Do No Harm: Stories of Life, Death and Brain Surgery by neurosurgeon Henry Marsh in which he describes cases and what it’s like to be a neurosurgeon has deservedly become a global best seller. It follows another book by a neurosurgeon that has also become a global best seller: Paul Kalanithi’s When Breath Becomes Air.
Janan Ganesh suggested in the Financial Times that there is such a big audience for these books because most clever people these days work in what others have called “bullshit industries” (financial services, human resources, public relation, the media, etc) where they don’t experience the existential challenges of death, sickness, suffering, and pain. They read the books to learn something about those challenges. Ganesh’s diagnosis sounds plausible to me, but both books are well written and have a compelling structure.
Kalanithi builds his around his life and terminal illness, while Marsh uses cases based around particular diseases as his structure. Kalanithi died young, while Marsh made it to retirement and so is able to write about how neurosurgeons change as they age. Kalanithi becomes a neurosurgeon to try and understand more about what it is to be human. Marsh didn’t have such grand aspirations, and became a neurosurgeon attracted by its excitement and because he was bored by the other options; but, nevertheless, he did achieve understanding denied to us who are neurosurgeons.
Marsh describes himself at one point as “recklessly honest,” which seemed to me right and one of the things that makes his book great. He isn’t out to make us like him, even if we admire him, and he comes across as arrogant, making clear at one point that he feels himself superior to all the others in a supermarket queue . For some his book is spoiled by his rather juvenile disdain for managers, and his attitude to his juniors seems patronising if affectionate. For me his book was enhanced by his reckless honesty.
Here are the many quotes I took from the book, and I’ve grouped them under headings. I urge you to read the book, and I hope the quotes might prompt you to do so. If you’ve already read the book you might be interested to see which quotes I’ve selected.
How neurosurgeons change as they age
Most neurosurgeons become increasingly conservative as they get older – meaning that they advise surgery in fewer patients than when they were younger. I certainly have – but not just because I am more experienced than in the past and more realistic about the limitations of surgery. It is also because I have become more willing to accept that it can be better to let somebody die rather than to operate when there is only a very small chance of the person returning to an independent life. I have not become better at predicting the future but I have become less anxious about how I might be judged by others. The problem, of course, is that so often I do not know just how small the chance of a good recovery might be because the future is always uncertain. It is much easier just to operate on every case and turn one’s face away from the fact that such unquestioning treatment will result in many people surviving with terrible brain damage.
It [to do an extremely difficult operation in difficult circumstances] certainly required a self-confidence and independence that I was subsequently to lose.
The life of a neurosurgeon
Thirty years of struggling with death, disaster and countless crises and catastrophes, having watched patients bleed to death in my hands, having had furious arguments with colleagues, terrible meetings with relatives, moments of utter despair and of profound exhilaration – in short, a typical neurosurgical career.
‘Terrible job, neurosurgery. Don’t do it,’ I said as I went past him on my way to the door.
As a neurosurgeon you have to come to terms with ruining people’s lives and with making mistakes.
The excitement of neurosurgery
Like all surgeons all I want to do is operate.
Despite this [the complications of the operation] I could not help but experience the intense excitement, concentration and fierce joy I always feel when I do these dangerous operations. ‘One’s on a higher plane of existence when operating like this,’ I said to Haru, only half-joking, turning aside for a moment from the microscope’s eyepieces. ‘It’s utterly addictive.’ Haru said nothing but I knew that he understood me perfectly.
Reflections on death and dying
I walked away down the dark hospital corridor, [wondering] at the way we cling so tightly to life and how there would be so much less suffering if we did not.
I have little direct contact with death in my work despite its constant presence. Death has become sanitized and remote.
I rarely have to confront death face to face, but occasionally I am caught out.
It is so very difficult to tell your patient that there is nothing more that can be done, that there is no hope left, that it is time to die. And then there is always the fear that you might be wrong, that maybe the patient is right to hope against hope, to hope for a miracle, and maybe you should operate just one more time. It can become a sort of folie à deux, where both doctor and patient cannot bear reality.
I have spent much time talking to people whose life was coming to an end. Healthy people, I have concluded, including myself, do not understand how everything changes once you have been diagnosed with a fatal illness. How you cling to hope, however false, however slight, and how reluctant most doctors are to deprive patients of that fragile beam of light in so much darkness. Indeed, many people develop what psychiatrists call ‘dissociation’ and a doctor can find himself talking to two people – they know that they are dying and yet still hope that they will live.
Hope is beyond price and the pharmaceutical companies, which are run by businessmen not altruists, price their products accordingly.
Why neurosurgeons operate when it might be better not to
There are degrees of malignancy with tumours and you never know what will happen to the individual patient in front of you – there are always a few long-term survivors – not miracles but statistical outliers. So I tell my patients that if they are lucky they might live for many years, and if unlucky it might be much less. I tell them that when the tumour recurs it might be possible to treat them again and, although to some extent it is clutching at straws, you can always hope that some new treatment will be found.
[I’ve put this quote under two headings.]It is so very difficult to tell your patient that there is nothing more that can be done, that there is no hope left, that it is time to die. And then there is always the fear that you might be wrong, that maybe the patient is right to hope against hope, to hope for a miracle, and maybe you should operate just one more time. It can become a sort of folie à deux, where both doctor and patient cannot bear reality.
Few people outside medicine realize that what tortures doctors most is uncertainty, rather than the fact they often deal with people who are suffering or who are about to die. It is easy enough to let somebody die if one knows beyond doubt that they cannot be saved – if one is a decent doctor one will be sympathetic, but the situation is clear. This is life, and we all have to die sooner or later. It is when I do not know for certain whether I can help or not, or should help or not, that things become so difficult.
Disdain for managers
As with all NHS chief executives in my experience (I have now got through eight) they do the rounds of the hospital departments when they are appointed and then one never sees them again, unless one is in trouble, that is. This is called Management, I believe.
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 this 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.
Fuck the future, let it look after itself, it’s not my responsibility. Fuck the management, and fuck the government and fuck the pathetic politicians and their fiddled expenses and fuck the fucking civil servants in the fucking Department of Health. Fuck everybody.
How to be a great neurosurgeon
‘Prof B’s a really fantastic surgeon, amazing technician,’ my registrar said, ‘but do you know what he was called by his residents before he moved to his present job? They called him “the Butcher” because he trashed so many patients as he perfected his technique with these really difficult cases. And he still gets some terrible complications. Doesn’t seem to trouble him much though.’ It’s one of the painful truths about neurosurgery that you only get good at doing the really difficult cases if you get lots of practice, but that means making lots of mistakes at first and leaving a trail of injured patients behind you. I suspect that you’ve got to be a bit of a psychopath to carry on, or at least have a pretty thick skin. If you’re a nice doctor you’ll probably give up, let Nature takes its course and stick to the simpler cases. My old boss, who was really nice – the one who operated on my son – used to say ‘If the patient’s going to be damaged I’d rather let God do the damage than do it myself’.
It is an experience unique to neurosurgeons, and one with which all neurosurgeons are familiar. With other surgical specialties, on the whole, the patients either die or recover, and do not linger on the ward for months. It is not something we discuss among ourselves, other than perhaps to sigh and nod your head when you hear of such a case, but at least you know that somebody understands what you feel. A few seem to be able to shrug it off, but they are a minority. Perhaps they are the ones who will become great neurosurgeons.
There were two other lessons that I learned that day. One was not to do an operation that a more experienced surgeon than me did not want to do; the other was to treat some of the keynote lectures at conferences with a degree of scepticism.
Relating to patients
Patients become objects of fear as well as of sympathy. It is much easier to feel compassion for other people if you are not responsible for what happens to them.
I recognized myself in his surgical manner – affable and business-like, with that wary sympathy all doctors develop, anxious to help but worried that patients will make difficult emotional demands of us.
We had discussed his case at the morning meeting, in the slightly sardonic terms that surgeons often use when talking about alcoholics and drug addicts. This does not necessarily mean that we do not care for such patients, but because it is so easy to see them as being the agents of their own misfortune, we can escape the burden of feeling sympathy for them.