In this conversation, Steven and I discuss how a great mentorship led him to a career in neurosurgery. We also discuss how pediatrics has its own specific challenges, both on the operating room table and in communicating with the patient.

Todd Schlosser: Thank you for joining us here on Scrubbing In. I’m Todd Schlosser, and I am joined today by Dr. Steven Hwang, attending spine surgeon at Shriners Children’s Hospital. I wanted to talk to you today about sort of what got you into healthcare, how you ended up where you ended up, and why you love the work that you do. So let’s start out with sort of how you got into healthcare. What was it that drove you into a career in healthcare?

Dr Steven Hwang: Mostly, it’s mentorship. I think when I started in college, I was thinking about medicine and thinking of a lot of different options. I found that along the way I just had good mentorship that helped guide me down certain paths. I was doing a little bit of research at the time; my mentor was a physician, so I shadowed him a little bit; I built a strong bond with him, and then kind of followed in that path. When I started it actually was the opposite thing I was thinking about. My Dad’s a radiologist, and probably as a rebellious college kid I didn’t want to follow in his footsteps; I wanted something different. But I found I really liked it, I really enjoyed it, and I started looking at it more and more and found I was more drawn to it.

Todd Schlosser: So, was this post college, you were doing research and then you

Dr Steven Hwang:  During College. Yeah, so during the summers in college and during certain block time you have.

Todd Schlosser:  Sure.

Dr Steven Hwang:  I kept on enjoying it and I liked it more, and I found I did better … I had more affinity, I think, for those topics certainly than economics or other things, concepts I just couldn’t grasp as well.

Todd Schlosser:  Right. So the human body is a much more alluring concept to you than numbers and figures?

Dr Steven Hwang: Yeah.

Todd Schlosser: Sure, I definitely understand that. As you transitioned from sort of collegiate life to professional life, how did you make that jump? Did you immediately start a residency somewhere or?

Dr Steven Hwang:  I went from college; applied to medical school, and then went from there into medical school.

Todd Schlosser: Where did you go to medical school?

Dr Steven Hwang: University of Toronto. I grew up in Canada, so

Todd Schlosser: Oh, did you? Okay.

Dr Steven Hwang: I did my undergrad at Yale and then went back to Canada, Toronto, for med school.

Todd Schlosser:  Awesome.

Dr Steven Hwang: During med school, similarly, I kind of did research in the summers and looked at opportunities, and found a kind of a niche area that I liked that I found interesting, a subspecialty that kind of I was drawn to. Similarly, I think I had good mentorship. There’s a resident that I worked with in the lab, as well as the lab the physician director that I took call with and really enjoyed taking call and seeing patients. So that kind of led me down kind of a neurosurgical path. I chose to do that in my residency training after medical school.

Todd Schlosser:  How long have you been in that neurosurgery actually practicing it?

Dr Steven Hwang: My training was six years. I finished in 2009, and I did two extra years of additional fellowship training, so since 2011 I’ve been in practice.

Todd Schlosser: Okay. So, roughly eight or nine years? Excellent. When you, I guess, found that neurosurgery was where you wanted to go, is it anything in particular that made you want to work with kids with spine issues? Did you start out with adults or?

Dr Steven Hwang: I did. So most of my training was adults. We did a little bit of pediatrics. Most training programs have a little bit of pediatric training. So, I did a little bit; I really enjoyed it. I think, similarly again, my Chairman at the time was doing pediatrics, and I really enjoyed working with him; he was a great mentor. At the time he kind of said, “Why don’t you think about pediatrics? Your personality is kind of more a fit for that maybe in some ways.

Todd Schlosser: I’m assuming that was a compliment.

Dr Steven Hwang: I think so, too. I took it as a compliment. I don’t know what he meant. That kind of led me down the pediatric path. Then, I did a fellowship, it was kind of a pediatric fellowship in neurosurgery. Before that I actually came here and did a pediatric spine fellowship for a year. I found I enjoyed both the spine and pediatrics, so I tried to blend both together a little bit.

Todd Schlosser:  When you say here you mean Shriners Children’s?

Dr Steven Hwang: At Shriners I spent a year here in 2009.

Todd Schlosser:  Then you went away and then came back to Shriners?

Dr Steven Hwang:  I did, yeah, I went from here to I went to Houston for a year, took a pediatric neurosurgery fellowship for a year, and then I came back. I actually went back to Boston to work for about four and a half years and then came back here a couple years ago.

Todd Schlosser:  So, what are some, and I’m sure there are some probably a lot more than we can talk about in 15 minutes, but what are some of the bigger nuances that are different between like an adult patient that needs spine surgery and a child who needs spine surgery?

Dr Steven Hwang: The classic thing, you know they say children are not little people, so have to treat the sympathologies in an adult as you would a child. I think some of nuances, the big nuance at least in spine and, I think, even in the brain, is growth and development. So, the younger the child there is more potential for growth, more potential for development, and we have to take that into account when we try to treat the underlying medical problems. If they come in with a certain pathology, say scoliosis, if we just straighten them when they’re really young historically we found that it leads to all kinds of other problems. Because, their torso may be short, even though they’re straight that leads to a lot of disproportionate cosmetic issues and medical issues.

Todd Schlosser: Sure.

Dr Steven Hwang: So, those are things that definitely come into play much more in pediatrics than in the adult population.

Todd Schlosser: So, obviously, you have to train for all of those sort of nuances that you have to kind of handle on a case-by-case basis I imagine? Can I talk to you about the nuances of when you’re talking to the patient?

Dr Steven Hwang:  Sure.

Todd Schlosser: Because you’re talking to someone who is a child. Of course you have their parent there, as well, so that’s got to be a different sort of an interaction.

Dr Steven Hwang:  Yeah, totally different. I think it’s very important to, obviously, explain this so the family is comfortable, both medically and just in simple kind of straight-forward terms, but also try to explain to the child, depending on the age, so that they understand it and it makes sense to them. Obviously, depending on what they need done, sometimes it can painful; sometimes you’re recovering from a surgery or something, and you want them to at least have an understanding so that they can frame it and, hopefully, understand why it’s necessary.

Todd Schlosser: I imagine that you meet with them beforehand to sort of answer any questions that they have. I realize you’re doing this a lot and you have a lot of patients that you touch, which is great. You want to be available to those who need help. Do you have to explain it sort of two different ways to like the adult, the parent in the room, and then the child?

Dr Steven Hwang: Sometimes. Most cases … So, we have a great team that help us out; the PAs, our care managers; there’s a whole team that helps make it manageable. They field a lot of the questions and talk directly to the families on our behalf. Certainly we see them several times at the clinic before surgery, multiple times. I think definitely there’s one discussion, especially of a very young child, that’s a little more at the adult level, the parents and the pros and cons, especially of a very informed family that wants a lot of the details and numbers related to it, so there’s a very kind of more detailed discussion with the family, the parents. Then, there’s sometimes a more simplified discussion for the child. Often the best case that it happens through the parents so the parents will help redirect some of the discussion we have to explain to the child during the same time. But it is … Sometimes they get it and sometimes they don’t, especially young, young infants.

Todd Schlosser: Sure.

Dr Steven Hwang: We try to do our best. We definitely have Child Life and services that help here, as well, to facilitate some of that.

Todd Schlosser:  So, you mentioned you having a great team that works around you. I wanted to talk to you a little bit about that team when you’re in the actual OR, because you’ll have yourself kind of leading the team because you’re the hands of the surgery, and you’ll have a perfusionist sometimes I would imagine; you have anesthesiologist; you have a neurophysiologist. So, as you’re leading that team, obviously there’s a lot going on at all times during surgery. What is it like as the leader of that team when your job is really to do and their job is to inform? Is that a struggle?

Dr Steven Hwang: It’s not. It works very, very smoothly. I think in most circumstances, at least where I’ve been, where I’ve worked, the environment I’ve been in has been very cooperative. When push comes to shove there has to be a leader to run things, just like when there’s a code, or arrest, or something somebody has to take charge. Generally here it’s very collegial, so everybody’s very supportive. We have … Particularly here we have … There are certain cases that we do that are very stressful, that are high risk where maybe a very bad scoliosis, or a child may have some spinal cord compression already, and so there’s a high chance that they could get worse and we use every tool we can to make it as safe as possible. If there is an alert change, like the neuromonitoring changes, or there is an alert that we think the child may be getting weaker, they may have an enlarging injury to the spinal cord, there’s a whole checklist in place here to help to make sure that we don’t forget anything.

Dr Steven Hwang: That moment of stress, and everything’s elevated, we want to make sure that all the Ts get crossed, everything’s covered to make it as safe and have the child recover. That’s where the team comes in where … I tend to listen to music in the operating room, but if there’s a moment where something, the stress picks up a little bit, the nurses know well, they turn off the music, everybody quiets down, everybody’s paying attention; we go through a checklist of things to make sure that everything’s covered. We often call in one of my partners, and vice versa. Everybody has a different opinion so that you can get a perspective on everything. It’s a really good team effort.

Todd Schlosser: It’s built in such a way to make the focus on the patient, make it as safe as possible for the patient. But, in those high-stress moments have you … and I sort of see surgeons as very cool under pressure, and that may not always be the case with everybody, but that’s sort of how I’ve met most surgeons and how I see most surgeons. So, is that a skill that you develop over time, or is that something that you’ve sort of always been able to do?

Dr Steven Hwang:  I think it definitely comes with experience. I think your stress level and your comfort level, managing certain situations, changes with that experience. The first time you’re in a situation where there’s a monitoring alert where the electrophysiology is changing and you’re worried that the child may have spinal cord compression, it’s very scary. As you see more and more and become more comfortable, it’s still nerve wracking, or still very anxious about it, but you know how to manage it; you know how to approach it, and it’s much more methodical. I think it’s similar for any stressful circumstance, with that exposure to the experience you’re just more comfortable managing it and probably better at managing it, but it is still scary. There’s definitely some component that I think is built into your personality a little bit, as well. I think some people also tend to manage stress, I’d not say better but differently, more calmly perhaps whereas others may not.

Dr Steven Hwang: I’ve worked with colleagues that I love at Grey Nuns and different places and mentors that I’ve worked with and everybody reacts kind of differently to those stressful moments. I’m sure there’s all kinds of previous stories that you hear about. But usually they kind of solve it in their own way; they just have different ways to cope with it.

Todd Schlosser: Excellent. So, you mentioned when we were setting up here while we were talking that you do some mission work. I wanted to ask you a few questions about that. Where is it that you go on these mission trips?

Dr Steven Hwang: So, we go regularly, kind of collaboration with my Shriners organization and this organization, WPP, that I collaborate with. We tend to go to St. Vincent’s. We go one week a year to St. Vincent’s, and we’re trying to build and kind of develop a program in Guatemala now. There are a lot of, basically, untreated children in Guatemala. In the past we’ve gone to Cambodia, Barbados, probably sounds like a vacation place, but we have gone …

Todd Schlosser: We go there to work.

Dr Steven Hwang:  Yes, yeah, we do. It’s not all fun and games.

Todd Schlosser: Absolutely. So, when you’re there are you doing spine surgeries on children in need …

Dr Steven Hwang: We do, yeah.

Todd Schlosser:  … I would imagine.

Dr Steven Hwang: Yeah, so mostly the countries are children who haven’t had care, or don’t have access to care. Same thing, we’ll bring a whole team down so there’s people we trust; we work with both from a scrub tech in the OR, the neuromonitoring specialist, neurophysiologist, anesthesiologist.

Todd Schlosser: So, they have none of that infrastructure down there?

Dr Steven Hwang:  It depends. Place by place is different. Some places have local anesthesiologists we use. Most of the countries don’t have neurophysiologists. Some of them, obviously, have their local nurses and scrub techs. So, there’s different variability in the infrastructure available. But, also the comfort level and experience is varied. Guatemala, we’re trying to set up … Right now it’s still very preliminary. We’re taking a look at the place, looking at the site infrastructure. Hopefully we identify a site in a hospital that is safe to perform the surgeries and then train kind our equivalent compatriot down there. My goal would be to train a local surgeon down there and have our scrub tech train a local scrub tech down there …

Todd Schlosser: Oh, so it’s a teaching tour as much as it is a surgery.

Dr Steven Hwang: Exactly. The goal is to treat the children but also train local physicians to be comfortable performing the same surgery so that they can take over X number of years down the road. It’s always very rewarding actually.

Todd Schlosser:  In any sort of industry we give back at what you’re good at doing; what you may normally get paid at doing. It’s nice to be able to give back at that skill, especially one so highly trained. To that end, I wanted to ask you, and we’ll kind of close on this question. If you could give advice to someone who is looking to enter the field that you’re in, or really the medical field in general, what advice would you give them.

Dr Steven Hwang:  I think a lot of people are … A lot of physicians, you hear them say, “Don’t go into medicine.” I would say, I love what I do and I think most physicians who are happy, I think enjoy what they do. So, I think most importantly find something you’re passionate about; find something you enjoy doing. I think the rest for the most part will kind of fall in place. I think if you love what you do you’ll be happy doing it no matter what. It’s not a chore to do the training, or go through all that. It can be tough at times, certainly, but it’s worth it as long as you’re happy doing it and you enjoy it.

Todd Schlosser:  Awesome. Well, thank you so much, Dr. Steven Hwang. I appreciate it. Thanks for joining us here on Scrubbing In.

Dr Steven Hwang:  Thank you. Thanks for having me.

Todd Schlosser: Absolutely.