Do No Harm: Stories of Life, Death and Brain Surgery
Henry Marsh | Weidenfield & Nicholson | $35
This is a frightening book. Frightening because of the honesty of its author, British neurosurgeon Henry Marsh, CBE, who admits to feeling and then often saying things that most doctors would like to say, but know they shouldn’t. Frightening for the lay person who may not be aware that mistakes are an inevitable part of medical practice. And most frightening of all, perhaps, for those who run the British National Health Service, who will discover just how much one of their most senior clinicians detests the system he works in.
Marsh is well-known to British audiences, having appeared in a BBC documentary series, Your Life in Their Hands, in 2004, and more recently in an award-winning film, The English Surgeon, which depicts his twenty years as a visiting neurosurgeon in the Ukraine. At sixty-four, with thousands of operations behind him, he is comfortable talking about his errors; he even discusses the experience of being on the receiving end of a £6 million medical negligence case, something a mid-career doctor would probably avoiding mentioning.
Like all memoirs, this one needs much decoding. Is the image that he creates of himself as a curmudgeonly remnant of a disappeared medical world an accurate one? Could Marsh really be so grumpy, ill-mannered and immature in his relations with his colleagues and hospital administration? Is he really as selfish and short-tempered as some of the narrative suggests? Could a neurosurgeon, whose bread and butter is managing head injuries, really refuse to wear a helmet when he rides across London to work each day? (Actually, I’ve seen a photo of him riding helmet-less, so this appears to be true). Can a man who read philosophy and economics at Oxford before he studied medicine really pepper his conversation with as many instances of the F word as a Scorsese movie?
I often baulk at the ingenuousness of American medical-narrative writers. Or maybe it’s disingenuousness. American doctor-writers will depict their less-than-perfect inner responses and express feelings of guilt; or they may describe their embarrassment if they haven’t done the “right” thing or felt the “right” emotion. But usually the error in their intention hasn’t been the cause of the harm to the patient – that’s usually beyond their control. It can all be a little cringe-worthy.
This book is very different. At times Marsh took me beyond the cringe, to a place that I am, unfortunately, all too familiar with. Not only does he describe the way he is feeling, he is also honest enough to tell us what he does when he feels it. Here he is describing a consultation with a patient with chronic back pain:
With patients like this, when I know that I cannot help them all I can do is sit quietly, trying to stop my eyes drifting away out of the window, over the car park, over the hospital’s perimeter road, towards the cemetery on the other side, as the patients pour out their misery to me, and wait for them to finish. I then have to find some form of words with some expression of sympathy to bring the hopeless conversation to a close and suggest that their GP refer them onto the Pain Clinic with little hope that their pain can be cured.
I don’t know of any doctor who hasn’t felt something like that, but the book is full of examples of where he goes beyond just imagining. When he meets with the mother of a patient who has recently died and she complains about the way the staff handled her son’s last days, he throws up his hands after forty-five minutes and shouts at her. Then he follows her out of the hospital to apologise (one of many apologies he has to make after losing his temper in a variety of settings). When the mother explains that she understands that he would have to defend the hospital’s actions, he says he isn’t trying to cover up for anybody: “I don’t like this place and have no loyalty to it whatsoever.”
When the neurosurgical ward is closed because of an outbreak of a virus that causes severe vomiting and diarrhoea, he is outraged. One of his colleagues removes the poster on the entrance to the ward and Marsh writes an email to the management that compares the hospital to a concentration camp. When confronted by the CEO he regrets using the word “concentration” and suggests that “prison camp” would have been adequate. Droll enough, but as a reader with expertise in this area I was appalled. He is partially right when he says that the pathogen in question, norovirus, is an “unpleasant but usually harmless virus.” But in a hospital setting it is highly contagious, is difficult to prevent from spreading from patients to staff, and can kill the elderly and infirm. I’m amazed that a neurosurgeon would not see the risk that constant vomiting and explosive diarrhoea would have on a patient who has just undergone neurosurgery.
Marsh tries to explain his attitude towards authority thus:
I may appear to others to be brave and outspoken but I have a deep fear of authority, even of NHS managers, despite the fact that I have no respect for them. I suppose the fear was ingrained in me by an expensive English private education fifty years ago, as was a simultaneous disdain for mere managers. I was filled with ignominious dread at the thought of being summoned to meet the chief executive.
It is hard then to reconcile the fact that for twenty years Marsh has travelled to Ukraine to perform surgery in rundown Soviet-style hospitals, where selection for surgery is haphazard at best and proper equipment almost non-existent.
If you want to understand the “surgical persona” this book is an excellent place to start. I feel that I know Marsh – I have worked with variations of him throughout my career. He dislikes talking to his patients on the morning of an operation, preferring “not to be reminded of their humanity and their fear” and he doesn’t want them to see his own anxiety. But once the patient is anaesthetised and on the operating table he finds that “the dread is gone and has been replaced by fierce and happy concentration.” He describes how the elation that he used to feel as a young surgeon has evaporated, how the uncommon but unforgettable surgical disasters that he has been involved in have blunted his joy at operating and how he rides into the hospital to see his patients the night before surgery with dread and “almost a feeling of doom.”
He hates what is now internationally known as “clinical governance,” a system that holds clinicians responsible for the care of patients, that emphasises the avoidance of error through the development of better systems of communication between the various clinicians involved in the care of patients. For Marsh, surgery is still “single combat.” “Like all surgeons all I want to do is operate.” He sacrifices personal relationships for his work; he laments that his obsession for his craft, the sense of self-importance that it produced in him, and the long working hours led to the end of his twenty-five-year marriage. He describes a “good day” as one on which he doesn’t lose his temper, and he pines for an era when a surgeon could “relieve the intense stress of their work by losing their temper, at times quite outrageously, without fear of being had up for bullying or harassment.”
There is no room for ambiguity in Marsh’s surgical worldview – indeed, he describes uncertainty as the thing that tortures doctors the most. Through the book runs a sense of narcissism and entitlement that is common in doctors, surgeons especially. He lets us know that his patients think he is one of the best neurosurgeons in the country, even though he humbly denies this in the next sentence. We learn that within four years of finishing his training he had one of the largest private practices in the country. When he takes his team to operate in a district hospital that doesn’t normally perform neurosurgery, he is upset that no one pays him much attention. He treats with contempt and rudeness a hapless instructor who has to deliver “mandatory” education on communication to all staff. He parks his car in a delivery bay at night because it is closer to the operating theatre and is outraged when his car is threatened with clamping. When he explains to a patient that his operation has been postponed, the patient offers that, as a builder himself, he understands that delays and disappointments are common; but Marsh can’t resist commenting that there is a gulf between neurosurgery and building.
And, like most doctors, when he himself needs surgery for a retinal detachment he finds the experience troublesome. But he likes what he can, for the moment, barely see:
The retinal surgeon was a little younger than me but I recognised myself in his surgical manner – affable and businesslike, with that wary sympathy all doctors develop, anxious to help but worried that patients will make difficult emotional demands of us.
Some of his commentary on modern medicine resonates. The self-centredness of the previous generations of doctors, exemplified by Marsh, was at least balanced by their hard work and an intolerance of laziness and poor patient care. The shortening of doctors’ hours has been an important change but it is possible that things have gone too far and now the constant changing of shifts has led to a dangerous discontinuity of care.
The junior doctors... rather than becoming ever more safe and efficient now that they slept longer at night, had instead become increasingly disgruntled and unreliable. It seemed to me that… [they] had lost the sense of importance and belonging that came with working the long hours in the past.
The arrogance and sense of self-importance of the old-school doctors was at least founded in their craft – the modern doctor often thinks that when it comes to work–life balance, “work” should always give way to “life.”
Marsh’s description of the impossibility of obtaining truly informed consent for a procedure is helpful and his discussion of the equipoise that faces doctors when they make a decision to treat or not to treat is cleverly done. He hates modern hospital architecture and provides a simple guide for future construction – focus on the humans not the architecture. His criticism of hospital IT systems is a universal gripe.
I had a sense that retirement could not come too soon for Marsh – his increasing frustration, lack of enjoyment and sense of helplessness within the behemothic NHS all add up to a diagnosis of professional burn-out. (I imagine that this condition is often disguised by the contradictory British attitude towards authority and bureaucracy: openly hate and demonise the system but quietly live within it.)
Though my annoyance with the author grew as I progressed through Do No Harm, this is an eminently readable and consistently literate book, and in parts the language is achingly beautiful. The opening chapter is a masterful piece of tension-building which ensures that every time he subsequently describes an operation, you fear for the outcome. His description of neuroanatomy is lucid but not overly simplified and he expertly touches on virtually the whole of neurosurgery.
Medical readers will find much of the book cathartic and lay readers may find themselves cheering a maverick super-surgeon who fights the forces of evil bureaucracy and middle management. But ultimately, regardless of the correspondence between the memoir Marsh and the real version, I tired of his organisational misbehaviour, finding it childish rather than heroically anarchic. If you have worked for more than thirty years in a system that you believe is flawed, then your responsibility, beyond pointing to the flaws, is to try to improve it. Although I read this book quickly and with great interest, I couldn’t help conclude that it amounts to eloquent, but ultimately miserable, terms of surrender. •