continue training plastic surgery and craniofacial surgery. As you know, neurosurgery residency is quite long. Once I finished, not only did I realize that I enjoyed neurosurgery, but I found I was tired of being a resident! I ended up doing a pediatric neurosurgery fellowship, which ultimately allowed me to do a lot of craniofacial work. That being said, I did general neurosurgery.

Has being a neurosurgeon met your expectations? Why?
Over the course of my 30 years as a neurosurgeon, academic training has evolved such that there are very few general neurosurgeons. There’s a tendency to do sub-specialty training, frequently in spine surgery. The reason, I believe, is unfortunately that spine surgery can be quite lucrative and most patients don’t require long hospitalizations. In fact, many go home the same or the following day.

For a whole variety of reasons, the reality is also that most neurosurgeons in the private practice setting want to do things that are fairly straight-forward. When you end up with patients in the intensive care unit for long periods of time, it consumes a vast amount of your time. And, frankly, it consumes a lot of your time that’s not compensated. When working at the university hospital, I have residents. But I also run an outreach clinic which is without residents. The nature of the job is such that if I do any procedure which sends patients into the intensive care unit for several days, like a major craniotomy, that adds hours on top of my already twelve-hour day.

What do you like most about being a neurosurgeon? Explain.
The privilege of caring for people and alleviating their suffering. That’s true of any part of medicine. It truly is a privilege, and I think people occasionally forget that. But nothing could be more satisfying than to be the person who is able to intervene and save someone’s life. I mean, what could possibly be more stimulating, enjoyable, or meaningful than doing something like that?

What do you like least about being a neurosurgeon? Explain.
I thoroughly enjoy all aspects of neurosurgery except the intrusion of electronic medical records. In theory, they are supposed to increase the efficiency of our work, but they were never designed to do that. At least in the US, their purpose is to document care for billing purposes. The information required for this is different from the information which needs to be transmitted to another physician. As an example, we have this feature that automatically populates notes with every bit of data on events which have occurred over the last 24-48 hours. I may only need information about the white cell count, if everything else is known to be normal. Yet, before I write anything, my note is populated with three or four pages of useless information that I don’t need. You can imagine what that’s like if you have a patient with multiple specialists involved, and you have to sort through ten, twenty, thirty pages of useless information per day which hides one or two lines of pertinent data. It’s very frustrating.

What’s your typical work-week like?
I typically operate one or two days a week, but it can be every day at times. Then I’m in clinic typically two days a week. I usually devote the remaining day of the week to research or administrative tasks. That’s of course highly variable since I’m on call 5-7 days a month.

Tell me more about how you started CCARE.
Growing up, I observed how people who had the means, ability, and position to help another or alleviate the suffering of another chose not to do so. Then, of course, I saw the converse being the case: I’d see people who had limited to no resources, who still reached out and attempted to help others. I wanted to understand what motivates people to do good and what is it about our species, from an evolutionary perspective, that motivates people to do good.

This ultimately led me on this quest, and onto the founding of CCARE. I had begun this project as something simply called Project Compassion, a very informal group that I brought together to do some preliminary research in this field. It then popped into my head that I should invite the Dalai Lama to Stanford to give a talk about this subject. He himself had begun some collaborations with other scientists in this field. At our very first meeting, we immediately hit it off, and at the end of that very first meeting and, he spontaneously offered a donation to this work, making the Dalai Lama the founding benefactor! That led to two other individuals coming forward to give significant donations, which then led to the formalization of the center at the Stanford School of Medicine.

How do new insights from compassion research promise to inform clinical practice?
Oftentimes, we don’t appreciate how stressed we are by the nature of our jobs, the decisions we have to make, and the demands on our time. Of course, when you’re stressed and anxious, this stimulates your sympathetic nervous system. Not only do you then chronically release hormones that can be deleterious to your health; this also results in decreased function of the executive control areas in your brain. This limits your ability to make thoughtful, discerning decisions. Your creative ability and productivity are reduced.

Then, when you’re overwhelmed and stressed and your sympathetic nervous system is stimulated, you go into this mode of saying “well, I should never have become a doctor, I’m failing my patients, I’m a fraud.” When you’re able to treat yourself compassionately, the stimulation of your sympathetic nervous system decreases, allowing you to be more present, further allowing you to be more compassionate and kind to those around you, whether it’s co-workers or patients. When you’re in that mode, of course, everything works better.

There’s a large amount of data supporting the notion that if a physician practices compassion for self and others, it does more than simply improve their relationships with patients. When a patient is shifted from the anxiety or fear associated with being sick or ill, to feeling cared for and safe, it actually boosts their immune system, decreases stress hormones, and results in improved wound healing, decreased use of narcotics for pain, decreased length of stay, and fewer readmissions.

What do you like most about running CCARE?
Well, of course, the most gratifying part is the research that supports the hypothesis that kindness and compassion are deeply hardwired into us and the fact that when one exhibits these behaviors, one’s physiology works at its best. Based on this research, we’ve been able to develop techniques that allow us to train individuals to be more compassionate and to reap the benefits of these behaviors in their own lives.

What do you like least about running CCARE?
Like all things, I don’t think anyone enjoys administrative realities. The other aspect is that early on, our work was supported by these significant donors. More recently, I have had to spend a fair amount of my time trying to raise funds to continue our work.

On average: How many hours a week do you work? How many weeks of vacation do you take?
You know, it can be very challenging. I’m not just a neurosurgeon in the sense that I’m simply a clinician; I give lectures all over the world. I recently completed editing the Oxford Handbook of Compassion Science that was just published; writing it was a three-year endeavor. Writing “Into the Magic Shop” took a couple of years. I’m also doing research.

As mentioned before, I’ve been a neurosurgeon for 30 years. There’s a difference between your motivations when you’re starting out and when you’ve been in a field for years. Also, this area of the world—Silicon Valley—is extraordinarily expensive to live in. Even as neurosurgery faculty member at Stanford, many of our junior faculty can’t afford homes. Which is extraordinary: here you are, one of the top specialists at a major academic institution, and you have to live in an apartment. Now, don’t get me wrong, there’s nothing wrong with living in an apartment. But after 10 years of very arduous training, owning a home should be an option! Working long hours in a very difficult job, then feeling as if you’re not being rewarded appropriately, can oftentimes be demoralizing.

How do you balance work and life outside of work?
I have a family. It’s difficult oftentimes to have a balanced life, but I’m very blessed because my family is very supportive of the work that I do. When I’m off, I really try to be off.

In the States, we are paid by how much we work, and for me, my motivation is not to make the most money in the world, or to do as many operations as possible. My job is simply to be a good doctor, and to feel comfortable about what I do.

What types of outreach/volunteer work do you do, if any?
I lecture at science conferences, universities, student and physician groups, and even in corporate environments.

Periodically, I have done neurosurgery in third-world countries. The challenge with that is, frankly, that in a disaster or in a third world country, the last thing you need is a neurosurgeon. The cost in terms of equipment, support, care unit care, is so high that you could spend the equivalent amount on clean water, or emergency doctors, or family doctors. Their impact is much more significant than that of a neurosurgeon in resource-poor settings.

What is your personal mission statement?
I’ve been very blessed with many options. I have, among other things, been an entrepreneur and CEO. I was successful in the dot-com period, and I’m a long-standing philanthropist. I’ve never defined myself as just a doctor. I do what motivates me at the moment, something I’m passionate about. I tell students considering neurosurgery that it’s a very demanding vocation. If there’s anything in the world you would rather do, that’s what you should do.

The same is true of being a doctor. Nothing is sadder to me than seeing unhappy individuals whose parents have forced them to become a doctor because “you’ll always have a job”. You have to be happy, even when you’re coming in at 2 or 3 in the morning. You have to be kind, compassionate, and caring when you see someone suffering. The issues that you’re dealing with cannot cloud what you need to do on the job. A significant number who go into medicine can’t cope with this, and they’re chronically miserable. It’s not doing them or their patients any good.

From your perspective, what is the biggest problem in health care today?
The intrusion by the cooperate practice of medicine into doctors’ practice of medicine. Here in the States, we have private medicine. As the fundamental motivator of capitalism is profit, using that model in healthcare is fundamentally contradictory, and leads to poor care. In the United States, we spend more than any other industrialized country in the world on healthcare, and we have the worst outcomes of any other industrialized country in almost every quadrant measured. We also have the highest level of patient dissatisfaction. We still have forty million people with no access to healthcare.

Where do you see medicine at large in five years?
I think understanding the biological effect of gene therapy will have an ever-increasing positive impact on medicine. The challenge is you can’t get away from the fundamental nature of medical care which is, as Dr. Francis Peabody said in 1925, “The secret of the care of the patient is in caring for the patient”. A machine is not going to soothe the child who’s in pain, or hold the hand of a dying person as they transition. There is no substitute for the human connection. That connection is just as, and potentially more, powerful than anything that I do as a neurosurgeon for a patient.

Where do you see neurosurgery in five years?
I think, in terms of neurosurgery, we have probably reached the limit of what we can do from a technical point of view. There are only so many ways you can access the brain and use surgical tools, and the conditions that affect the brain or the spine are ones that are less susceptible to the use of robotics as other specialties. So I believe the future of neurosurgery is going to be based more on the use of biologics, such as gene therapy.

What is your final piece of advice for students interested in pursuing a career in neurosurgery?
More than anything, be compassionate and kind to themselves, because it’s only then that you can really demonstrate true compassion to others. The last part of my book relates to a lecture I gave to an incoming class of medical students at Tulane, my alma mater:

“You have sealed your path with an oath. This path will take you to life’s deepest and darkest valleys, where you will see how trauma and disease destroys large. Sadly, you will also see what one human is capable of inflicting upon another. And, more sadly, what one human is capable of inflicting upon themselves. But it will also take you to life’s highest peaks, where you will see

the meek demonstrate strength you thought not possible; where you will see cures for which you can find no explanation; and where you will see the power of love and compassion to save lives, and by doing so, see the face of God”.

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