OMALU SPEAKS about “conformational intelligence” in many of his talks that I can relate to. There is a kind of status quo that exists in the realm of success and privilege, which unless you have a chance to deal with, is hard to understand. The people who demonstrate this kind of behavioral characteristic are all around us. It is about not breaking with established traditions and having everyone around you follow that path no matter what. As the saying goes, “if it isn’t broke, don’t fix it.” But it is broken, and traditions and fear have led to the chaos that we now see in this field. The real discoveries of the past and modern times have come from people who “think out of the box” and are willing to leave the draw of conformational intelligence behind. Following an established script may be attractive now and offers some level of security, but you can sacrifice your future and the future of others trying to hold on to traditional ways of doing things at times.
My story as a physician in a well-known academic center and spearheading the development of a large brain injury program illustrates what conformational intelligence is all about. I spent 25 years creating this program and subsequently saw the program go up in smoke when a new management team took over the hospital. Without their clear understanding of the program’s value, impact on the flow of patients through the system, the positive image of the hospital and community, positive financial impact on the system, and service to the community, the entire program was shut down without notice and without significant thought of how to continue the program or find a replacement. Yes, maybe I was too much of an entrepreneur. Maybe I did not fit all the traditional stereotypes of one carrying the message of brain injury at a major medical Institution. Maybe just having trained at the same institution and going on to develop your own way of thinking was not seen as prestigious. Yes, maybe there was someone else out there who could do a better job. And maybe the ego of one or more of the leadership team was just a little bit bruised. Thus, shutting down an economically viable and sustainable program without notice or explanation was the thing to do. Starting in 1988, when TBI and concussion were like a foreign language to neurologists, few training programs in neuroscience incorporated training for students and residents to include the evaluation and treatment of TBI/concussion. Around that time, I was part of a growing movement of neurologists who took an interest in developing the field of neurological rehabilitation and brain injury. I must give credit to the protection and support provided by many of the old forerunners in the field of neurology, some of whom are not alive today. They gave me a chance to develop a program with my own creativity. I am forever grateful and thankful to my many professors and the visionary leaders at the University of Miami, Miller School of Medicine, and the Jackson Health System who overlooked my many limitations and gave me a chance. Visionary doctors such as Peritz Scheinberg, Noble David, Barth Green, Walter Bradley, and many others not mentioned here took a risk but gave me an opportunity to develop this program. With little administrative skills and financial support, I was able, with the help of others and my team, to build a strong program. There was a time when we had 60–80 patients admitted to the different hospital departments, being treated for some form of TBI or concussion. The centers included the inpatient and outpatient neurological rehabilitation unit and an acute early intervention neurological rehabilitation program, known as the Intermediate Head Injury (IHI) unit. In the IHI unit, patients were transitioned from the ICU. Our version of the IHI unit was one of only a few that existed around the country at the time. I recalled going through the trauma accreditation site a few years ago when one of the reviewers said to me that this concept of the intermediate brain injury unit was transformative, beyond its time, and he wished that others would adopt such a program. He further indicated that in his entire career as a neuro-trauma doctor, he had never seen this kind of transitional program in the acute care settings, where early neurological rehabilitation intervention was introduced to manage physical, cognitive, and emotional disabilities while in the acute care. The success of this program lay in aiding discharge planning, identifying challenging neurobehavioral, cognitive, and physical impairment early, and providing early treatment interventions to avoid longer-term challenges. This is where we learned the value of early intervention instead of the wait-and-see approach that many programs have adopted and continue to practice even today. On the IHI unit, we were able to take patients at a time following their injuries where most physicians and nurses felt uncomfortable with providing care. This is when I believe TBI/concussion patients are the most neglected, and the consequences of such neglect have major long-term implications for the patients, their families, and society. This stage of care was in the intermediate phase between the ICU and going to the rehabilitation center, prior to going home from the acute care, or before going to a long-term care facility from acute care. This was the stage where patients are treated for some of the most difficult signs and symptoms associated with TBI and concussion, such as agitation and aggression, pain, medical complications, and some of the worse physical, cognitive, and neurobehavioral impairment. It is during this period that the brain starts to develop compensatory behavior that can have long-term effects on recovery. Be that as it may, in hindsight, given the value of such a program, I wish I had done a little more in my time to promote this concept nationally. The impact of this kind of system on patient care, physicians, families, and the outcomes of the patient were impressive. This together with an integrated neurological rehabilitation program operated by neurologists for many years provided us a unique opportunity to marry physical rehabilitation, neuropharmacology, neurophysiology, neuro-cognition, and neuro-behavior with function based on the limitations noted in brain organization. It was in these programs that I truly learned the concept of brain hierarchical organization and got to understand what recovery and outcomes meant. We saw a large number of patients with varying degrees of severity of injuries and worked with neurologists, trauma surgeons, neuropsychologists, orthopedic surgeon, oral-facial maxillary surgeons, neuro-radiologists, rehabilitation specialists of all kinds. We had the best laboratory to not only evaluate and treat brain injury but also to understand the natural history of how a brain recovers. I can confidently say that there are very few programs today that allow for such comprehensive and inter-disciplinary evaluation and treatment of TBI/concussion. I was fortunate to be at the helm of this program. It gave us a chance to develop certain principles to treat brain injury that has restored many lives and allowed others to achieve a level of functional independence that they would not otherwise be able to. I chose to write this book for generations beyond because of the unique opportunity I had and hope that it will stimulate others to develop similar programs.
At that time, we were the only level 1 trauma center in all of Miami-Dade County for almost all the years I practiced, and all trauma patients came to our center. This is no longer the case. I can confidently say that Jackson Memorial Hospital had the best laboratory over the years for us to truly understand the natural history of TBI and concussion. While we were able to conduct some studies, we did not have clear leadership in place to do what was required to provide the kind of research needed, and that I regret.
Other than the fact that certain decisions often made by administrators may have come from a place of fear, anger, hatred, self-centeredness, traditions, and biases, shutting down a brain injury program with over 25 years of history that was clinically relevant, financially sound, independently self-supporting, and with an excellent reputation was a travesty. This left a huge gap in trauma care at our institution, starting from acute care to neurological rehabilitation and into the outpatient system. The motivation for the move remains a mystery to the doctors in the system, nurses, therapists, and the community. I truly believe that unless someone else could provide a better explanation, this situation best fits the term conformational intelligence gone loco. I have seen this type of situation with many of my colleagues around the country, and in one national meeting, this was forwarded as an issue. At the time, I did not think our program would come to the same fate and freely gave advice to others that I could not take myself. Putting myself out there would give administrators, board of directors, medical professional organizations, legislators, physicians, nurses, and patients a voice to say no to zealous leaders who do not understand the facts about how their decisions can impact not just a delivery system but also the lives of people needing care. I can speculate what was on their minds, but to date, no explanations were provided for the move.
I am telling you this story because I see this as a trend in the field of brain injury and just about all of medicine in the country. The boards of hospital systems and the senior leadership
