PNA Spotlight: Dr. Bernard R. Bendok

This month the PNA Spotlight focuses on Bernard R. Bendok, M.D., the William J. and Charles H. Mayo Professor and Chair of Neurological Surgery at Mayo Clinic in Arizona. He was kind enough to answer a few questions from the PNA. Here are his answers, lightly edited for clarity.

Please tell us about your early life, and why you chose pituitary medicine.

I was born in Detroit, and at age five, we moved to Harper Woods, so I spent my childhood living along Lake St. Clair. From age nine to fifteen I lived in Lebanon because my parents moved us there for family and work reasons. In ninth grade during the biology lecture on pituitary disease, in that moment, I decided to be a doctor. My passion for pituitary disease really stems back to this day. I remember distinctly: I was so amazed that this little gland could be a symphony conductor of the body. I didn’t know anything about being a doctor. We have no physicians in the family. Nobody had talked to me about being a doctor. But I knew, at that moment, that I was going to be a doctor. I didn’t know I was going to be a neurosurgeon, but I knew I was going to be a doctor.

Please tell us about your medical training and your mentors.

I went to medical school and did my residency training at Northwestern. I did my fellowship at SUNY Buffalo. While in medical school I learned from a pioneer in pituitary diseases named Dr. Ivan Ciric. He was a towering figure, an amazing surgeon, and an incredible human being. I had the privilege of writing the review of his autobiography, called “Listen to the patient.”  It’s a phenomenal book about health care and the passion and joy of being a doctor, and so I was inspired by him.

I was also inspired by my mentor, Dr. Hunt Batjer, a vascular and skull base neurosurgeon. The pituitary sits between two major blood vessels. So, I’ve been very interested in the relationship between the vessels and tumors of the head and neck. That’s really where I spent all my time. Both Dr. Ciric and Dr. Batjer were technical virtuosos of neurosurgery, who inspired me to aim for technical excellence and innovation. They both emphasized to me the importance of caring for the patient with the highest degree of integrity and empathy.

My third mentor was Dr. David McLone, a pediatric neurosurgeon. He taught me to appreciate the importance of integrating scientific inquiry into clinical practice. He was the most caring physician I have ever known. When I was on pediatrics, I was really struck by the role of the pituitary gland in child development and health. Those were all the different inspirations that came together to inspire my interest in pituitary issues, both in health and in sickness.

When I came to Mayo Clinic, I wanted to develop a neurovascular and skull base program that integrated my expertise in brain vessels and my passion to treat tumors and neurovascular diseases. The most important and risky part of pituitary surgery is the possibility of injuring the carotid artery. So, as a vascular neurosurgeon, I bring a unique perspective to pituitary surgery. I come at it from a slightly different perspective, perhaps, than others. All surgeons are unique and have slightly different backgrounds. I have an appreciation for both the vessels and tumors of the skull base. I want to be of service to patients who have pituitary disease and continue the traditions that my academic mentors instilled in me. I have a passion for technical excellence and individualized care. Dr. Ivan Ciric used to say, “Let’s think about what we can do for the patient, not to the patient.” It is only a one-word difference, but it is an important distinction.

I was so impressed by the way Dr. Ciric loved to perfect an operation. He made it picture perfect. It was like art. From a young age, I was always a fan of Renaissance artists like Michelangelo and Da Vinci. My passion is to perfect the sculpting, perfect the art, and deliver a good outcome for the patient that protects him or her from current or future threats. At the end of the day, we’re in the birthday business. We want to give people more birthdays, more time with their family, more quality of life, more energy, and more enjoyment in life. And so, the mission is to help, sometimes cure, sometimes heal, sometimes fend off threats if it’s not fully curable, and to do it with as low risk as possible. I try to do this by being a student of anatomy, a student of technical finesse, and a student of innovation.

After my fellowship in Buffalo, I came back to Northwestern and spent about a decade there as faculty. Then I was recruited to Mayo Clinic in 2015 to help build up the neurosurgery department. One of my passions has been to build up the skull base program, which includes the pituitary program. At Mayo Clinic, I’ve been able to build a team that truly cares about pituitary disease.

One thing that I tell my students: don’t copy me 100%. Maybe you can be inspired by the spirit of my work, but you must keep innovating. We have introduced augmented reality and virtual reality at Mayo Clinic. We have a skull base lab where we rehearse and innovate new techniques. Dr. Ivan Ciric used to sit in a room and look at MRI and CT images for hours and prepare a 3D image in his mind. Now we can take the MRI and CT and superimpose it on the patient, create an avatar, and blend the avatar with the patient. So now when we look at the pituitary, we see the MRI in the field. We can see beyond the bone, beyond the tissue, like having X-ray vision. Augmented reality is bringing the imaging and superimposing it on the patient to see hidden anatomy. This approach has great potential to enhance outcomes.

What is it like to analyze images with augmented reality?

Initially, when you’re starting on your early learning curve, everything looks the same. But then you start to develop the art of noting subtle differences and details. You must use all your senses in the operating room, even your hearing. A tumor being suctioned can sound different than normal tissue, and it has a vibration and unique feel when you touch it with micro-instruments. The more you do with intense perception, the more you start to appreciate the differences. To a novice, all rocks look the same. To an archeologist, every rock looks subtly different. A rock is a boring structure to the novice. To an archeologist, it tells a story of the cosmos. Anything can become interesting if you look deep enough. The only time something is boring is when you don’t know enough about it. Pituitary surgery brings excitement, challenge, and risk but also great potential to help fellow human beings. You gain experience, pay attention, listen to your mentors, and learn by going to conferences. You study videos of your own surgeries, so that every encounter becomes multiple encounters.

What is your advice for students considering pituitary medicine?

The most important thing is to be a lifelong learner. For pituitary surgery this means you should be a lifelong student of anatomy, pituitary physiology and diseases, and a lifelong student of patients. Let’s just say a patient’s spouse says to you “We haven’t had a baby yet. My husband (the patient) is depressed. He’s gained a lot of weight; he’s lost all his friends.” It may be that the man has a prolactinoma. So, you have to be able to pick out this profile. The pituitary tumor is not just an MRI and a blood test.

Take acromegaly, for example. With acromegaly, you develop coarse features. All of a sudden, your social life goes downhill. Your energy goes down. Your heart starts to grow, which can lead to heart failure. You become fatigued, and your shoes don’t fit anymore. It affects the whole family. My advice to someone who wants to be a pituitary surgeon is to become a student of the families and the patient. Learn from your colleagues. Become a student of the anatomy, spend time with mentors, get feedback, start slowly, and build up your experience.

What do people need to know more about when it comes to pituitary disease?

There’s probably a top 10 list for that. Most people don’t realize that a routine MRI often over-estimates pituitary tumors. I often see patients who are very anxious because they think they have a tumor, but it turns out it’s just an artifact.  A pituitary tumor can cause visual loss, but the patient may not realize it until significant damage has already occurred. Sometimes people can have consequences of hormone-producing tumors and can go misdiagnosed for years. Maybe they can’t have children, so they go to fertility specialists, or they just keep trying. Most people don’t realize that it can be treated if the cause is a pituitary tumor. Most people don’t realize that they should get two opinions and go to a busy pituitary center.

Another misconception is that radiation may be better than surgery for newly diagnosed pituitary tumors. Radiation is a useful tool if surgery has been maximized. On the other hand, there are some situations where it’s just the opposite, where I think it should be radiation first. It’s important to get opinions from both pituitary surgeons and radiation oncologists with significant pituitary experience. We saw a young adult, probably 18 or 20 years old, who had two or three surgeries at a place that doesn’t do a lot of pituitary surgery, and they referred him for radiation. But that person never underwent the optimal surgery. We took him to surgery and removed the entire tumor. He did well. So, I think that people need to go with a very experienced team. It’s human nature to want to go somewhere convenient, local, down the street. But for something like this, people should prioritize center expertise. Most doctors, including me, are willing to do phone calls or video consultations with patients. I’m willing to give second opinions all over the world. And it’s good to get that perspective, because the most important thing people need to have is a true understanding of what can and cannot be done, and what should and shouldn’t be done. The most valuable gift that you can give to a patient diagnosed with a pituitary tumor is perspective and knowledge. Knowledge is power, and I think that’s as important, or more important than any surgery I can do. Surgery is the result, but the road to surgery should be full of education and perspective sharing.

How many surgeries have you done?

I would estimate that I’ve worked on more than 1,000 pituitary tumors. We’re doing anywhere from 60 to 100 a year and growing. We have started using proton beam radiosurgery for select cases where surgery is either not an option or surgery has been maximized.