Dr. Clara Starkweather

PJ: What inspires you to do what you do?

CS: The patients - I saw a neurosurgery case for essential tremor when I was just starting medical school, and it was an awake deep brain stimulation surgery. This person couldn’t feed themselves because of how bad their tremor was. I remember, as soon as the stimulating electrode went into the right place and they turned it on, she was able to lift a water bottle to her lips and write her name for the first time in years. It was very powerful. It was an emotional moment for the patient. Seeing that kind of impact was very addictive to me. It's just so cool that the work we do has an immediate impact. That very short time course of - we showed up today, and we did our best to fix this problem, and sometimes it is fixed - that's magical to me.

PJ: What is the best piece of advice you have received on this path?

CS: There was a PGY3 general surgical resident I worked with when I was an MS3 on my rotations. I think this was my first time doing 24-hour shifts. At morning rounds, I was presenting patients that had come in overnight in front of everyone. She said, do not say the words “like” and “um.” If you say those words again, I will take your presentation away from you. Write your presentation on a cue card and read it directly off the cue card if that's what it takes for you to stop saying that, because it injects uncertainty into everything you say, and it makes people take you less seriously. And women tend to do it more.

PJ: How do you see neurosurgery evolving in the next 10 to 20 years?

CS: In the next 10 to 20 years, we're going to be expanding indications for functional neurosurgery. That's the area that I'm part of; I study how the brain makes decisions. We're just now starting to understand the building blocks of psychopathology so that we can modulate the underlying circuits that go awry in these conditions. For example, people have tried stimulating different brain areas like the nucleus accumbens for refractory depression, refractory meaning they've exhausted all medical treatments and even electroconvulsive therapy. They've escalated to the point of trying an invasive neurosurgical trial. What typically happens in these trials, is the intervention will work in about 50% of people. If you think about the diagnostic criteria for depression, (e.g. sleep disturbances, loss of interest in your activities, guilt feelings, less energy, concentration issues, psychomotor slowing, etc.), you need five of those nine criteria to be diagnosed as depressed and there are so many permutations of that. So, two depressed people could just overlap on one symptom. A depressed person who's really anxious but has preserved energy, versus a depressed person with a lot of psychomotor slowing, versus a depressed person with anhedonia are three different patients. To me, it’s no surprise that trying the same target in all three of those people would not work. That's a different pathway of treatment in my mind. There's been a lot of work in this area. It's called computational psychiatry, and the goal is to try to break down behavioral phenotypes that correspond to underlying dysfunction in neural circuits. To me, that's the frontier: understanding behavior so that we can modulate behavior in a very precise way instead of having some blanket term like depression, which I think is very imprecise. It's not a surprise that clinical trials have been successful in only a subset of patients.

PJ: What do you wish medical students knew or considered before committing to neurosurgery?

CS: I wish people came in with a solid knowledge base. I think it's good to familiarize yourself with the field and make sure that the field broadly is interesting to you. I had a mentor who suggested I read Greenberg from cover to cover, which is a very useful book, but very dense. On my Sub-Is, I knew a little bit about everything. Even though I was naive of patient care as a whole, I did know what an external ventricular drain was and why would we place that and where it goes, and what are the skull landmarks. From reading Greenberg, you would know some neurosurgical basics, but you would also have a flavor of whether general neurosurgery is interesting to you. For me, I like looking at radiographs of the spine and learning about spine biomechanics, stuff that's different from where I envisioned my research home within functional neurosurgery. I think it's important that you're excited about that stuff too, and learning it and doing it, because so much of your time will be spent in residency learning the general stuff. I personally love how I feel when I hold a drill, and I loved putting in external ventricular drains as a junior resident. I feel tremendous satisfaction from that. If all I had was the research interest in functional neurosurgery, but I wasn't really into the bread and butter of neurosurgery, this would be miserable. I think that it's great that a lot of people have research interests, but I would encourage them to learn about the general neurosurgery. It'll equip you very well for sub-internships and it'll be impressive when you know all this stuff off the top of your head, and you're familiarized with looking at radiographs. You can practice on Radiopedia, which is an awesome website that I used a lot in conjunction with Greenberg to prepare myself. But you'll also establish whether you have that baseline interest in the subject material. Even as an attending neurosurgeon, I think it's very likely that I'll wind up doing some basic spine cases and basic cranial trauma. I think that's a very reasonable expectation when you get your first job, that you must be excellent at general neurosurgery. You’ve got to figure out whether you're interested in doing all that stuff too.

PJ: Is there a case or patient experience that has stayed with you or impacted your perception of the field?

CS: There was a psychiatric patient who was in our closed loop deep brain stimulation trial. He was a very depressed person - you would feel it sitting next to him. I was sitting in his room, waiting to run my experiment with him, and he was looking at his breakfast, eating it slowly. The research team was getting geared up for the day and started a stimulation protocol of a prefrontal brain region. Without being prompted, he started suddenly articulating a really different vision of his own future. He started saying, “you know what, maybe I will have a partner someday. Maybe I will go for that graduate degree.” It was very striking. I just felt all the hairs in my body raise up. It was kind of the same feeling I had when I saw that essential tremor patient - where there was such a marked immediate change. I don't think the patient really realized it either. He had a really pessimistic view of his life, and then suddenly was just volunteering this information that was a very different worldview than anything I'd ever heard before. He didn't report any somatic symptoms that would tell him that anything had changed in terms of stimulation. That was incredible to me, and it reminded me of why I went into neurosurgery.

PJ: How do you emotionally and mentally deal with bad outcomes in a field where it can be super common?

CS: I think it's important to go to therapy. When I was a third-year resident, I got run over by a bus. It was at Haight and Stanyan.

PJ: The hardest thing you’ve done is not neurosurgery residency.

CS: I think neurosurgery residency is still harder than getting run over by the bus. Thankfully, I was pretty okay. I'm like a cockroach. You can't kill me.

CS: UCSF provides free therapy to faculty and residents, which I think is a perk that should be talked about more. I had not gone to therapy during residency up to this point. My PCP, who's a wonderful person saw my ED visit and recommended therapy after thinking I’d have anxiety around intersections. That turned out not to be a problem, but it ended up helping with decompressing after difficult cases. There was this patient who had a ruptured aneurysm, and I put an external ventricular drain into her in the middle of the night. The drain was in the right position but because her intracranial pressure was so high, the whole brain collapsed around the drain. There was no ventricle left, and her pupils blew before we were able to get any intervention underway. I had to talk with her adult children, who are my age, and this person was young; she was 60. I did talk to her children, and I felt like a complete failure because she had come in way too late for us to meaningfully intervene. That was the kind of situation that I found very helpful to decompress with the therapist. I got to explore if there was anything redeemable from that situation. You could talk about it with your friends or family, but they may not be trained to help you decompress something like that. The therapists at UCSF are awesome, and they'll meet with you over Zoom and at odd hours. I've been very grateful for that, and I feel like that took a burden off me having to tell my mom who has no idea what to say about something like that. That really takes the burden off you shoving that information onto your friends and family.

PJ: What is one thing you know now that you wish you had known earlier in training?

CS: How to say no. I think I said yes to too many projects during intern year, and I should have just focused on my one thing that I really want to do. When you're in residency, a lot of people want to work with you, and you may get a lot of requests to do all kinds of things, but ultimately, it's about what you really want to push in the field and identifying one mentor, maybe two, who can really help you push that. Then, unfortunately, you will have to say no to some things, and I regret I didn't learn that sooner. I think did some things half-heartedly my intern year, and looking back, I feel bad about that. I think at this point, I've learned how to finely tune what takes my attention outside of the clinical work, and I think that's very important.

PJ: If you were to not do surgery, what do you think you would do?

CS: If I weren't doing surgery, maybe neuroscience or carpentry. I did a lot of woodworking when I was a little kid in Georgia, and I thought it was super fun. It's very satisfying. I love watching videos of joineries coming together. My dad was into that. I love arts and crafts. I love making elaborate Halloween costumes if time allows. I think my most elaborate one was two years ago. I was a snail. I took a cardboard box out of a dumpster, and I rolled it into a shell that I wore.

PJ: What is your Halloween Costume this year going to be?

CS: I’ve became a big fan of the basketball team, The Valkyries, a WNBA team in the Bay. I got peer pressured into going to a game and got addicted. Basically, they introduced this really goofy little bird named Violet, and she’s their mascot. I think birds made from cardboard look cool. So, I think I might be Raven, violet's goth counterpart, and make her out of cardboard.

PJ: What hobbies do you engage in outside of the hospital?

CS: I love eating. I have a cookbook club with my friends where whoever is hosting has a cookbook and then everyone chooses a recipe out of the host's cookbook and brings it to their house. The host makes a themed cocktail or dessert. Even if I come home super late, at two in the morning, I always cook myself something and I think it's a little rare; I think a lot of people don't cook for themselves. But to me, it's one of the most fundamental skills, so you can take care of your body. I really enjoy making Korean food. My mom is Korean, and I've been learning her secrets recently. The most elaborate thing I made recently was spicy beef stew, a Korean dish.

PJ: What do you feel like neurosurgery has that can be hard to find in other specialties?

CS: I feel a sense of wonder always, even in the simplest cases. I feel wonder. I think neural tissue is just so exciting. I remember the first time I put an electrode into a brain; it was in a bird brain when I was an undergrad. I heard the snapping and crackling of electricity, and you could just hear multi-unit activity from thousands of neurons around the tip of this tiny electrode. I felt like I was seeing, maybe how an astronomer feels when they look at the stars. You feel wonder at seeing a little slice of the universe, but that's how I felt even with a tiny brain so getting to work with neural tissue and humans every day is such a privilege and fills me with wonder.

PJ: What is a question you wish more people would have asked you or would ask you? Is there something that you feel is left unsaid when it comes to your career and what you do?

CS: I think a lot of people assume that neurosurgery is a field filled with high ego, and I have not found that to be the case. Of course, there are specific examples, but I think overall there's a lot of humility, wonder, respect and fear of harming somebody because the consequences can be so great. What we operate on is personal; it's what makes you a person. I think the vast majority of neurosurgeons are full of those qualities and I don't find the god complex neurosurgeon that you may see in a TV show to be the primary role model or example.

PJ: What are you most proud of personally and/or professionally?

CS: Personally, I'm very proud of my relationship with my co-residents. There’s only three of us per year, so it's important that we function as a unit and that we have each other's backs. There's a tremendous amount of trust between us. Between the three of us, we can solve almost anything, and we can clean up almost any mess and make sure that patients are well taken care of. I remember during junior residency, sometimes I would mess up and then the two of them would catch it. Having that trust to be able to tell someone you messed up and here was the mistake, and let's clean it up - That is really important. I felt a lot of camaraderie with the two of them. They're like my brother and sister forever because of the kind of group dynamic we have. I'm very proud of that. Professionally, I am proud of what I was able to accomplish scientifically so far. I think it's just the beginning, but I have a solid idea of a circuit model for a part of prefrontal cortex. I didn't think I would have it because there's such a zoo of responses in the prefrontal cortex. It's such a multimodal area that it could be very hand-wavy scientifically. But I feel really excited about the project that I've been able to come up with, and very grateful for the support of my mentors. I'm very much excited to continue going in this line of research that I'm developing. I feel very proud of that.

PJ: Who do you admire?

CS: I really admire my boss from grad school. I think that was probably one of the best boss-mentor-mentee relationships because he was not afraid to acknowledge gaps in his knowledge and not afraid to seek out ideas from people more junior. Even in front of lab meetings, if he had a gap in knowledge, he wasn't afraid to say, “oh, I actually don't know very much about that. Let's talk about that.” Despite being one of the most knowledgeable people in neuroscience and studying reinforcement learning in the brain, he was very humble and was able to break down really hard concepts into something you can draw on a chalkboard and make a biologist understand. I really admire him. I admire that humility.

PJ: Thank you so much for carving out part of your day for this. I hope it inspires many to come.