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. He discusses his specialization in peripheral nerve surgery for treating 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. The conversation offers insights into both the changing landscape of surgical training and the innovation required to tackle complex medical issues.

#PlasticSurgery #MedicalPodcast #SurgicalLife #SurgeonSpotlight #HandSurgery #DoctorInterview #HealthcareHeroes #InspiringSurgeons #MedicalJourney #PodcastLife #SurgeryEducation #FutureSurgeons #BotoxAndBurpees #BotoxandBurpeesPodcast #LifeInMedicine @michigan_surgery @umichplasticsurgery @umichmedicine#chronicpain

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S04E87 From Academia to Private Practice: Dr. David L. Brown's Journey in Treating Chronic Pain

Transcript

[00:00:04] Dr. Sam Rhee: 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. 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 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 is the 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.

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. I have with me A longtime friend and a colleague and seen, uh, he was one of my first attendings actually as a plastic surgery or plastic surgery resident, Dr. David Brown, uh, 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. Uh, let's go through, uh, Dr. Brown's training a little bit so you know who he is. He, uh, graduated, uh, undergraduate at Wittenberg University, which is actually really pretty close to me because I grew up in Columbus.

Um, and then in, in a, with a degree in chemistry. And then you went to Vanderbilt University for your medical school training or, uh, medical school and you graduated there. And then you did your. General Surgery Residency at University of Cincinnati. So you're one of those old school guys who did a full General Surgery Residency before doing your plastic surgery training.

[00:03:14] Dr. David Brown: Actually, wha Yeah? I left after four

[00:03:18] Dr. Sam Rhee: Oh, that's right! You did four! So it was one of those, uh, uh, did. That's an interesting story. I can tell you about that later if you want.

Yeah, I, I have heard it. That's a good story. Um, and then you went to, uh, Michigan, University of Michigan, where you did your, uh, um, Plastic Surgery Residency. You're a fellow there. And, um, and then you stayed on as a, uh, as faculty. And I remember because I just started my plastic surgery residency there and you were a brand new faculty member pretty much that, that first year I started. Yeah. And, uh, you got a lot of crap because, you know, it's kind of weird when you're a fellow and then you suddenly become, uh, an attending and I, I remember, uh, people, uh, sort of giving you that, uh, the jibe, uh, when the business, when you started. Uh, but you stayed on for 26 years at University of Michigan and, uh, you, uh, were a tenured professor, uh, in the Department of Plastic Surgery, sorry, Division of Plastic Surgery.

But in January of this past year, you, you left after 26 years and you are now at, uh, St. Louis, Missouri at Neuropax Clinic, um, where you specialize in, um, peripheral nerve, uh, injury and pain. Uh, you have, uh, found the surgical treatment of chronic pain to be the most rewarding due to the incredible results you've seen with this.

Innovative techniques. Your specialties include pain following mastectomy, knee and hip replacement, shingles, hernia repair, and abdominal nerve pain. And, uh, you have a ton of, uh, accolades and awards. You were, uh, you served as president of the, uh, ASPN, the American Society of Preferral Nerve, board of directors of the American Society of Plastic Surgeons, president of the Michigan Academy of Plastic Surgeons, and, uh, oral boards examiner for the American Board of Plastic Surgery.

Um, so welcome, Dave. It's great to talk to you, Uh, and I, and I really appreciate you coming on to this podcast. Um,

[00:05:27] Dr. David Brown: Well, thank you. I'm, I'm, I'm super honored to have you ask. It's, it's, uh, been fun listening to, uh, many of your past, uh, episodes and hearing what other people had to say, and I think this is an awesome forum. So thanks for having me on.

[00:05:43] Dr. Sam Rhee: Um, you represent, uh, someone that I've known for a really long time. Um, you are a Michigan lifer. Uh, and so, uh, your training really, uh, was similar to mine in the sense that we had many of the same faculty members and, uh, And people that we worked with. Uh, 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, uh, and short circuit that into, uh, into plastic surgery training at Michigan. What

[00:06:18] Dr. David Brown: Thank you. So, you. know, uh, uh, going into, um, general surgery residency, I really thought I wanted to be a vascular surgeon. Uh, do a Vascular Surgery Fellowship. Um, I found out in pretty short order, I, I didn't really love that specialty. Um, and that's, you know, a whole nother story, but, uh, people of, uh, yours and my kind of era, I think, um, know that those, those are very difficult, uh, kind of emotional, uh, patients to take care of.

And, um, when I, when my thinking kind of switched to plastic surgery, um,

[00:06:54] Dr. Sam Rhee: was the opposite. I

[00:06:55] Dr. David Brown: 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. Um, and so, um, you, 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 Um, 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, uh, through the hospital operator at like 8 p. m.

while I'm on call and said, um, so what's your deal? Uh, it was a very interesting phone call. You might imagine who that was.

[00:07:53] Dr. Sam Rhee: It was Garner, right? Yeah.

[00:07:55] Dr. David Brown: It might've been, and, um, and, uh, I love Warren and you could just tell from that, uh, that, that, uh, first meeting of ours on the telephone, how it all went, but, um, he said, you know, uh, We can actually use somebody here in about three months.

Uh, 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, Ten.

um, I said, well, I really, you know, 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, and I'll never forget. Um, her name was Trish Abello. And, um, I told her, you know, kind of where I was with the whole thing. And, and I just remember Trish saying, you know what, doesn't matter.

I will cover you. Um, you know, get there, do what you need to do, uh, for you and your career. And, um, kind of the, the rest is history there. So, um, I think, I think some of those themes, uh, maybe we'll talk about tonight, um, on the rest of this, uh, podcast, but I, I really remember that as being, you know, very pivotal time in, in my life and my career and, um, you know, really pivotal decision that Trish made on the spur of the moment.

And I don't know that she knows that. I have thought I should tell her a million times, so maybe she'll see this podcast.

[00:09:34] Dr. Sam Rhee: know, Michigan does have a, uh, a soft spot for, uh, people like you and me who had abrupt transitions like that. Um, I, I had something similar, um, coming from my program, uh, into Michigan and, uh, Gardner was definitely a personality and I had a similar experience when he contacted me as well. So, uh, I, I can certainly relate.

Very impactful. It's, it's funny how those little crossroads can really make a ginormous decision in, uh, impact in our lives. But, uh, 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, uh, that, that impacts you now or that you even think of, uh, now as a surgeon?

[00:10:23] Dr. David Brown: Wow, that, that's, that's, that's hard to, to nail down. I mean, I think we could spend probably a whole, a whole podcast series. We could do ten episodes. Um, you know, I, I think, and, and, and maybe we can, and talk about this, because I've, I've heard you bring up this theme on, on other podcasts you've done. Um, kind of about serendipity, but also about, uh, mentors and people who, you know, took the time at certain points that, that you just kind of remember little snippets about that helped you, um, either guide you or bring you up or just show you, Hey, listen, here's a, here's a path to what you want to do.

And, and you don't, you don't really forget those things. Um, and the one thing, uh, which maybe some of the things we'll talk about are more that, um, I should do what I say, because, uh, I do have a few little, um, I guess words of wisdom I'd like to leave for any other residents coming up behind us, um, and one of them is to remember those things and say thank you for them, um, And, and so maybe, uh, I really should have reached out to Trish before now, but, um, you know, I, I really appreciated the way, uh, Warren Garner taught me, uh, in the operating room when I came to Michigan.

When you, when you asked, you know, what were the differences, I, I found that I learned a lot, um, at, at the University of Cincinnati. I, I learned a lot because I worked 140 hours a week and there's only 168 hours in a week. Um, and so it was, it was, it was hard, it was hard not to, um, but the learning was, uh, hands on and pass and, um, it, it, it gave me a good found surgical foundation to know, 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. Uh, things were, uh, as, as good as I could make 'em in somebody's healthcare. Um, and, you did,

but by the same token, right? It w it was a really hard system and I know you've had podcasts about that. Um, and, and when I got to Michigan, to answer your question, um, I, I found people more focusing on me as a, as a learner and as a developing surgeon, um, with more dedicated time to.

You know, teaching me things and, um, just a more active environment. Um, and you know, people like, um, Ed Wilkins and Steve Buckman and Paul Soderna and those folks who, who, uh, you know, really spent a lot of time Hack Newman working with us, uh, as trainees, I'll look back and, uh, really remember that fondly.

So those were, those were several of the. Kind of main differences in, in that period of time.

[00:13:38] Dr. Sam Rhee: 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. It is, is the way surgical residents and, uh, training is now. And you just recently, uh, left Michigan. So, you know, one of those compare and contrast type of situations, uh, 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 like, like, what do you see that are both good and bad points to that?

[00:14:32] Dr. David Brown: Great, great, great question. We could go on, but, uh, for hours, but, um, you know, one of the things that I, that I, when you say what, what is something I remember, I remember being a second year resident, um, and our chairman left a copy of a newspaper article in all of our mailboxes for us to read and, and to summarize it, it was, 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, that's really what they need. And It's

that, that really summed up the entire kind of philosophy of things. And, 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, um, you're right. It, the, the plastic surgery training wasn't significantly easier. I, I, but, um, 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 but things needed to change, right?

I knew people who weren't there for their children's births um, and, uh, I mean, You can, you can say every family occasion or, or hospitalization or surgery that somebody had and they, they couldn't make it because they were in the hospital. And, and you and I both know, um, the kinds of conditions that people trained under that just needed to change.

And they have. Uh, they've, they've changed a lot. The question is, I think, you know, have, have they changed too much? Has this, you know, the pendulum usually swings and, and. You know, maybe then finds that it's not at the right apogee yet either and has to come back so, so much. And, um, you know, I'd posit to you that maybe, maybe it swung too much.

It's, it's hard to know and maybe we'll know in 10 years. Maybe we won't.

[00:17:18] Dr. Sam Rhee: 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.

[00:17:27] Dr. David Brown: Well, sure. I mean, um, you know, I think, 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, or through our entire lives, or whatever the, the, the entire emergency room visit. Um, and, 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, to what's happened, right. People aren't, um, 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, they weren't getting enough sleep or they didn't yell that too much.

Um, you know, I think we, we do have to be mindful though about, you know, how much. Um, we really take The job as a, as a shift work, um, what, what it looks like when you turn over care to, to another physician who's going to assume

[00:18:46] Dr. Sam Rhee: hate and

[00:18:47] Dr. David Brown: the care of that patient for you and how that's done and be very mindful of that And I think in, in many instances that happens really, really well. Um, obviously there are opportunities as these culture shifts happen for things to go a little too far and, and need to come back. Um, you know, one of the original, uh, complaints of long work hours in the list of all the other things was, um, 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.

[00:19:27] Dr. Sam Rhee: That's

[00:19:27] Dr. David Brown: up taking care of patients for the entire week. You're not reading a book. Um, and, and there was an interesting study that came out, uh, I don't know if 10 years after the, uh, duty hour work week change that said that, um, the number of hours that residents were, were reading was actually at or below what it had been before the duty hour change.

Um, It's not entirely surprising. I mean, you know, you, you need, you need some time to live life and do your laundry and, you know, get a haircut, which there, there was time, wasn't time for, but anyway, I don't have, I guess, real criticisms. I'm just saying, you know, I think we're still figuring it out. Where that, where that, um, where that best practice is.

[00:20:21] Dr. Sam Rhee: I might argue this is a permanent shift. I know, um, young surgeons coming out, they don't go solo. They don't, uh, 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, you pick up wherever that other person left off or your group left off.

Um, oftentimes they're not in control of their own practice. Uh, they are part of a larger organization or administrative group, uh, hospital. 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, or, or it'll be the minority of us because, because I don't think if people will see it as wrong to operate on a patient, hand off that care to somebody else, let them manage that patient when you come on, you might be managing somebody's else, uh, someone else's post operative care, Uh, care or, um, patients, and it's just going to be figuring out how to use, you know, how to make those transitions less, uh, error prone or fraught with difficulty or problem, uh, 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, uh, and sort of seeing the whole thing through. And I don't know if it's I don't, I'm just saying that that's the way it's going to be.

[00:22:07] Dr. David Brown: I don't disagree with you. Again, I, you know, there are certain elements that, that needed to change. Um, and, but, but hopefully we'll, we'll get smarter and better, um, as this goes. Cause that's, I guess why they call it a practice of medicine. Right. Um, but, um, you know, one of the things that's, that's been a little tough is, Honestly, this, the whole idea of wellness and happiness, maybe that, that, that, uh, what was that movie?

Happiness with a Y, Right, Right, yeah, the pursuit of happiness.

pursuit of happiness. Um, and I, I think, I think there's room to come back and make gains in, in, in both ways, right?

[00:22:54] Dr. Sam Rhee: make

[00:22:56] Dr. David Brown: And most people, I think most of our, our trainees feel this way and act this way. But I think there's an opportunity for some to say, you know what, um, wellness for me is, is not being at work. And, and, and I don't, I don't think that's what it was, what that word in, in our specialty was really designed or brought up for, right? It doesn't mean that I just work less hours. Although I'm, 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. work, and you have to learn to be efficient at work, and you have to learn to take good care of patients that makes you happy.

Um, and you have to seek out that happiness in a system, um, in, 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, Uh, 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,

um, it's, it's more about the systems and the, 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, you know, how many, how many hours I was at work or.

What weeks of vacation I got, although those are important.

[00:24:44] Dr. Sam Rhee: All right. Let's, uh, let's, 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, um, and then I transitioned out into private practice, and I thought that was one of the most, um, 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, uh, 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, uh, you're now, um, in, at, uh, Neuropax, a private practice with another, uh, another surgeon.

Uh, you know, no more academics, no more You know, provided secretaries, no more salary, no more, you know, protected time and vacation and all this sort of stuff. Like, why on God's green earth after 26 years would you, would you leave, uh, tenure to do this? ha! uh, I, I, um, 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. Um, I, I am his Clark, Clark Kent. Uh, No, nothing could be further from the truth. Um, so, you know, I, I think, um, I, I really did love my time at Michigan. Um, you know, I, I, it was actually really, really difficult for me, uh, to leave.

[00:26:39] Dr. David Brown: And I, and I felt, you know, as I was doing it very sad about that, to be honest, um, because of the people I mentioned, uh, And that, that that really was my, and, and still is my family. And, and that, that stuff's hard in life. Um, those, those sorts of changes and transitions are, are difficult, but, you know, I, I always had a bit of a, um, private practice mindset, I think.

And, you know, one of the things that. highlights that is, um, you know, I used to, I used to complain quite a bit about, um, the state of our outpatient clinic. Um, and, um, so much so that when it came time to name a medical director, when they started doing those kind of, um, uh, administrative things across Michigan's outpatient clinics, um, our, our chief at the time said, Hey, guess what?

You get to be the, you know, The, uh, the, uh, medical director of the outpatient clinics, um, 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, um, residents to do what we thought was best to take care of patients. And the administration levels kind of grew, uh, particularly in the last few years. Uh, to the point that it became, became harder to make independent decisions about what was good for plastic surgeons and plastic surgery patients. Um, in deference to decisions that were being made across, you know, big giant health systems. Um, and so, I guess that brings me back to, Independent, uh, private practice. Um, and you know, I'd always had that is the grass greener kind of look over the fence, um, mentality. I, I, 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, you know, maybe I have six or eight years left to practice.

Um, Um, and I certainly wouldn't do it with two or three years left. Um, 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, um, you know, a dozen of us across the country currently devoting our full time practices to peripheral nerve surgery for treating chronic pain.

Um, and Rob's one of them. And I wouldn't have left if it hadn't been for, um, the right opportunity. And especially the right person, right? That's, that's what, that's what drew me to Michigan. Um, it's what brought me back when you said, you know, I, uh, after, after being a fellow there, and I, I came back as junior faculty, right?

It was for those people. And so I never would have left that if it, if it didn't seem like a really good, uh, match of, of people. And, and Rob is a really good person. He's a great surgeon. He actually writes a lot of papers and we, the two of us, will continue to do so, so we're going to try to keep, um, Lee Dellon's saying alive, um, about, um, privademics, which is some, uh, at least still being somewhat academic in a private practice, and, um, to the point that we're, we're even going to have, uh, fellows, and we have a fellow starting with us.

Uh, here next year that I'm really excited about.

So, um, the, the transition's going well, 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, do what I want to, to take care of patients. Um, I, I miss, I miss Michigan. We're being honest, uh, miss the people.

Um, but, but this is also very good. And. That was one of the things that I did want to talk about tonight, which is, um, taking chances and, and never passing up, um, an opportunity, even though it looks hard. And everybody I talked to has, uh, has kind of the same attitude and the same questions that, That you did for me tonight.

And that is, you know, what were you thinking? And, uh, fair enough. I mean, I understand, uh, that, that question, um,

[00:31:52] Dr. Sam Rhee: whatever.

[00:31:52] Dr. David Brown: maybe what was I thinking five years ago or 10 years ago? or uh, you know, what would I be thinking five or 10 years from now if I hadn't done it? So, um, You know, uh, my, my, my excellent long term friend, mentor, colleague, and then, uh, finally, boss at Michigan, Paul Soderna, used to always give me a little bit of a hard time because I'd really get into hobbies.

Um, and I, I'd get into scuba diving or, uh, flying airplanes or, um, sailing boats around different parts of the world. And just throw my whole self into it for, 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, um, you know, it's just another thing I wanted to, I wanted to tackle and, and, uh, something I just had to do before I died, I guess.

[00:32:54] Dr. Sam Rhee: makes sense. I, uh, 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. Um, 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, uh, by doing peripheral nerve surgery. 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. Um, people communicating. People must say, I have chronic pain from a mastectomy. Who do, uh, 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 gotta go see these guys and they'll come out and they'll see you.

Um, you know, certain special Uh, Medical conditions, warrant, travel, to specialists, um, is that what you're seeing in your practice? And, how do you manage that sort of, you know, really broad, um, like a very niche specialty, but drawing from a very broad geographic area?

[00:34:27] Dr. David Brown: Sure. You, you, you, yeah, you couldn't, you couldn't be more right about that. And I think that's one of the things that is really exciting to me. Um, you know, the fat, so the, the, the field is, um, 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, and other parts of us, our joints, to the brain to tell us how those parts are feeling, um, and, and their sensations.

And many things like injury, um. accidents, surgery, uh, and, and just sometimes 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 medical training, in our residencies, even, even in practice, other than, and I was, fell victim to this, that there are pain medicines, which, as it turns out, aren't really pain medicines, um, in opioids and other things, um, and there are more people with, living with chronic pain than there are with, Heart disease, diabetes, and cancer combined.

Um, and they've been absolutely the best patients to take care of, um, in, 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. This, this has just been for me. It just. Just as, as my partner Rob Hagen now says, it, it just pushes my happy button. I mean, um, these folks are miserable. This, uh, field is so new that, um, 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, even probably people in your close family say, couldn't really describe what it is that you do. And

[00:36:49] Dr. Sam Rhee: they think I do lipo, which is kind of true, but whatever. Go ahead.

[00:36:53] Dr. David Brown: right? I mean, there's, there's a very narrow definition in society, public opinion about what a plastic surgeon is, despite the fact that we, we do all kinds of reconstruction and cosmetic things they don't, can grasp. So then to add onto that, this little niche, um, is, uh, it's, it's hard to get that information to patients, but you're right.

Um, and, and I never really thought too much about being at. 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. Um, 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, nothing feels better than it.

You know, a woman coming from, uh, New York City to see me for, uh, chronic, uh, mastectomy pain from a bilateral mastectomy eight years ago. And, um, or a woman from Florida that I treated last month for chronic, uh, neuropathic pain from shingles. So that, 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, there's never been a solution. Um, pain after total knee. replacements and all sorts of things. So it's, it's just been, uh, just another gift that medicine's given me the ability to to interact with these patients and, and help them. 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. I used to always tell patients, um, when they 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, you had surgery and now, you know, there's some pain that goes along with that.

And then you, you might not see that patient again, or you'd see him 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, 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 anymore because they hurt and we knew that removing them wasn't, wasn't the answer, right? But sometimes you couldn't say no because people were just in such pain and were so insistent and I, 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 a breast cancer.

Um, 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, um, to add to a, an implant. But we always did that operation with a couple days hospital stay. And she told me, you know, I work on a, on an assembly line.

I'm really tough. I'm, I'm not going to stay in the hospital. And so, well, you know, there's, it's really bad. There's a lot of pain with this. We need to admit you to the hospital a couple of 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, 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. And she came back and she said, you know what, the pain in my back that I'm having is unbelievable. Can't get rid of it. It's, it's horrible and you got to do something about it. And I'd heard that obviously before we've all heard that. And. To us, you know, surgeons, it was always a thing about, um, you know, I don't know how to help people who are having pain, so they're, you know, just aggravating to me and, and, and them. Anyway, I spent a lot of time looking into it and, um, 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. 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, 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.

Um, I don't know, just at that moment that I said that that is just for all the stuff I'd been doing. Really, um, and that was kind of the tip of that iceberg, so to speak.

[00:42:33] Dr. Sam Rhee: Working on patients who are in dire straits, such as the ones that you have, um, as a, as a surgeon, it doesn't sound so appealing to me on a couple levels. First of all, uh, these are patients that are very desperate. Uh, 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, it's a nebulous problem. It's, it's, it's not always clear that you can guarantee or, or high, or have a high likelihood that you would definitely find a good outcome.

Um, pain is difficult sometimes. And so 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, you know, as a batter, what are you hitting here? 250? 300? Like, is this a 90 percent 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.

[00:43:50] Dr. David Brown: Um, I'd first say that, you know, um, in all the time I've known you, and so what has it been, 20? If we had to add it up, it's been at least 20 years. Yeah. more than that probably.

[00:44:02] Dr. Sam Rhee: More. Yeah,

[00:44:03] Dr. David Brown: You, you're, you are one of the most insightful and, and most, um, empathic people that I've, that I've known, and, and I don't know if I've gotten to tell you that before, but no, I mean, and, and you're right, and, and so that's another thing is people are going, so full professor and you left Mystic, you know, what, what are you thinking, right?

I mean, anybody that I, that I try to talk to about it. 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'd be bad for me. Um, and, and, and so that's what basically what you just said, um, the, the, the miracle comes when you, you realize actually, and even as I started doing this and, and in the first 50 or a hundred patients I took care of, it was That, that innate, it's not innate because it was ingrained in us, I'm sure, um, feeling of I'm gonna make it worse, or I'm not gonna be able to fix it, and then it's my fault, um, internalizing all those feelings is there, and, and just, just like any, any complication that, that you have and you feel absolutely horrible and crushed about, With anything else that's still true with, with this, it turns out that these issues are mostly solvable.

So when you say, you know, what am I, what's my batting average? Well, it's not perfect, but it's everything it was in. hand surgery and cancer reconstruction and, um, cosmetic surgery and so forth, right? You, you, you have to understand the problem really well and you have to learn to diagnose it and, um, pick, pick the right patients that you think you can help and make better.

And the really awesome thing is that, um, it's actually a majority of patients come in or referred to us, uh, for, for issues of pain,

[00:46:13] Dr. Sam Rhee: he got.

[00:46:14] Dr. David Brown: a majority. are A, straightforward to diagnose, B, nerve related, and C, treatable. And it, it, it isn't what I thought it would be that was so scary, which is, you know, I'm, I, 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.

Um, and, and, it's, it's, it's just really, I don't know, it's really awesome.

really really an incredible thing.

[00:46:52] Dr. Sam Rhee: when you do these surgeries now, um, is the technical part of it the most challenging? And are you, 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, what has changed now with this? This or what are, what's getting you jazzed about this kind of surgery? The, you know, the, the new stuff.

[00:47:21] Dr. David Brown: Sure. Well, first of all, you know, as we started the podcast and I, and I said that I originally wanted to go into vascular surgery and,

uh, in general, 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. Um, and I, I love. I love dissecting out nerves. I love finding them. You know, I think the residents, um, 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.

And have you ever seen this nerve that goes here? And, um, it was a little silly, but it, but it was really fun. Um, and, and, the answer to your question specifically though is no. Um, it, it's just a, it's just a new paradigm of understanding. Um, in fact, the, the exam and the tests for doing it are so ridiculously simple.

Anybody could learn it in a couple of days. Um, the, um, the, the, the biggest thing you have to do, I think, is. As my college, uh, 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 the, 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. Um, if, yeah. And, um, with, with peripheral nerve surgery for pain, first of all, you have to Demsey,

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, um, chronic pain from, um, postherpetic neuralgia, which is the term for chronic shingles pain. When everybody has said that you're not going to help 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, um, you have to suspend your disbelief that, um, and

[00:50:10] Dr. Sam Rhee: again, again, and uh, where's my train of thought?

[00:50:14] Dr. David Brown: That, oh, that, uh, you know, somebody who, who, who gets a really bad ankle sprain could have permanent nerve pain from making, and I just, in my, 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.

I describe it to patients like a, um, one of those fiber optic light cables and, and some of the cables are all broken in inside and you see down it.

[00:50:57] Dr. Sam Rhee: It is. It

[00:50:58] Dr. David Brown: And, and patients come in with, you know, healed orthopedic injuries from that. Um, but they have chronic burning pain on their foot. is. And, and it. just goes on and on and on that list of things that you have to tell yourself, 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. Um, just like we, just like we do in all of plastic surgery and this is, people say to me, how, how do you do that? How is a plastic surgeon doing this? And um, you, you know, as well as anybody that, that's our specialty is, um, doing things with the soft tissues all over the body and being innovators.

in that space. Um, 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, um, it is, it is what our specialty does. And, um, it's, it's just been a real, um, a real boon for me in the last 10 years.

[00:52:11] Dr. Sam Rhee: 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, uh, as, uh, as surgeons. So, uh, no doubt, I think, uh, I think you're right. If anyone has to dig out nerves, identify them, Uh, identify what's traumatized.

That, 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 herpetic neuralgia with surgery also blows my mind. I'm gonna be doing some, uh, Medline searches, uh, after this podcast just to, to learn a little bit more about it. and there, there's not much out there about it. Um, which is, which is, you know, the beauty of what, of what we're doing.

[00:53:01] Dr. David Brown: Um, and I read, I read, so, oh, that's it, that's an awesome, interesting story. Um, on how I came to do that. So, um, I had a patient come, 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. GLIA, idiot,

well, but I don't know how to help you with that. And he said, well, here's a, here's a journal article. and if I'm not mistaken, it was, Uh, Yvonne Duchik's, um, about a couple of patients he treated this way. And he said, you know, you, uh, 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, he taught, he taught me what to do to him. And since that moment, I've, I've tried to help anybody I can with, with this issue. I, I just got to, An email today from somebody in, um, Australia. Um, these folks are, like you said, very, very desperate.

They're, they're, it's very hard to find anybody to help them. Um, and, and hopefully we can help this person find, uh, someone in Australia to do it, but it's, um, it, you just have to take those, those building blocks and those techniques and, and put them all together to solve these problems,

[00:54:42] Dr. Sam Rhee: Do you do any other surgery at this point other than peripheral nerve surgery?

[00:54:46] Dr. David Brown: a little. Not a lot, but then again, like I said, I've been here three months, but that is, that's what, um, Rob, uh, Hagen and I, uh, is our, is our plan, and to be two people who, he does a lot of, um, uh, headache surgery, thoracic outlet, uh, nerve surgery, upper extremity surgery, and some trunk, and I do trunk and groin and back and lower extremities.

So we overlap but we can cover from head to toe and that's a, that's a unique thing. You know, I think, 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, 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, uh, I, our, our kind of next step, which we've already, I've already started doing, um, is operating on people for low back pain that I think we're going to find out years. 80 percent of the patients who don't have a problem in their, in their spine itself, we're, we're going to be able to have operations to fix in the next five years, um, that people be doing all over the country to fix all of these people with low back pain.

[00:56:35] Dr. Sam Rhee: Uh, I think you're onto something. Intu intuitively. Uh, there are a ton of people I know, because I know a lot of athletes, have had surgery, um, for whatever reason, discs issues, uh, 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,

[00:57:10] Dr. David Brown: Well, the, the, so there's this, there's a whole constellation, constellation of symptoms in the lower back that we know of already, right, including the the sets, which are the. the joints of the spinal col uh, the spinal column, the

bones, and their little nerves. And we were just at, um, uh, one of the large manufacturers of instruments.

So when you say are there, there are new, uh, tools out, we're learning to use this minimally invasive tool to go in, in section or remove, permanently remove the nerves. Go to those joints.

So that's for facet arthropathy.

Um, I've operated several times, maybe 10 now on the superior colonial nerves, which are the set of nerves that come out just above the, uh, 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, your pelvis. Um, and, and those are, those are solvable problems. The,

[00:58:22] Dr. Sam Rhee: Mm-Hmm.

[00:58:23] Dr. David Brown: sacroiliac joint is, uh, a very common source for inflammation and low back pain of which I was unaware five years ago, but, um, is getting a lot of attention now for both.

Uh, 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.

[00:58:51] Dr. Sam Rhee: What do you think about, um, 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, uh. Pain treatments are working, or EMG for example, are you just like electro stimulating some of these peripheral nerve issues as well?

[00:59:15] Dr. David Brown: Sure, that's, that's a long, uh, complicated answer and I don't want anybody to mistake, you know, anything I'd say in that space because it's, um, there's a lot of nuances to that. But, but I will say that, you know, as a surgery resident, as a young faculty surgeon, I, I would have thought acupuncture and massage therapy and, um, uh, different things couldn't possibly be, um, you know, as therapeutic as, as they were being touted. Again, I think you have to have a, an open mind to at least listen to the arguments and the, the reasoning behind it and look and see what patients are getting treated out there, because when, 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, I'm sure, and I don't know anything about acupuncture, but I'm, I'm sure it helps a lot of patients.

[01:00:32] Dr. Sam Rhee: uh. Okay. So I think you already answered my next question, which is what, where do you sell your, 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, your, your, 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 Tik Tok now, I guess. Um, you I hope, I hope, I don't wind up on TikTok.

you will, I guess, I bet you, if you were to figure this stuff out. I, I'm, I'm I'm going to admit something to you, Sam. I, I, I was addicted to TikTok.

were you,

[01:01:20] Dr. David Brown: I was. I, uh, just

between you, up. It was, uh, boating, uh, videos, uh, cute dogs, and, um, I don't know, movie clips. Is that what came up on your

I, I, I, I had, I had TikTok for a total of one week. And my my wife would Um, I could not 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 2, 3 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 do? Um, that was is this your, 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? Uh,

[01:02:23] Dr. Sam Rhee: like sort of end of career type stuff.

[01:02:25] Dr. David Brown: that's, I think that's my plan. Yes, that's, that's my plan. Now whether that comes to fruition, I, I don't know. Maybe something, some other shiny thing will make me look and say But, um, I, I, that, that, that is my plan is to, um, take care of as many patients, uh, with chronic nerve pain in as good a way as I can, um, while I, while I still have, have this ability.

[01:02:53] Dr. Sam Rhee: 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?

[01:03:09] Dr. David Brown: Is this, is this person already a young plastic surgeon

[01:03:13] Dr. Sam Rhee: Either, either way, younger than that or at that level. Either way.

[01:03:17] Dr. David Brown: Well, um, I, I guess I'd say, you know, there's, there's a lot of prerequisites and, um, one, one thing I'd say is, um, in as much as you can, choose the harder, more difficult route. Because then it, it, it leaves you more options open later. to do

And, and I guess the, 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, um, 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. And if you are a plastic surgeon and want to start doing it, um, There are lots, lots of people who just love doing it to, 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, um, uh, Tim Tolstrip and Eric Williams and Rob Hagen and the people who are, uh, doing it really well.

Um, John Winograd, uh, Susan McKinnon. Um, and, and it, it's. It's, uh, it's, it's a, it's a really great, tight, small group, and any of us would be, would be happy to help.

[01:05:13] Dr. Sam Rhee: it's been eye opening on so many levels for me to hear you talk about your life, your transition, what you're doing now, your enthusiasm, and I think for a field that is going to potentially provide tremendous care for a huge number of people who I think are underserved. I certainly want more people to hear about what you do.

I think there are a lot of people that can benefit and um, I appreciate you taking the time to share. I never would've 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.

[01:05:57] Dr. David Brown: Thank you. Thank you, Sam. Um, it's, um, it's, it's really great to, to have been asked to do this. Uh, I, I think it's an incredible thing you're doing. Uh, it, it's amazingly time consuming, and I'm sure, um, but I think you're reaching a group of people that is, is very unique, maybe like, peripheral nerve surgery.

Um, you know, it's, it's a, it's, it's, 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, uh, asked me to be, uh, on this, uh, recently, and I really appreciate being one of the people that you did ask.

[01:06:37] Dr. Sam Rhee: Thank you so much, Dave. Appreciate it.

[01:06:39] Dr. David Brown: All right. Thanks, Sam.