Rex Marco, MD Talks Better Care for Spine Patients, Encourages Sympathy and Mindfulness for All Recoveries
07 July 2021
I had the privilege of spending an hour talking with Dr. Marco over Zoom™, where he discussed various topics important to his life and work as a surgeon, educator, and patient with a spinal cord injury.
Here’s the complete list of topics Dr. Marco covered with links to each section.
- My journey with AO North America
- Getting insured as a fellow
- Expanding surgical conversation online
- Awakening the Fearless Surgeon
- Being a sympathetic surgeon
- Improving treatments for spinal cord injury
- Moving away from narcotic medications for spine surgery
- Preventing spinal cord injuries
- Recovering with mindfulness
- My injury
- Transitioning through injury
- Is there anything you would like to share with surgeons who might be experiencing difficulties or hardships in their personal life or work?
My journey with AO North America
My journey with AO North America started when I became an attending at MD Anderson. After finishing my fellowship in reconstructive spine surgery and musculoskeletal oncology, I came down to MD Anderson to combine the two fields and take care of patients with spinal column tumors and do things to help improve the care.
Since then, I've been involved in AO North America a lot through the Banff course and through other courses put on by AO North America.
Getting insured as a fellow
Most recently, I've been given very different topics to talk about. The first talk I gave was to a group of insurance agents about my story and my experience with the benefit of having life insurance and disability insurance, and the nuances of those things that can really affect how you're set up if you do happen to have an injury like this.
One of the more important things I realized is that an own occupation type of disability insurance plan—that's paid for after taxes and has a cost-of-living adjustment—is something to really consider. Now, when I try to go back to work, because my policy was not own occupation, if I have any work at any capacity, I have to pay back the disability insurance first. If it’s own occupation specific, then if I do take a job I don't have to pay back half the money that I earn.
The other thing that’s important is that I also get taxed on my plan because I paid for it with pre-tax dollars. If you pay for a plan with pre-tax dollars, you have to get taxed on it if you receive the benefits. But if you paid for it with after-tax dollars, then you don't have to pay taxes on the benefit. Plus, the own occupation plan paid for with after-tax dollars you get for your whole life, instead of the plan stopping at age 65. Although that plan is more expensive, it's something that you may want to consider, and it can change your life if you do happen to need that plan.
I also was very fortunate to have signed up with an accidental life and dismemberment policy. Since I have a functional dismemberment of four extremities, that plan did actually help me out. Because I had some whole life plans with the company when I became disabled, they continue to pay those plans because they don’t expect me to pay for them with my own funds.
Lastly, the other plan that we had was a long-term care policy. I had no idea that I would ever want such a plan, and I told the fellows at the course that the last thing I wanted to do as a fellow was to spend money on life insurance. I wanted to get a car and put a down payment on a house and pay back my student loans and start to do things that I couldn’t do with the income that I had as a resident.
Listening to insurance agents really helped me in the long run, because you really don’t know what’s going to happen in your life.
I’ve been really fortunate to have income protection in place. Almost every fellow that’s going to graduate and go into practice can set aside some funds to help do income protection, and that’s been really helpful for me and something that I’m trying to pass on to any of the surgeons that I talk to.
It’s just little things that could make a huge difference. Right now, it’s actually really hard for me to get back to work because I’m taxed on any income I make and I have to pay back the disability insurance plan.
Expanding surgical conversation online
I started a didactic series for my fellows and residents. Every week I pick a lecture that I’ve given in the past and I record it on Zoom™. One of the amazing things from the pandemic is that every lecture I give can be recorded, and they can listen to it on their own or listen to it live. If I’m busy or not feeling well I can always just play it for them instead of having to give it live.
In the past, I was never able to teach my residents and fellows the stuff I was teaching around the country at AO courses or national meetings, and now I’ve been able to give them almost every talk that I feel is important to educate them on what I think about tumor surgery, or everything I’m thinking about when I’m placing a pellicle screw. Instead of teaching them in the operating room I can teach them over a series of four lectures. Five out of six of my trainees said they preferred learning that way over learning from me in the operating room, which was sad and interesting to learn.
There’s a lot less stress in the lecture environment and I can take the time to tell them what I’m thinking rather than just have them watch it and think that they’re learning just by watching me. Other topics like adolescent idiopathic scoliosis or adult deformity, trauma, all those other areas—there’s no fellow in the past twenty years that I’ve been able to teach those topics to in a formal way.
The didactic series is really helpful for me and I think for my fellows and residents. Doing a weekly case conference, which is what we’ve always tried to do in our fellowship, being able to participate in that through Zoom™ has been great—that’s another great thing that’s happened with the pandemic.
Awakening the Fearless Surgeon
Other things I’ve started to talk about and people have asked me to talk about—a group asked me to be a key-note speaker for adult transformative learning. The title of my talk was “Awakening the Fearless Surgeon,” talking about how my childhood upbringing gave me skills to become the surgeon that I became and also trained me to be someone that had other issues that were not relational.
Perfectionism can be something you might want in your surgeon; if I expect other people to be as perfect as I expect myself, that can create harm for other people. Or, because I feel like I need control and perfectionism in my operating room, if I impart all of those things on other people in the room or if I get stressed and scared because things aren’t going as well as I planned and I take that fear, and stress, and anger out on other people—even if I just stay in silence—I’m harming other people.
Learning to acknowledge that concern, anxiety, fear, anger, or stress, really helped me in the operating room, become a much better teacher, a much better surgeon, a much more relational surgeon to the people in my room. That talk was really helpful for me to put it all together and talk about my journey to awaken the fearless surgeon.
For me, initially, I never really felt fear—I felt excitement. Now I know that that excitement was really originating from fear: fear of not doing the best job, fear of getting my patient off the table, fear of not getting a complication, or fear of being able to fix the complication that was occurring or about to occur. And then that instantaneously triggering my brain to trigger stress response in my body and then take out that stress on other people.
Being a sympathetic surgeon
Other talks that I’ve been asked to give are, “From Surgeon to Patient: Lessons Learned.” Lessons learned in terms of how to advocate for myself when things don’t go well for me as a patient and when people aren’t treating me like a human because I’m a disabled person.
Now, I recognize that I had ableism and other people have ableism, and that’s not okay. Being able to talk about that and advocate for patients with spinal cord injuries and other disabilities are some of the lessons that I learned as a patient. How to be empathic, and sympathetic, and compassionate from a different perspective.
I know it’s impossible for surgeons to exactly put themselves in their patients’ position and have complete empathy like I now can have, but we can do better to have empathy for patients who are suffering from their condition.
Everybody’s suffering, even the patient with chronic pain, who, from the surgical standpoint we can’t help with surgery, necessarily, but we can help them. We can empathize with them, and we can sympathize with them. I learned in medical school that sympathizing was suboptimal, but I learn now that sympathy is something that, if we know how to do it, we can really help our patients. Especially if we can just say: “I’m sorry that you’re experiencing that suffering” or “that you experienced that suffering.”
We’ve learned that a lot from trauma-informed care and work on adverse childhood events. Many people have had adverse childhood events or other trauma. Just saying “I’m sorry you experienced that. No one should ever have to experience that” and “would you like to see someone about that?” Just those few sentences can help people heal and help with high blood pressure and other chronic diseases.
In one system, the Kaiser system in California, they’ve trained all their physicians to ask those questions and say those sentences so that everyone in their plan can get better care. That’s just from learning how to say, “I’m sorry you experienced that.”
And compassion, which is defined by some people that I have studied as truly desiring that no one suffers. I put that all together with the escape key on the keyboard: empathy, sympathy, and compassion. Those are some of the things I talk about in my ‘Lessons Learned’ talks.
Improving treatments for spinal cord injury
I have a talk coming up that’s “From Surgeon to Patient: Lessons Learned” with a research update in spinal cord injury—giving a research update on the things that we’ve learned, largely from the AO with Michael Fehlings and others like Brian Kwon and Alex Vaccaro. They are leading the charge to really teach everyone around the world that it’s important to get more rapid care for patients who have spinal cord injuries, keep their blood pressures at an optimum of 85mm of mercury, and maybe even to give them neuroprotective medications like Riluzole, which we don’t know the results of that study yet, but it is coming.
The timing, and blood pressure, and neuroprotective medications, along with working with EMS and transport and the hospital trauma bay to help get patients into the operating room—or at least decompressed in the emergency room with something as basic as traction—can really make a difference for people with our injuries.
And then further research on the patient living with chronic spinal cord injury, work with functional electrical stimulation with implantable stimulators in the spinal cord or transcutaneous stimulation, which can help with motor movement as well as blood pressure control, maybe even regulation of bowel and bladder and sexual function.
Those are really promising research endeavors, as is cellular therapy with stem cells, probably stem cells that are more neural-derived, like swan cells or oligodendrocytes, and maybe other precursors that can be guided towards axon regeneration or myelination. And working with other agents that help break up the glial scarring. Something which seems to be promising to do that is chondroitinase. A lot of this work is coming from people like Dr. Fehlings who are really involved in the AO. That update will be fascinating and important, I believe.
Moving away from narcotic medications for spine surgery
Another thing that I like to talk about is getting my patients off of chronic narcotic medications before any major spine surgery, and not giving them chronic narcotic medications after spine surgery. In my practice, I was able to get all of my patients off of chronic narcotic medications for the last couple years prior to any spine surgery and I felt they did a lot better because they were then able to make their own endorphins.
Also, we taught them techniques to make neurotransmitters like dopamine and serotonin which helps them feel better, speak better, have less anxiety, and [allows them to] make pain medications to help with their pain control rather than take an opioid which suppresses their own natural pain medication manufacturing ability and suppresses their ability to make normal levels of dopamine and respond to normal levels of dopamine.
So when we were able to do this, and get them off of their narcotic medications before surgery, they didn’t require as much medication after surgery, they had more tools to make their own medication, and we didn’t go through cycles of severe disabling pain, screaming and yelling—requiring so much narcotic medication that they were almost not breathing and their liver was so amped up they would metabolize all their narcotic medications and then wake up screaming after almost not being in a survivable state because their respiratory drive was suppressed so much by the narcotics.
That cycle was really insane on the floor, and the nurses would just look at us like, “what did you do to this patient” and “what can we do to help?” There was nothing, but after getting all of my patients off of narcotic medications before surgery, that cycle didn’t occur.
I think that’s going to be really important research, using mindfulness techniques to help patients get off of their narcotic medications.
Preventing spinal cord injuries
I think the best way to treat spinal cord injury is to never let it happen. If we can teach people that it’s safer to jump in and not dive in, unless you’re a competitive diver or swimmer, it’s probably best to just jump in. I don’t see any other situation where you would really want to dive in. I think that would prevent a lot of spinal cord injuries.
Safer tackling, so that we have fewer and fewer catastrophic injuries, which are already at a much lower level. Safe tackling is being taught; we’re doing research to get the message out that there are even safer ways to teach tackling.
Maybe someday we’ll be able to get the message across that driving under the influence can lead to more and more spinal cord injuries. I know there’s already a big push to not drive under the influence, but I think we can have increased awareness around the fact that driving under the influence does lead some people to get paralyzed if they are in an accident.
I know other people who have just been riding their bike around the neighborhood and they weren’t looking and they ran into a car and they got paralyzed. So, making people aware that if you are going to ride your bike around the neighborhood to keep aware and look up. I know it’s nice to look around, and it can be dangerous. So, look around and wait until you know there are no cars in front of you to start looking around.
If we can prevent just one spinal cord injury, that saves one to four million dollars. It takes that much to take care of someone with a spinal cord injury.
Recovering with mindfulness
One of the other talks I’ve been able to give is “Mindfulness for You and Your Child – Preparing for the Teenage Years.” For me, mindfulness has been a really important thing for my recovery before and after the accident, and for my patients, and I think it can help our kids grow up to be more present and mindful.
That’s a really exciting area for me because I’m involved in a teacher certification program for mindfulness teaching. Getting the opportunity to teach at least one more person about the potential benefits of mindfulness has definitely been something that’s given me meaning to my life.
I was on a mountain bike ride with our family’s recovery group. The group I was with, we were on this trail, we were riding back on it, and we were playing this game called ‘no dabs’ where you try not to touch your feet on the ground. If we touched our feet on the ground, we were going to do ten push-ups for every time we did that. I love push-ups, so I didn’t mind touching my feet on the ground, and I didn’t want to, because I wanted to ride so that I didn’t have to do that.
I got to this area, and I let this one young lady go before me and get a pretty big lead because I didn’t want to come up on her and I wanted to go fast. I had a fair amount of speed and came over this little rise and I saw that everyone went right, but I knew if I went right, I would run over more roots and I might touch my feet. To the left was a really smooth pathway, so I went left.
At the bottom of that smooth pathway was a divot, and I went around and up it in my mind but it never happened. My tire just got stuck in that little knoll, and the next thing I knew I heard a crack. I know now that that probably meant that I flew over my handlebars and landed on my head. I wasn’t sure if the crack was my helmet or my neck. I had no pain, and I wasn’t sure what was going on.
In that moment, I knew that it was going to be helpful for me to be calm and breath. That’s what I had learned; I had gotten a lot of breathwork in before my accident and learned to find peace and calm with breath. I would breathe, and I knew I could do that, and I felt some peace then.
I thought that I might be paralyzed, and that that crack might have been my neck. I had this title of a book in my head, called Radical Acceptance, and in that moment, I told myself that if I was paralyzed then it was important for me to accept that.
We always said a prayer that was called the serenity prayer. The first line has you ask for serenity to accept the things you cannot change. I knew that the thing I couldn’t change was that crack, that turn, and whether or not I was paralyzed in that moment. And I asked for serenity to accept that if that did occur.
The next line is the courage to change the things that I can. The things that I could change are how I approach this and how I was breathing, to keep breathing, to find serenity, and to accept whatever happened, and to hope that someone came along and found me. Or that I just got up. But that wasn’t happening.
The last line is the wisdom to know the difference. I knew I already knew the difference, and by saying those lines so many times before my injury, I already had the wisdom to know the difference.
Then my friend came, and he came running up and I heard panic in his voice and that moment I thought, “this is probably not a good scene” and “I probably don’t look good.” He got below me because I was starting to slip down this slope, and he started to yell my name and I asked him if he could touch my leg. He said he was, and I couldn’t feel it, and I asked him if I was moving it, and he said that I wasn’t, and I was trying.
I knew then I at least broke my back, then I asked him if I could move my arms, and he said I wasn’t. Then I knew that crack was almost certainly my neck and not the helmet and I was paralyzed. I had sadness, and knew that, because I couldn’t feel or move, I knew I had less than a five percent chance of walking again, and if I don’t recover then I’ll probably never operate again or might not even work again—I probably wouldn’t be able to coach or hold my unborn child.
Again, I continued to breath and try and find some peace, and repeat the serenity prayer over in my head, and help guide him to help me because I knew that I needed to get to the hospital as soon as I could and get reduced as soon as I could. I had vision of reducing my own neck because I had heard stories of people that had done that, but when I remembered I couldn’t move my arms I knew that wasn’t going to be a possibility.
He keeps trying to hold me and keep me from slipping down. By that time, the whole group was there and we decided that it was important to wait for EMS. They came and they wanted to follow protocol and put a collar on me and take my vitals, but I could sense that my friend was getting tired and he wasn’t going to be able to help me much longer. The EMS guys couldn’t get below him and help support me and I knew they would just take a long time to get a collar on me, get me up, and put me on a backboard in a very awkward position and take my vitals.
I looked at my other friend and I said “you need to just get me up.” The EMS leader was unhappy, but I looked at him again and I said “you need to get me up.” He looked at everyone and said, “alright, let’s get him up.” All my friends got me up and I taught one of the young ladies to stabilize my neck and keep it in line while everyone else pulled me up onto the trail. Then the EMS got me loaded and back into the ambulance and to the trauma bay.
Within two-and-a-half hours of my injury, I was in the operating room, which is miraculous. I knew that was one thing that we could change to help increase the likelihood I would recover.
Transitioning through injury
I would say that I was at the pinnacle of my career. I was really a lot more comfortable with my clinical acumen and surgical experience and knowledge and was able to combine both fields of musculoskeletal oncology and reconstructive spine surgery to practice both and take care of patients with both problems and combined problems.
My accident occurred right when I was really in a, I would say, a groove in terms of those fields and in terms of who I was as a person and in terms of my emotional growth and emotional intelligence and recovery from some childhood trauma and educational trauma, and was really able to combine all of those, I would call, areas of learning. And then my accident occurred.
I can no longer operate; I can't move my arms or legs. My injury is at a level that’s so high that I don't have any functional movement of my arms or legs. I still want to do my best to take what I've learned and teach that to other people in all walks of life, from parents with young children, to high-school-age kids, spine surgeons in training, residents in training, spine surgeons in practice, and other people who have my injury and might benefit from the things that I've learned from life.
Is there anything you would like to share with surgeons who might be experiencing difficulties or hardships in their personal life or work?
If that question triggers any kind of response in your brain, then I think you would probably benefit from talking to someone. Finding a trauma-informed specialist to talk to or going to a group like Adult Children of Dysfunctional Families (also known as Adult Children of Alcoholic or Dysfunctional Families).
If you are experiencing difficulty with relationships in the operating room, in the clinic, with your patients, with your staff, with your partner, with your kids, with your family—you would probably benefit talking to someone and going through and looking up how many adverse childhood events you’ve had in your life. If you’ve had one, I personally believe you would benefit from talking to somebody.
One of the least invasive, non-labelling, diagnostic ways to talk to someone is through an anonymous group like ACA. You could even just order the step-study book, which is where I started in that. It just spoke so loudly to me, and it meant so much to me. If you or your family members have any of these issues then there’s probably some underlying trauma, and that may be why you’re experiencing the communication issues that are occurring.
So many of us have had trauma just in our training and we don’t even understand that. Another book called Trauma Stewardship is amazing because it shows healthcare works that have experienced trauma and they may be experiencing harm and imparting harm on others—learning how to do good self-care can really help them take care of other people. The other book that I think will be really helpful for me is What Happened to You by Bruce D. Perry and Oprah Winfrey. Those books are anonymous and can maybe help guide you to find the help that you may benefit from.