John A. Duncan III was very sickly as a child. Even as rheumatic fever was becoming rare, he contracted it. He also developed juvenile polio and spent months in the hospital. Then he recovered and grew into a healthy man.
“Ever since that,” he said, “I have always wanted to be in medicine and give back a little bit.”
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Duncan didn’t become just any kind of doctor. He’s a neurosurgeon, and a pediatric specialist at that – one of only two in the state, along with Dr. Stephanie Greene.
He is chair of neurosurgery at both Rhode Island Hospital and Hasbro Children’s Hospital, associate chair of the neuroscience department at Brown University’s School of Medicine, and president of a 20-year-old practice devoted to one of the toughest fields in medicine.
Duncan, Greene and five colleagues at Neurosurgery Foundation Inc., a nonprofit offshoot of Brown, remove brain tumors and aneurysms; repair the damage from massive head injuries; cut into spinal cords to cure crippling pain; and insert stents to remove excess brain fluid.
One wrong move in this kind of work can paralyze a patient, leave him unable to speak or even kill him. But when it’s done well, it can be the stuff of miracles.
Just last Wednesday, Duncan plucked a tumor out of a little boy’s brain stem. Most doctors wouldn’t even try, he said; the risks are huge. But it worked. “We took it out,” he said, “and the child did great. He’s going to be fine.”
Dr. Adetokunbo Oleyese, who specializes in trauma and spinal disorders, said the doctors’ confidence in their ability to do these complex surgeries comes from knowing how much they’ve trained – all have completed fellowships as well as their normal residencies; he had eight years of training after medical school – and the skills they’ve gained with practice.
Still, Oleyese said, “you have to remember that you’re taking care of people, and you’re having people entrust their lives to you. That’s no small responsibility.”
These seven doctors aren’t the only neurosurgeons in Rhode Island, but unlike their colleagues working in the community – who can choose their patients and the kinds of cases they’ll handle – the Neurosurgery Foundation doctors have to step in whenever they’re needed.
They’re the surgeons who get called when a patient with a major head injury gets wheeled into the Rhode Island Hospital emergency room, or when a little girl with strange symptoms shows up at Hasbro Hospital and, on getting an MRI, is found to have a tumor in her brain.
About 40 percent of their patients come to them that way, Duncan said. And although as a team, they can divide up their duties, it’s still a lot of work – last year, executive director Ellen T. Matesanz estimates, they treated about 4,000 patients.
For almost a decade – until Greene arrivedm two years ago – Duncan was the only pediatric neurosurgeon in the state, he recalled, and he took calls 24/7. There was no alternative; if a child needed help, he was the only one who could provide it, unless the family went to Boston.
Treating whoever needs it also has financial implications, Matesanz said. A large share of the patients are poor, covered by RIte Care or uninsured. The practice has to develop payment plans, but some can’t afford to pay at all.
“There’s an awful lot of write-offs at the end of the day,” Matesanz said – as much as a quarter of each year’s revenue, including lower-than-needed payments by insurers. “But there are workers’ comp cases, legal cases and insurers that pay well, and we’re able to make enough money to cover the costs.”
Another challenge for the practice is the cost of teaching. All the doctors are members of the Brown neuroscience faculty. They have residents assigned to them who shadow the doctors during rounds and surgery – and who also have to be paid for their work.
It’s an inherent part of the doctors’ mission, however, and they love it. “We chose academics because we’d like to pass on a little bit of us onto others,” Duncan said.
Now, Duncan is taking his teaching further, prompted by a trip to Peru that he made with a plastic surgeon from the Leahy Clinic at Dartmouth College. The two had worked together on craniofacial surgeries before, and his colleague wanted to teach the doctors in Lima how to do those procedures.
Neurosurgeons don’t usually do this kind of work abroad, Duncan said, because unlike, say, a child whose cleft lip is fixed, a brain surgery patient needs substantial post-operative care the doctor may not be able to stay long enough to provide. But he went to Peru anyway.
What he found at the public children’s hospital in the capital city were terrible conditions, “like medicine in the 1950s here, at best.” And he met a little girl, 11-year-old Fiorela Sangama, who had an arteriovenous malformation (AVM) that threatened her life.
Duncan feared that under those conditions, operating on Fiorela would kill her, so he organized a small humanitarian mission to bring her to Providence and have her undergo Gamma Knife treatment here. She came in July of last year – and while she was being treated, the doctors discovered an aneurysm that also needed to be removed.
“It was a great operation,” Duncan said, and Fiorela recovered well. She also inspired Duncan to keep reaching out to more people in need, both by teaching local doctors how to conduct more sophisticated procedures, and by bringing equipment and materials.
To finance it all, he started the Fiorela Foundation, which in March will sponsor its fourth trip to Peru. Ever the teacher, this time he’s taking one of his residents as well, Dr. Marc Goldman, to show him what it’s like to practice neurosurgery among people living in the Third World in abject poverty. Duncan can’t wait.
“I obviously give everything of myself to the people and the kids in Rhode Island,” he said, “but for the little bit of time I spend in Peru, that time gets things accomplished in orders of magnitude that could never be accomplished here, because they’re so needy.
“It just makes my heart sing,” he added. “It makes me feel great.”
